WHITTIER, CA - Federal health inspectors documented serious infection control violations at Whittier Pacific Care Center that put vulnerable residents at risk of dangerous healthcare-associated infections.
Critical Medical Equipment Found on Contaminated Floors
During a January 2025 inspection, surveyors discovered sterile medical equipment lying on floors throughout the 7716 S Pickering Avenue facility. In one alarming incident, inspectors found a resident's suprapubic catheter drainage bag lying on the floor beside the patient's bed.
The catheter system drains urine directly from the bladder through an abdominal surgical opening, making sterile technique essential. When catheter equipment contacts floor surfaces, it introduces bacteria directly into the urinary tract, potentially causing serious infections that can progress to life-threatening sepsis.
"The catheter bag should never be touching or laying on the floor as the floor is dirty and could contaminate and make Resident 62 sick," the facility's own Infection Control Nurse told inspectors.
Feeding Equipment Contamination Threatens Patient Safety
Inspectors also discovered feeding tube equipment on the floor in another resident's room. This equipment connects directly to a gastrostomy tube surgically inserted through the abdomen into the stomach for nutrition delivery.
Floor contamination of feeding equipment poses severe risks including peritonitis (abdominal infection), sepsis, and gastrointestinal infections. These complications can be fatal in elderly, medically fragile nursing home residents.
The facility's Assistant Director of Nursing confirmed that contaminated feeding tubes must be completely replaced due to infection control concerns, acknowledging the serious nature of this violation.
Staff Hygiene Failures Between Patient Care
Perhaps most concerning, inspectors observed a Certified Nursing Assistant providing care to multiple residents without performing hand hygiene between patients. The staff member touched one resident's knee, arranged meal service, then immediately moved to care for another resident without washing hands.
Hand hygiene represents the single most effective intervention for preventing healthcare-associated infections. Proper technique prevents transmission of dangerous pathogens including antibiotic-resistant bacteria that are common in nursing home environments.
The observed CNA admitted to inspectors that she "was supposed to perform hand hygiene before and after providing care to each resident, but she was too busy passing the tray today and she forgot."
Enhanced Barrier Precautions Ignored
Additional violations involved family members of a resident with ALS who required Enhanced Barrier Precautions (EBP) due to his tracheostomy tube and high infection risk. Despite posted warnings and available protective equipment, family members entered the room without required gowns and gloves.
Inspectors observed family members handling contaminated linens without protective equipment, creating risk for spreading multi-drug resistant organisms throughout the facility and potentially to their own homes.
Enhanced Barrier Precautions exist specifically to prevent transmission of dangerous antibiotic-resistant bacteria. These protocols require gowns and gloves during all high-contact activities including bathing, dressing, linen changes, and medical device care.
Medical Consequences of Infection Control Failures
These violations create cascading health risks for nursing home residents who often have compromised immune systems. Healthcare-associated infections in long-term care facilities result in approximately 380,000 deaths annually according to federal data.
Urinary tract infections from contaminated catheter systems frequently progress to urosepsis, a life-threatening condition requiring immediate hospitalization. Gastrointestinal infections from contaminated feeding equipment can cause severe dehydration and nutritional complications in residents who are already medically fragile.
Cross-contamination between residents through inadequate hand hygiene spreads respiratory infections, skin infections, and antibiotic-resistant bacteria that are extremely difficult to treat.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive infection prevention programs with specific protocols for medical device care. Industry standards mandate that catheter drainage bags remain elevated above floor level and that all feeding equipment maintain sterile technique.
The Centers for Disease Control recommends hand hygiene before and after every resident contact, with alcohol-based sanitizers or soap and water. Enhanced Barrier Precautions require strict adherence to protective equipment protocols when caring for high-risk residents.
Professional nursing standards emphasize that infection prevention is a fundamental patient safety measure, not an optional convenience that can be skipped during busy periods.
Quality Assurance System Failures
The inspection also revealed that facility leadership was unaware of ongoing problems with their Restorative Nursing Assistant (RNA) program, discovered only during the federal survey. The Administrator and Director of Nursing stated they had no knowledge of continued issues with RNA services until inspectors identified the problems.
This systemic failure suggests inadequate oversight mechanisms for identifying and correcting quality deficiencies before they impact resident care.
Additional Facility Deficiencies
Inspectors cited the facility for undersized resident rooms, with 11 of 39 bedrooms measuring less than the required 80 square feet per resident. While current residents and staff reported adequate space for care delivery, the rooms technically violate federal space requirements.
The facility also failed to maintain working call light systems in resident rooms. Three residents' call lights were non-functional, preventing them from summoning help when needed. One resident reported repeatedly pressing his call button while hungry, but staff never responded because the system wasn't working.
Facility Response and Oversight
Whittier Pacific Care Center must submit a detailed plan of correction addressing each violation. The facility faces potential enforcement actions if corrections are not implemented effectively.
This inspection follows a previous August 2024 survey that identified insufficient RNA staffing for 19 residents, indicating ongoing quality assurance challenges at the facility.
Federal and state oversight agencies will conduct follow-up inspections to verify that infection control protocols, room occupancy standards, and call light systems meet regulatory requirements before considering the violations corrected.
The complete inspection report and facility response are available through the California Department of Public Health and the federal Nursing Home Compare database.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Whittier Pacific Care Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
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