Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Emanate Health Inter-community Hospital- D/p Snf during CMS and state inspections, most recent first.
A resident with a history of joint replacement, colon cancer, heart disease, and hypertension, who was dependent on staff for toileting and used an external catheter, was observed with a urine collection bag that was only partially covered. Staff confirmed the bag should have been fully covered to protect the resident's privacy and dignity, as required by facility policy.
A resident with multiple medical conditions was found in bed with all four side rails raised, despite a physician order and facility policy limiting use to three rails. Staff confirmed this was not in accordance with the resident's care plan and acknowledged the potential for the resident to feel trapped.
A resident with significant mobility and cognitive impairments did not receive required pressure ulcer prevention measures, including proper heel offloading and regular turning, as documented by staff observations and records. Additionally, the facility did not initiate or document appropriate treatment for the resident's moisture-associated skin damage, failing to follow its own protocols for assessment and intervention.
A resident was admitted from the ICU with a urinary catheter in place, but the facility did not obtain a physician order or reassess the medical necessity for the device for two days. Nursing documentation confirmed the catheter remained in use without an order, and the DON acknowledged the oversight. Facility policy required daily assessment and prompt removal or provider contact if no order was present, but these steps were not followed.
A resident with a pressure ulcer was placed on Enhanced Barrier Precautions (EBP), but the family was not informed about the precautions or the need for PPE during high-contact care. A family member was observed providing care without gown or gloves and reported not receiving any education about EBP from staff. The DON confirmed that facility protocol required family notification and education, but this was not done in this case.
The facility failed to develop and implement individualized care plans for four residents, leading to deficiencies in addressing their specific medical needs, including scrotal edema, nutritional deficits, and diabetes management.
The facility failed to accurately monitor and document a resident's fluid intake and output and daily weight, despite having fluid restrictions and a history of kidney disease and heart failure. This lack of documentation and monitoring was confirmed through interviews and record reviews, revealing gaps in the resident's medical records.
A facility failed to monitor a resident's weight and implement a calorie count as per policy, leading to incomplete and inaccurate documentation of the resident's caloric intake. The resident, with a history of chronic illnesses, had physician orders for daily weight measurements and a calorie count due to poor oral intake, but these were not consistently recorded, impacting the resident's nutritional assessment and care plan.
A resident with Guillain Barre Syndrome and anxiety disorder was prescribed Prozac for depression, but the facility failed to document monitoring for side effects or adverse effects. Interviews confirmed that licensed nurses were responsible for this monitoring, but it was not done, potentially impacting the resident's well-being.
The facility failed to meet food safety requirements when a bag of leftover food in the patient nourishment refrigerator was not labeled with a date or patient's name, and trays of fresh eggs in the dairy and poultry refrigerator were not labeled to indicate if they were pasteurized. The DON and DFS confirmed these deficiencies, which had the potential to result in food-borne illnesses.
The MD failed to attend three consecutive QAA Committee meetings, as required by the facility's QAPI Program. The DON confirmed the MD's absence and emphasized the importance of the MD's role in providing oversight and input on quality improvement initiatives.
The facility failed to follow infection prevention and control practices for two residents with peripheral IV catheters. Both residents had undated and unlabeled IV sites, contrary to the facility's policy requiring IV sites to be changed every 96 hours. The issue was confirmed by the RN and DON during observations and interviews.
Urine Collection Bag Not Fully Covered, Compromising Resident Dignity
Penalty
Summary
A deficiency was identified when a resident's urine collection bag was not fully covered while the resident was in their room. During an observation, the urine collection bag was seen hanging on the left side of the resident's bed with only the top portion covered, leaving the bottom half exposed. Both a Certified Nursing Assistant and a Resource Nurse confirmed that the bag should be fully covered to maintain the resident's privacy and dignity, in accordance with facility policy. The resident involved had a history of joint replacement, colon cancer, heart disease, and hypertension, and was dependent on staff for toileting and bathing. The resident was cognitively intact and used an external catheter for urine collection. Facility policy requires that care be provided in a manner that maintains or enhances each resident's dignity and respect, which was not followed in this instance.
