Average — CMS composite of the measures below.
The next survey window likely opens around November 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 West Covina Healthcare Center during CMS and state inspections, most recent first.
Failure to care plan for a resident’s left shoulder pain. A resident with morbid obesity, chronic pain syndrome, and spinal stenosis reported left shoulder pain after pulling a blanket over the shoulder, later had swelling and severe pain not relieved by meds, and was sent to the ER. RN, LVN, and DON stated care plans must address changes in condition, but the resident’s care plan had no specific issue, goal, or intervention for the shoulder pain.
A resident with cerebral ischemia, type 2 DM, and moderately impaired cognition had a designated responsible party who requested the resident’s medical records through a legal services entity. The facility’s policy required resident access to records within 24 hours of request and photocopies within 48 hours, and staff reported an internal expectation to send records within seven working days. The MRD and DON stated that the chart was difficult to locate because it was stored in boxes, and the MRD had physical limitations, resulting in the records being sent after the required timeframe and violating the resident’s and responsible party’s right to timely access to medical records.
Two residents with cognitive impairments were involved in an unwitnessed physical altercation resulting in alleged facial injuries, but nursing staff did not initiate or document required neurological assessments as outlined in facility policy. Staff interviews and record reviews confirmed that neurological checks were not performed or recorded after the incident, despite clear protocols mandating such assessments following suspected head injuries.
Incomplete and Non-Specific Care Plans for Infection Monitoring: Two residents had care plans that were not specific or fully implemented. One resident with a GT and severe cognitive impairment had a care plan for GT-site infection risk that listed a goal but no specific infection-control interventions. Another resident with a surgical site infection had a care plan requiring monitoring and documentation of signs and symptoms, but the MAR, TAR, and nursing notes showed no documentation of that monitoring. Staff interviews confirmed the care plans lacked specificity and that the required documentation was not completed.
Improper Food Labeling and Expired Food in Refrigerators: Surveyors found expired PBJ sandwiches and flour tortillas in the kitchen refrigerator, along with multiple unlabeled or improperly dated food items in a residents' refrigerator, including chicken, liquids, desserts, tortillas, cheese, and leftover meals. The DS and AS stated food items needed clear dates and resident identifiers, and the IPN stated food in the residents' refrigerator was considered expired after 72 hours and food without a specific use-by or expiration date could not be given to residents.
A resident with a G-tube and CRE had medication administered through the tube, but the LVN returned the syringe to the pole bag without rinsing it as required by the facility’s infection control protocol and the syringe manufacturer’s instructions. In a separate event, a resident on EBP for a G-tube and pressure injury had an EBP sign posted outside the room, but a CNA made the bed without wearing a gown during linen care, despite staff stating gowns and gloves were required for EBP high-contact activities.
Failure to obtain informed consent for psychotropic medication: A resident with COPD, depression, and anxiety was ordered Lexapro for depression, but the resident stated staff never discussed the medication or asked for consent. The ADON confirmed the psychoactive medication consent form was not signed by the resident or the physician, and the facility policy required informed consent before administration.
Advance Directive Not Readily Accessible: A resident with COPD and difficulty walking had intact cognition but required varying levels of assistance with ADLs. Staff could not locate the resident's Advance Directive in the chart or PCC, and the SSD confirmed the copy was not found in the record. The ADON stated the AD should be uploaded in PCC and readily accessible, while the facility policy required executed ADs to be maintained in the medical record and readily retrievable by staff.
Psychotropic Medication Monitoring Not Documented: A resident with COPD, depression, and anxiety was prescribed Lexapro for depression, but the active order record did not identify a specific target behavior for the medication. During record review, the ADON stated that licensed nurses should monitor target behavior each shift to determine whether the medication was effective, and the facility policy required behavioral monitoring and documentation of triggers, episodes, symptoms, and the resident’s response to interventions.
