Whittier Hills Health Care: Diabetes Monitoring Gaps - CA
Resident 301 arrived at the facility in December 2024 with a medical history that included type 2 diabetes, hemiplegia, and Alzheimer's disease. Her hospital records from GACH 1 showed blood sugar readings between 151-154 mg/dL during her stay, well above the normal range of 70-100 mg/dL.
When facility staff checked her blood sugar after admission, it measured 118 mg/dL. But no physician had ordered ongoing monitoring.
The admitting registered nurse told inspectors she received a report from the hospital but found no orders for blood sugar monitoring in the resident's file. "I did not see any order for blood sugar monitoring or any physician progress notes that indicating blood sugar monitoring and treatment were not needed," RN 1 stated during a January 8 interview.
The hospital had failed to send the resident's medication administration record and orders from her stay, according to the nurse. Most hospitals typically provide discharge summaries, lab work, and medication records when transferring patients, she explained.
But the facility's own admission process proved equally problematic. The nursing home had no written procedures guiding staff on what hospital records to review during admissions.
RN 1 acknowledged the facility used an Admission Report Check List to gather information from hospital nurses before transfers. However, the form lacked any section prompting staff to ask about recent vital signs, blood sugar checks, or insulin administration during the hospital stay.
The Director of Nurses confirmed the systemic gap during a January 9 interview. The facility had no policy requiring nurses to review specific hospital records upon admission, she told inspectors. "I trusted her RNs to know what hospital records to review and to request when some records were not sent with the resident," the DON stated.
This trust-based system failed Resident 301, whose diabetes history was documented but not addressed with appropriate monitoring orders.
The facility's Quality Assurance and Performance Improvement policy, revised in January 2022, requires a comprehensive approach to maintaining safety and quality through systematic assessment of clinical care. The policy mandates addressing "all systems of care and management practices."
Yet the admission process lacked the systematic approach the policy described.
Infection control violations compounded the facility's systemic problems. Resident 204, diagnosed with shingles, was placed under contact isolation precautions but the required warning signage never appeared at his room entrance.
During a January 9 observation, inspectors found no contact isolation sign posted outside Resident 204's room. A family member was visiting without wearing the required isolation gown, having only put on a surgical mask and gloves.
"I did not see the isolation cart with gowns," Family 1 told inspectors. "I wore a surgical mask and gloves as a precaution, but I was not aware that I had to wear an isolation gown."
The Infection Prevention Nurse acknowledged the oversight. Proper signage was her responsibility, along with the nursing staff, she explained. "The Contact isolation precaution signage was important because it prompts the visitor or whoever was entering the room to ask for assistance and wear the correct personal protective equipment."
The facility's infection control policy, revised in October 2022, explicitly requires posting "clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE." The policy mandates gowns and gloves for anyone entering a contact isolation room.
Resident 204 had physician orders for Valacyclovir to treat his shingles and specific instructions for contact isolation. The antiviral medication was prescribed for seven days at 1000 mg every eight hours.
Another infection control failure involved Resident 3, who had a foley catheter bag touching the floor beside his bed. Licensed Vocational Nurse 2 discovered the violation during an inspection on January 8.
"The Foley bag should never be touching or laying on the floor as the floor is dirty and could contaminate and make Resident 3 sick," LVN 2 explained to inspectors.
The facility's catheter drainage policy, dating to 2007, clearly states drainage bags should be positioned below the resident's bladder level and "kept off the floor." The Director of Nursing confirmed this was facility policy to prevent cross-contamination.
Resident 3 had been readmitted in December 2024 with metabolic encephalopathy and chronic obstructive pulmonary disease. His physician had ordered the urostomy with attached foley bag, with instructions to change the bag every three days or as needed.
Sanitation problems extended beyond medical equipment. Inspectors found an unidentified black back brace hanging in Resident 122's room, though the resident's personal belongings inventory showed no such item.
"The black back brace was not his belongings," Resident 122 told inspectors on January 7.
Certified Nurse Assistant 1 had noticed the brace hanging from a doorknob since her 6:30 AM shift began. She suspected it belonged to night shift staff, as the company had been distributing back braces to support workers during resident transfers.
The Director of Nurses called the situation unsanitary. Staff should never leave personal belongings in resident rooms because "the resident could take it and use it," she explained. "The back brace could have bacteria that could cross contaminate bacteria."
By January 10, the Social Service Director had found the brace but couldn't determine its owner. The DON speculated it belonged either to a previous resident or an employee. If it came from a discharged resident, housekeeping had failed their terminal cleaning responsibilities.
The facility's housekeeping policy requires nursing staff to remove all linens and personal care items during terminal cleaning when residents are discharged.
Safety hazards extended to the smoking area, where a broken door latch allowed cigarette smoke to drift into the facility. The patio door remained propped open during smoke breaks, despite posted signs instructing staff to keep it closed.
Resident 97, whose room sat directly across from the patio entrance, had filed a grievance in November 2024 about constant cigarette odors. "I can smell all day, but it gets especially worst during smoke break," she told inspectors.
The facility had posted a sign specifically for her benefit: "When doing smoke breaks, kindly close the door (For Resident 97's room). Leave it closed until smoke break is over and make sure patio door stays closed."
But the door wouldn't latch properly. Activities Assistant 2, who supervised smoke breaks, told inspectors she had tried closing the door "best she could" but it wouldn't stay shut. She hadn't reported the malfunction to maintenance.
The Maintenance Supervisor confirmed the door couldn't latch during a January 7 inspection. He was unaware of the problem because no one had submitted a repair request. Checking facility doors wasn't part of his regular maintenance rounds, and he had no log for routine inspections.
The broken latch meant the facility couldn't implement its own smoking policy, which promises residents "a smoke free environment." Secondhand smoke exposure can cause lung cancer, stroke, heart disease, and death, the Director of Nursing acknowledged.
The Administrator said he trusted staff to lock facility doors after visiting hours at 8 PM but admitted they had no log to verify doors were functional and secure.
Maintenance fixed the patio door latch on January 8, one day after inspectors discovered the problem. The door could finally close completely and lock from the outside to prevent unauthorized entry.
A fence separating the smoking area from the maintenance parking lot had also been left unlocked, with an open driveway providing public access to the facility grounds. Maintenance installed a padlock after the inspection, with only two staff members holding keys.
Resident 97 remains in her room across from the formerly broken door, still smelling cigarette smoke that the facility's policy promises to eliminate.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WHITTIER HILLS HEALTH CARE CTR in WHITTIER, CA was cited for violations during a health inspection on January 10, 2025.
Resident 301 arrived at the facility in December 2024 with a medical history that included type 2 diabetes, hemiplegia, and Alzheimer's disease.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.