Improper Use of Four Bed Side Rails
Penalty
Summary
A deficiency was identified when a resident was observed in bed with all four side rails raised, contrary to the facility's policy and the resident's physician order, which allowed for a maximum of three side rails. The resident, who had a history of respiratory failure with hypoxia and congestive heart failure, required maximal assistance for activities of daily living but had intact cognition. During the observation, a CNA confirmed that only three side rails should have been raised and acknowledged that having all four up could make the resident feel trapped. Further review of the resident's records, including the Admission Record, History and Physical, Minimum Data Set, physician's orders, and the Side Rails Assessment, consistently indicated that no more than three side rails were to be used. The facility's policy also specified a three-rail maximum except under specific circumstances, which did not apply in this case. Staff interviews corroborated that the use of all four side rails was not appropriate and could be considered a restraint.
Failure to Implement Pressure Ulcer and MASD Prevention Protocols
Penalty
Summary
The facility failed to implement appropriate pressure ulcer and moisture-associated skin damage (MASD) prevention and treatment interventions for a resident identified as high risk for pressure injuries. The resident, who had multiple diagnoses including cerebrovascular accident with hemiparesis and seizures, was dependent on staff for mobility and personal care. Physician orders and facility protocols required that the resident's heels be floated off the mattress using pillows under the calves, and that the resident be turned every one to two hours to prevent pressure injuries. However, observations on multiple occasions revealed that the resident's heels were in contact with the mattress, and staff interviews confirmed that the correct technique for floating heels was not consistently followed. Documentation and observation also showed that the resident was not consistently turned every two hours as required. Review of the turning protocol indicated multiple instances where the resident remained in the same supine position for extended periods, contrary to the physician's order and facility policy. Staff interviews confirmed the importance of regular turning for high-risk residents and acknowledged that the resident was not repositioned as frequently as required. Additionally, the facility failed to initiate and document appropriate treatment for the resident's MASD. The resident developed MASD in the groin and buttocks areas, but there was no evidence that the facility's MASD protocol was implemented when the condition was first identified. Observations and staff interviews revealed that moisture barrier cream was not applied to all affected areas, and required documentation, including photographs and initiation of the MASD protocol in the electronic medical record, was not completed in a timely manner. The facility's policy required documentation and specific interventions for skin impairments, which were not followed in this case.
Failure to Obtain Timely Physician Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to reassess the continued need for an indwelling urinary catheter and did not obtain a physician's order for its use for one resident upon admission from the intensive care unit. The resident, who had a history of pneumonia, acute respiratory failure with hypoxemia, and acute kidney injury, was admitted to the facility with a urinary catheter in place. The discharge summary from the hospital did not indicate a need to continue the catheter, and there was no physician order for the device upon admission. Documentation in the resident's care assessments and nursing notes confirmed that the urinary catheter remained in use for two days following admission without a physician order specifying the medical necessity for the device. Nursing staff documented the presence and management of the catheter, but no order was present until two days after admission. The Director of Nursing confirmed that the catheter was used without a physician order and acknowledged that staff should have clarified the need for the device or removed it if there was no indication to continue its use. The facility's policy required daily assessment of the need for an indwelling catheter, prompt removal if criteria were not met or if there was no provider order, and provider contact if there was uncertainty. These procedures were not followed, resulting in the resident having an indwelling urinary catheter for two days without documented medical necessity or a physician order.