Inaccurate MDS Coding for Surgical Wound: A resident admitted with spinal stenosis and a surgical site infection had an MDS that coded no surgical wound, even though the TAR documented a surgical wound on the mid back. An LPN stated the assessment was inaccurate, and the MDSC confirmed it should have been coded yes for surgical wound. The facility policy required MDS information to match progress notes, plans of care, and resident observations/interviews.
Missing Physician Order for Oxygen Therapy: A resident with COPD was observed receiving continuous oxygen at 2.5 LPM via nasal cannula, but record review showed no physician order for the oxygen therapy. The ADON confirmed the absence of an order, and the facility's Oxygen Administration policy required verification of a physician order before oxygen administration.
Failure to complete antibiotic stewardship screening for a resident receiving Azithromycin for cough with phlegm. The ADON stated the screening evaluation was not completed, the IPN stated the resident did not meet criteria for antibiotics, and RN 1 said the infection screening form was thought to be completed by the Charge Nurse. The facility policy required antibiotics to be used under the stewardship program with key infection and medication information available before contacting the prescriber.
A resident with COPD, depression, anxiety, and GERD had an active order for Linzess for bowel management, but the MAR showed it was given at 9:00 a.m. while the pharmacy consultant noted it should be administered at least 30 minutes before the first meal on an empty stomach. The ADON stated the monthly MRR recommendation was supposed to be carried out by licensed nurses, but there was no clinical documentation showing the recommendation had been acted upon, despite the facility policy requiring MRR recommendations to be addressed and documented by staff and/or the prescriber.
Insufficient square footage was identified in multiple resident rooms, including several 3-bed rooms that did not meet the required space per resident. The ADM requested a room waiver, and surveyors noted residents and staff reported adequate space for care, mobility, and equipment use, but the rooms still fell below the minimum square footage standard.
A facility failed to report an alleged verbal abuse incident between two residents to the appropriate authorities within the required timeframe. A resident reported being called derogatory names by another resident, but the incident was not escalated to the Administrator or other required authorities as per the facility's policy. The Administrator was informed of the incident four days later by the resident's family member, highlighting a lapse in the facility's reporting procedures.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to call for assistance. One resident, with impaired cognition and mobility issues, mistook the bed remote for the call light, while another resident, requiring substantial assistance, could not locate or reach the call light. This was against the facility's policy, which mandates call lights be accessible to residents.
The facility failed to ensure that residents' Advance Directives (AD) were discussed, documented, and included in their medical charts, affecting three residents with varying medical conditions and cognitive abilities. Despite facility policy, ADs were not completed or signed, and there was no evidence of assistance offered to formulate them, as confirmed by staff interviews.
The facility failed to provide daily care for the gastrostomy tube (GT) sites of two residents, as ordered by physicians. One resident's dressing was not changed daily, risking infection, while another's dressing was observed to be unclean and falling off. Staff confirmed the need for daily dressing changes to prevent bacterial growth.
The facility failed to attempt alternatives before installing grab bars for two residents, risking entrapment and injury. One resident with hemiplegia and depression had grab bars installed without documented alternative attempts. Another resident with diabetes and heart failure had grab bars posing an accident hazard, with no record of alternative measures tried. The facility's policy mandates attempting alternatives before bed rail use, which was not followed.
The facility failed to create individualized care plans for two residents, one with dementia and another on high-risk medications. The absence of a care plan for dementia in a resident requiring substantial assistance and the lack of a plan for black box medications in another resident with End Stage Renal Disease and Congestive Heart Failure were noted. This oversight could lead to inconsistent care, as highlighted by the facility's staff and policies.
A facility failed to coordinate care with a hospice provider for a resident with Alzheimer's and CHF by not ensuring scheduled visits by the Hospice RN were documented. Despite the hospice sign-in sheet indicating visits occurred, there was no evidence of visit notes. The DON admitted responsibility for monitoring these visits and ensuring documentation, as per facility policy.
