Federal inspectors found the facility violated reporting requirements in three separate cases involving verbal abuse and missing money.
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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.
Instead, the medication wasn't given until 7:15 PM on January 9, well past the resident's preferred bedtime of 7:00 PM.
At 6:59:40 p.m., the evening receptionist abandoned her post to help a wheelchair-bound resident toward the back of the facility.
But a review of his medical records revealed no behavioral concerns or hallucinations until after the falls occurred.
Federal inspectors found the facility's Quality Assurance and Performance Improvement committee ineffective during a March complaint investigation.