Failure to Inform Family and Enforce Enhanced Barrier Precautions
Penalty
Summary
The facility failed to uphold its infection prevention and control program for one resident by not informing the resident's family that the resident was on Enhanced Barrier Precautions (EBP). The resident, who had multiple diagnoses including diabetes with neuropathy, aortic stenosis, and a urinary tract infection, was admitted with a stage two pressure ulcer and was placed on EBP due to the wound. The care plan indicated the use of EBP, and signage was posted outside the resident's room to indicate these precautions. Despite these measures, a family member was observed at the resident's bedside, leaning over and making direct contact with the resident's linens and clothing without wearing a gown or gloves. The family member reported that no facility staff had explained EBP, its purpose, or the need for personal protective equipment (PPE) during high-contact care activities. The family member stated that both she and her sister had been visiting and assisting with the resident's care since admission, but neither had been informed about the EBP requirements. The Director of Nursing confirmed that the facility's protocol required notifying family representatives about EBP at admission or when implemented, and that staff were expected to provide CDC educational materials and ensure compliance with PPE use during high-contact activities. The facility's policy also specified that residents and their families should be notified about EBP and provided with relevant information. However, in this case, the family was not informed, and staff did not ensure that EBP protocols were followed during family visits.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for four residents, leading to deficiencies in addressing their specific medical needs. Resident 76, who was admitted with a broken hip and had a history of kidney disease, hypertension, and congestive heart failure, did not have a care plan addressing his scrotal edema and fluid restrictions. Despite physician orders and progress notes indicating the need for close monitoring and specific interventions, the care plan was not updated to reflect these needs, and a urology consult was not included or followed up on time. Resident 16, admitted with acute kidney failure and a history of chronic myeloid leukemia, iron deficiency anemia, diabetes, and end-stage renal disease, did not have a care plan addressing his nutritional deficits. Although there were physician orders for daily weight measurements and a dietitian consult due to poor oral intake, the care plan did not reflect these interventions, leaving the resident's nutritional needs unaddressed. Resident 74, admitted with uncontrolled diabetes mellitus and diabetic ketoacidosis, and Resident 77, admitted with Guillain Barre Syndrome and type 2 diabetes, also lacked care plans addressing their diabetes management. Despite physician orders for blood sugar checks, insulin administration, and dietary consultations, the care plans for both residents did not include these critical interventions. The Director of Nursing confirmed that care plans must be individualized and updated to guide staff in providing consistent care, which was not done in these cases.
Failure to Accurately Monitor Fluid Balance and Document Intake and Output
Penalty
Summary
The facility failed to accurately assess and monitor the fluid volume balance for Resident 76, who had fluid restrictions ordered by the physician. The facility did not accurately document Resident 76's intake and output (I&O) and daily weight in accordance with the facility's policies and procedures. This failure was identified through interviews and record reviews, which revealed inconsistencies and missing documentation in Resident 76's medical records, including undocumented oral intake and missing daily weights over several days. Resident 76 was admitted with a left comminuted intertrochanteric fracture and had a history of acute kidney injury superimposed on chronic kidney disease, hypertension, and congestive heart failure. The resident had fluid restrictions and required close monitoring of fluid intake and output, as well as daily weights, to manage their condition. However, the facility's records showed gaps in documentation, with no evidence of oral intake assessments and missing daily weights for multiple days. Interviews with the nursing staff and the Director of Nursing confirmed the lack of accurate documentation and monitoring. The facility's policies and procedures required meticulous recording of all fluid intake and output, as well as daily weights for residents with conditions like CHF and CKD. The failure to adhere to these policies potentially compromised the resident's physical and psychosocial well-being, as accurate monitoring is crucial for managing fluid balance in such medical conditions.
Failure to Monitor Weight and Implement Calorie Count
Penalty
Summary
The facility failed to consistently monitor a resident's weight and implement a calorie count in accordance with its policies and procedures for a resident admitted with acute kidney failure. The resident, who had a history of chronic myeloid leukemia, iron deficiency anemia, diabetes, and end-stage renal disease on hemodialysis, had physician orders for daily weight measurements and a calorie count due to poor oral intake. However, weights were not recorded on several specified dates, and the calorie count was incomplete and inaccurately documented, as confirmed by interviews with the registered nurse and dietitian involved in the resident's care. The registered dietitian noted that the calorie count was important for developing the resident's plan of care and ensuring the resident met their caloric needs. The dietitian also highlighted that the calorie count for specific meals was not accurately recorded because the menus were not saved in the calorie count envelope, and meal intakes were not included in the calorie count. This led to an inaccurate assessment of the resident's caloric intake, which was crucial for determining whether the resident required additional nutritional interventions such as tube feedings. The Director of Nursing acknowledged that the resident had lost weight due to poor appetite and that the calorie count was ordered to assess the resident's caloric intake. The DON admitted that there was no designated licensed nurse to review daily weights to identify significant weight changes and that the dietitian was responsible for monitoring weight trends. The facility's policies and procedures for weights and calorie counts were reviewed, revealing that weights must be taken per physician's order and recorded in the electronic medical record, and that calorie counts must be initiated within 24 hours of a physician's order and documented accurately.