A resident developed and experienced worsening of Stage 2 pressure ulcers due to the facility's failure to adhere to the care plan, which required repositioning every two hours. Despite the care plan's instructions, the resident was frequently observed lying on his back, and CNAs admitted to not repositioning the resident due to being busy with other duties.
A facility failed to adhere to professional standards for a resident receiving IV antibiotics by not labeling the PICC line dressing with the date it was applied. The resident, who had sepsis and hypertension, was observed with an unlabeled dressing, contrary to the facility's policy requiring dressing changes every seven days and proper labeling. This oversight was confirmed by an RN Supervisor, highlighting a lapse in infection control measures.
A resident with Alzheimer's and heart failure was prescribed two liters per minute of oxygen but was observed receiving four liters per minute. An LVN admitted to not checking the flow rate, contrary to the facility's policy, risking respiratory complications.
A facility failed to conduct a post-hemodialysis assessment for a resident with ESRD, as required by their policy. The resident's Dialysis Communication Record was incomplete, lacking documentation of the post-dialysis evaluation. The DON confirmed the necessity of this assessment to ensure the dialysis site was free from bleeding and vital signs were stable, highlighting a lapse in following established care protocols.
A resident with COPD and asthma had a dusty electric fan at their bedside, which had not been cleaned for an unknown period. Interviews with staff indicated that equipment should be kept clean to prevent infection, but the facility failed to adhere to its policy on maintaining a clean environment.
The facility failed to meet the required square footage for 13 rooms, each housing multiple residents. Despite the deficiency, residents could move freely, and staff had adequate space to provide care. The administrator planned to submit a waiver, noting that the rooms accommodated necessary equipment and did not compromise resident safety. Residents did not express concerns about room size.
A resident with heart disease and dementia was observed with cheek discoloration, but the facility failed to document this change, notify the physician, or develop a care plan. Despite staff awareness, the necessary procedures were not followed, risking delayed care.
A resident with limited mobility and unable to self-administer medications had several medications stored at their bedside, contrary to the facility's policies. Interviews confirmed the resident's preference for bedside storage, but the facility's procedures required medications to be stored in locked compartments. This posed a risk of unauthorized access.
Two residents in the facility were unable to reach their call lights, potentially delaying care. One resident, with a fracture and muscle weakness, was found with the call light hanging off the bed, while another resident, with a stroke and epilepsy, reported the call light was often on the floor. Both residents were dependent on staff for assistance, and the facility's policy required call lights to be accessible, which was not followed.
The facility failed to develop and implement a person-centered care plan for a resident using an antipsychotic medication. The resident, who had diagnoses including heart disease, heart failure, and dementia, had physician orders for Seroquel but lacked a care plan to address its use, side effects, and effectiveness. The Assistant Director of Nursing confirmed the oversight, which was against the facility's policy for comprehensive care plans.
The facility failed to follow its policy for antipsychotic medication use by not attempting non-pharmacological interventions or conducting a psychiatric evaluation before prescribing and increasing the dosage of Seroquel for a resident with dementia and hallucinations.
A resident experienced severe adverse reactions and was hospitalized after an LVN administered Narcan nasal spray instead of Flonase. The LVN failed to follow the facility's policy of checking the medication label three times, leading to the error.
A resident experienced severe adverse effects and required hospitalization after an LVN administered the incorrect medication due to not checking the medication label. The LVN had not completed the required medication competency assessments, and the facility failed to adhere to its policies on competent staffing and medication management.
A resident experienced severe adverse reactions after an LVN mistakenly administered Narcan instead of Flonase and failed to document the error in the MAR. The resident, with a history of asthma and chronic pain managed with opioids, was transferred to a hospital for treatment. Interviews revealed the LVN did not verify the medication label and did not document the administration accurately, contrary to facility policy.
