WHITTIER, CA - Federal inspectors documented serious lapses in patient care at Whittier Hills Health Care Center during a January 2025 inspection, including failure to monitor a diabetic patient's blood sugar levels and widespread issues with oxygen therapy equipment maintenance.
Critical Diabetes Management Failures
Health inspectors identified significant care deficiencies involving a resident admitted from a hospital with a documented history of Type 2 Diabetes Mellitus. The resident, identified as Resident 301, arrived at the facility on January 2, 2025, following a hospital discharge where insulin treatment had been administered multiple times daily throughout December 2024.
According to the inspection report, hospital records from the admitting facility showed Resident 301 had received insulin injections on 19 separate occasions between December 10 and December 28, 2024, for blood sugar management. The hospital's discharge documentation clearly listed Type 2 Diabetes in the patient's medical history.
Despite this documented history, facility staff failed to implement blood sugar monitoring protocols upon admission. The admission checklist completed by facility nursing staff indicated awareness of the diabetes history, yet no physician orders were obtained for blood sugar monitoring or treatment. The facility's electronic medical record system did not reflect the diabetes diagnosis, even six days after admission.
When blood sugar is not properly monitored in diabetic patients, particularly those receiving tube feeding nutrition, dangerous complications can develop. Uncontrolled blood sugar levels can lead to diabetic ketoacidosis, a serious metabolic condition where the body produces excessive ketone bodies, causing dangerous acid accumulation in the bloodstream. This condition requires immediate medical intervention and can result in coma, hospitalization, or death if left unaddressed.
The inspection revealed that nursing staff did not identify the monitoring gap until January 8, 2025—six days after admission. A registered nurse documented that after reviewing hospital records, she discovered no diabetes medications had been ordered by the facility's physician despite the documented medical history. The nurse obtained orders from a nurse practitioner to begin blood sugar monitoring only after this discovery.
The facility's nurse practitioner stated she had not reviewed the hospital discharge packet when assuming care of the patient on January 6, 2025, assuming the covering provider had completed this review during the initial visit. This communication breakdown resulted in a critical gap in diabetes management for a vulnerable patient receiving nutrition exclusively through tube feeding.
Medical Equipment Safety Concerns
Inspectors documented multiple oxygen therapy equipment violations affecting three residents receiving supplemental oxygen. These findings raised concerns about infection control practices and adherence to the facility's own safety protocols.
In one resident's room, inspectors observed the nasal cannula and oxygen tubing lying on the floor while the patient was in bed. The facility's Assistant Director of Nursing acknowledged during the inspection that when not in use, oxygen equipment should be stored in sealed bags to prevent contamination. Current infection control standards require keeping respiratory equipment off floor surfaces, as floors harbor significantly higher bacterial counts than other environmental surfaces.
For another resident requiring continuous oxygen at 2 liters per minute, inspectors found the oxygen machine's humidifier bottle completely empty. The bottle, which prevents airways from becoming excessively dry during oxygen therapy, had been dated December 26, 2024—11 days before the inspection. Facility policy required humidifier bottles to be changed weekly or when empty.
Dry oxygen delivery without humidification can cause significant discomfort and medical complications. The nasal passages and airways require moisture to function properly; prolonged exposure to dry oxygen can lead to nosebleeds, nasal irritation, and damage to the delicate mucous membranes lining the respiratory tract. For patients receiving higher concentrations of oxygen, humidification becomes even more critical to prevent tissue damage.
A third resident's oxygen tubing was also found touching the floor. When the licensed vocational nurse was shown the tubing placement, she acknowledged it should not contact floor surfaces due to infection risk and stated she would change the equipment immediately.
Knee Immobilizer Sizing Issues
The inspection identified problems with medical equipment fitting for a resident recovering from a fractured kneecap. Resident 351, admitted in December 2024 with a right patella fracture, was prescribed a knee immobilizer to stabilize the joint during healing.
During observations on January 6, 2025, inspectors first encountered the resident standing without the immobilizer properly positioned—it had slid down to her ankle rather than supporting her knee. The resident stated, "This happens a lot. The brace keeps sliding down, and it doesn't feel like it's helping much."
Later that same day, when the resident was seated in a wheelchair, the immobilizer appeared loose with visible gaps around the knee and thigh area. The physical therapist reported having to readjust the device multiple times during therapy sessions and acknowledged the resident would benefit from a properly sized replacement. However, no action had been taken to order appropriate equipment.
Knee immobilizers serve a critical function in fracture recovery by limiting joint movement, reducing pain, and preventing further injury during the healing process. An improperly fitted device cannot provide the necessary stabilization, potentially delaying healing, causing additional discomfort, and increasing the risk of re-injury or complications such as improper bone alignment.
Elopement Risk Management Deficiencies
Federal inspectors found the facility failed to implement safety interventions for four residents identified as high risk for elopement—leaving the facility without staff knowledge or supervision. All four residents had cognitive impairments and documented elopement risk assessments, yet care plans addressing these safety concerns were not created until January 7-8, 2025, during the inspection itself.
Residents with Alzheimer's disease and other forms of dementia may not recognize safety boundaries or remember they are in a care facility. They may attempt to "go home" or wander in search of familiar surroundings. Without appropriate interventions such as alarmed exits, staff monitoring protocols, or secured units, these residents face serious risks including injury from falls, exposure to weather elements, traffic accidents, or inability to communicate their identity or location if they leave the premises.
The facility's Medical Records Director confirmed she could not find documentation of elopement risk in the interdisciplinary care planning records for any of the four residents, despite risk assessments identifying them as high risk months earlier. One resident's elopement evaluation was completed in September 2024, another in October, and two in November and December, yet no corresponding care plans with safety interventions were developed until inspectors questioned the omissions.
Additional Issues Identified
Nutritional Supplement Oversight: A resident with documented weight loss and a physician order for nutritional health shakes three times daily did not receive the prescribed supplement with her lunch meal. The meal ticket indicated a shake should have been included, but it was not on the tray when delivered. The facility's registered nurse requested the supplement from the kitchen only after a family member brought the omission to staff attention.
Emergency Medication Kit Management: An intramuscular emergency medication kit in the facility's medication room remained unsealed after a dose was removed on December 5, 2024—more than one month before the January inspection. Facility policy required resealing opened kits with color-coded locks and replacing them within 72 hours. The pharmacist stated the facility had transitioned to an automated medication dispensing system in late December, but staff continued accessing the old emergency kit without following proper documentation and replacement procedures.
Food Safety Documentation: Temperature monitoring logs for kitchen freezers showed incomplete entries, with both morning and afternoon temperature checks missing for January 4, 2025. Consistent temperature documentation provides the only verification that refrigeration equipment maintains food at safe temperatures, preventing bacterial growth and foodborne illness. Without complete records, the facility cannot demonstrate continuous compliance with food safety requirements.
The Director of Nursing acknowledged the facility lacked a standardized policy and procedure to guide nursing staff through the admission process, including which hospital records to review and how to verify diagnoses and treatment orders. She stated staff were expected to know what documents to request and review based on their training and experience, rather than following a systematic checklist approach.
Federal regulations require nursing facilities to provide each resident with care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The documented deficiencies at Whittier Hills Health Care Center represent gaps in fundamental care processes—from admission assessment through daily monitoring and equipment maintenance—that collectively compromised patient safety and quality of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Whittier Hills Health Care Ctr from 2025-01-10 including all violations, facility responses, and corrective action plans.
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