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring of fluoxetine (Prozac) for a resident diagnosed with Guillain Barre Syndrome and anxiety disorder. The resident was admitted with a history of progressive weakness and had completed intravenous immunoglobulin therapy. The resident was prescribed Prozac for depression, but there was no documented evidence of monitoring for medication side effects or adverse effects after multiple administrations of the drug. Interviews with the pharmacist and registered nurse confirmed that licensed nurses were responsible for monitoring and documenting any behavior episodes and adverse effects of psychotropic medications, but this was not done for the resident in question. The Director of Nursing stated that it was essential for the administering RN to monitor and document any adverse drug effects and target behaviors to determine the drug's efficacy. The facility's policy and procedure on psychotherapeutic drug management required informed consent, black box warnings, behavior monitoring, and care plan documentation, none of which were adequately followed in this case. This failure had the potential to cause a decline in the resident's physical and/or psychosocial well-being due to possible unidentified adverse effects.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety requirements in the kitchen when a bag of leftover food was observed in the patient nourishment refrigerator without a date or label indicating a 3-day expiration date and the patient's name. The Director of Nursing (DON) confirmed that the refrigerator was for resident use only and that leftover food needed to be labeled with a resident's name and dated to ensure it was not given to the wrong resident. The facility's policy indicated that patient food brought into the facility needed to be covered, dated, and labeled with a 3-day expiration date and a patient's name. The failure to label the food properly had the potential to result in residents experiencing food-borne illnesses. Additionally, trays of fresh eggs were observed in the dairy and poultry refrigerator without labels indicating if the eggs were pasteurized. The Executive Chef (EC) and the Director of Food Services (DFS) confirmed that the eggs were not pasteurized and were used in the cafeteria grill for staff and visitors. The facility's policy indicated that fresh shell eggs that are not pasteurized should only be used for hard-cooked, fried, or hard-poached eggs and must be cooked to a minimum internal temperature of 145°F for 15 seconds. The DFS stated that the facility would start ordering pasteurized eggs only since the facility's vendor offered fresh eggs that were pasteurized.
MD's Absence from QAA Committee Meetings
Penalty
Summary
The Medical Director (MD) failed to attend the quarterly Quality Assessment and Assurance (QAA) Committee meetings for three consecutive sessions, as required by the facility's Policy and Procedure (P&P) titled, Quality Assurance & Performance Improvement (QAPI) Program. This was confirmed during an interview and record review with the Director of Nursing (DON), who verified that the MD did not attend the meetings on 9/18/2023, 12/18/2023, and 3/21/2023. The facility's attendance logs and the QAA Committee documentation indicated that the MD was a key member of the committee and was expected to provide oversight and input on QAPI and Performance Improvement Projects (PIP). The DON acknowledged the importance of the MD's attendance for effective communication with providers and input on quality improvement initiatives.
Failure to Follow Infection Control Practices for IV Sites
Penalty
Summary
The facility failed to follow infection prevention and control practices for two residents with peripheral intravenous (IV) catheters. Resident 19's IV site was observed to be undated and unlabeled, and the Registered Nurse (RN) acknowledged that the IV site needed to be removed for infection control. The facility's policy required peripheral IV sites to be changed every 96 hours. Resident 19 had been admitted with multiple diagnoses, including chronic pain and opioid dependence, and had active orders for IV medications. The failure to date and label the IV site was confirmed during an observation and interview with the RN and the Director of Nursing (DON), who reiterated the facility's policy on IV site management. Similarly, Resident 77's IV site was also observed to be undated and unlabeled, with the tape coming off on one side. The resident stated that the IV site had been inserted about two weeks prior to admission. The RN confirmed that peripheral IV sites needed to be changed every three days and that the admitting nurse should have removed and reinserted the IV if it was not labeled. The DON confirmed the facility's policy of changing IV sites every 96 hours to prevent infection. The facility's policy and procedure on IV Therapy Peripheral: Access and Care required all peripheral IV sites to be changed every 96 hours unless veins were difficult to access and maintain.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,202 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Covina Rehabilitation Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Harvard Creek Post Acute | 0.6 mi | ★★★★★ | 22 | 0 |
| The Rowland | 1 mi | ★★★★★ | 5 | 0 |
| Glendora Grand, Inc | 1.2 mi | ★★★★★ | 3 | 0 |
| Citrus Heights Health Center | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Emanate Health Inter-community Hospital- D/p Snf.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.