Failure to Care Plan for Left Shoulder Pain
Penalty
Summary
The facility failed to develop and implement a care plan for a resident’s left shoulder pain after the resident reported the pain following an incident in which the resident tried to pull a blanket over the shoulder. The resident’s record showed the physician was notified of the left shoulder pain, and later imaging of the left shoulder showed no fracture or dislocation but did show moderate degenerative joint disease. The resident’s diagnoses included morbid obesity, chronic pain syndrome, and spinal stenosis, and the resident was cognitively intact but dependent on staff for several activities of daily living. The resident later reported severe left shoulder pain that was not relieved by pain medications, and the physician ordered transfer to the emergency room at a general acute care hospital. The left shoulder was noted to be swollen, and after the resident returned to the facility by ambulance, the physician was notified and no new orders were given. A venous duplex of the left upper arm showed no blood clot. During interviews, RN 1, LVN 1, and the DON stated that care plans should identify resident-specific problems, goals, and interventions, and should be updated when a resident has a change in condition such as new pain. Review of the resident’s care plan showed there was no care plan specifically addressing the left shoulder pain. The facility policy stated that comprehensive, person-centered care plans with measurable objectives and timetables are to be developed and revised as resident conditions change.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its policy and procedure titled "Release of Information" for one sampled resident, resulting in the resident’s responsible party not receiving timely access to the resident’s medical records. The resident had been re-admitted with diagnoses including cerebral ischemia and type 2 DM, had moderately impaired cognition per the MDS, and was later discharged and subsequently expired. The admission record identified the resident’s daughter as the responsible party. A written request for release of the resident’s medical records was submitted by a legal services entity and was documented as received by the facility. The facility’s policy stated that a resident may have access to records within 24 hours of a written or oral request and may obtain photocopies with at least 48 hours’ advance notice, excluding weekends and holidays. The Medical Records Director acknowledged that the request from the legal services entity was received and that the facility’s policy required records to be sent within seven working days, but stated that the records were not sent within that timeframe. The Medical Records Director reported difficulty retrieving the resident’s records because they were stored in boxes in the back of the facility and the director had physical limitations. The Director of Nursing confirmed that the facility could not easily locate the resident’s chart and that the records were released only after the chart was found. Both the Medical Records Director and the Director of Nursing stated that it was the right of the resident or responsible party to request and receive the resident’s medical records in a timely manner, and that the records could be needed for legal purposes and, if the resident were alive, for continuity of care.
Failure to Initiate Neurological Assessments After Unwitnessed Resident Altercation
Penalty
Summary
The facility failed to initiate neurological assessments for two residents following an unwitnessed resident-to-resident physical altercation involving alleged head injuries. Both residents had cognitive impairments and complex medical histories, including dementia and encephalopathy. After the incident, one resident was observed crying and covering a reddened left eye, while the other was noted to be in emotional distress. Both residents reported being struck in the face with a sandal during the altercation, but no neurological assessments were performed or documented for either individual. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required immediate neurological assessments for any unwitnessed head or facial injury, regardless of visible trauma. The staff acknowledged that neurological checks should have been initiated and documented according to the facility's protocols, which specify frequent monitoring intervals and comprehensive documentation in the medical record. However, record reviews revealed that no such assessments were conducted or recorded for either resident following the incident. The facility's own policies, including the Neurological Assessment and Fall Management Program, outlined the necessity and frequency of neurological checks after suspected head injuries. Despite these clear guidelines, the required assessments were not performed, and the absence of documentation was confirmed through both record review and staff interviews. This failure to follow established procedures constituted a deficiency in the standard of care provided to the residents involved in the altercation.
