The incident occurred on July 31, 2024, at Glendora Grand nursing home during a federal inspection.
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The resident had just undergone leg surgery and was diagnosed with acute osteomyelitis at the hospital.
"The LPN was not acting within the LPN's scope of practice," Chief Nursing Officer confirmed to inspectors on February 5.
On January 13, 16, and 19, only three nursing aides worked the entire facility's overnight shift instead of the planned four, inspection records show.
Federal inspectors found the facility violated reporting requirements in three separate cases involving verbal abuse and missing money.
Licensed Vocational Nurse 1 gave Resident 56 expired Ozempic injections throughout January and early February.
She stared blankly for about a minute, responding only to painful stimuli before becoming more alert.
Neither incident was properly reported to the Department of Public Health, police, or the state ombudsman.
The drug treats rapid emotional fluctuations from calmness to anger.
The facility's own service line checklist showed the same dish left the kitchen at 174 degrees — a temperature drop of more than 50 degrees.
Resident 198 had been admitted to Whittier Pacific Care Center on January 16 with spinal stenosis and coordination problems.
Extended spectrum beta-lactamase produces enzymes that make infections resistant to many antibiotics.