Incomplete and Non-Specific Care Plans for Infection Monitoring
Penalty
Summary
The facility failed to develop and implement specific, person-centered care plans for two residents. One resident was readmitted with carbapenem-resistant Enterobacterales and gastrostomy tube status, had severe cognitive impairment, limited ability to make self-understood, and was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and transferring. The resident’s care plan for risk for infection at the gastrostomy-tube site, initiated on 12/17/2024, was reviewed and found to include a goal of having no infection at the GT site daily, but it did not identify any specific interventions to address infection control. During interview, LVN 3 stated the care plan did not indicate specific interventions and that it should include patient-centered, specific actions such as monitoring for signs and symptoms of infection, including redness, discharge, and pain. The DON stated care plans should be comprehensive, specific, and patient-centered, and that non-specific care plans could lead to unclear interventions and possible delays in necessary care. The facility policy titled Care Plans, Comprehensive Person-Centered stated the facility should develop and implement a comprehensive, person-centered care plan for each resident. The second resident was admitted with spinal stenosis and infection on the surgical site, had clear speech, intact cognitive skills for daily decision making, and required assistance with oral hygiene, personal hygiene, toilet hygiene, showering, and transferring. The resident’s care plan for surgical site infection, initiated on 9/4/2025, included a goal of resolving the surgical site infection and an intervention for the charge nurse to document signs and symptoms of surgical site infection for four days. However, review of the MAR, TAR, and nursing progress notes from 9/4/2025 through 9/8/2025 showed no documentation of monitoring signs and symptoms of the surgical site. TN 1 stated the licensed nurse should have documented on the MAR, TAR, and nursing progress notes, and that the lack of documentation delayed necessary care and increased the risk of infection.
Improper Food Labeling and Expired Food in Refrigerators
Penalty
Summary
The facility failed to follow proper food storage and handling practices by leaving expired or improperly labeled food items in the kitchen refrigerator and the residents' refrigerator. During observation with the Dietary Supervisor, five individually packaged peanut butter and jelly half sandwiches in a white plastic container were found in the kitchen refrigerator with a use-by date of 12/1/2025, and a pack of flour tortillas was also observed with dates indicating they were expired. The Dietary Supervisor stated expired foods should be checked and thrown away and should not be mixed with non-expired foods because they could be given to residents by accident and cause stomach problems. In the residents' refrigerator in the Activity Room, multiple food items were observed that were either expired or lacked clear labeling. These included a jumbo oven roasted chicken, a container with yellow liquid, a foil-covered container labeled Activity, a brown paper bag with multiple food items, three ice cream bars in a plastic bag, a fast-food meal container, a bag of corn tortillas, and a bag of grated Parmesan cheese. Several items had only one date or no use-by or expiration date, and some did not identify whether the date reflected when the item was opened or when it expired. The Dietary Supervisor stated residents' food should be labeled with the resident's name, room number, date received or opened, and a use-by or expiration date. The Activity Staff stated food items in the residents' refrigerator needed to be checked for expiration dates and that items with only one date could not be verified as expired or not. The Infection Prevention Nurse stated food in the residents' refrigerator was considered expired after 72 hours and had to be discarded, and that food without a specific use-by or expiration date was considered expired and could not be given to residents. Facility policies reviewed by surveyors stated that refrigerated foods must be labeled, dated, and monitored, and that residents' food and food brought by family or visitors must be labeled with the resident's name, item, and use-by date.
Failure to Follow G-tube Syringe Cleaning and EBP Requirements
Penalty
Summary
Infection prevention and control measures were not implemented for a resident with a G-tube and CRE. The resident’s record showed diagnoses including respiratory failure and gastrostomy status, and the resident had severe cognitive impairment and was dependent on staff for multiple activities of daily living. During a medication administration observation, an LVN administered medication through the G-tube and then placed the syringe back into the pole bag without rinsing it off. The LVN stated she did not need to do anything to the syringe after flushing water to the G-tube. The infection prevention nurse stated the syringe should be rinsed with running water before being returned to the pole bag because of the infection control protocol, and the DON stated it was standard nursing care to rinse the syringe after each use to remove residue. The resident’s care plan identified risk for infection at the G-tube site and directed staff to maintain the G-tube. The facility’s policy required reusable equipment to be cleaned according to the manufacturer’s instructions. The manufacturer’s instructions for the enteral feeding syringe stated staff should rinse the syringe thoroughly with tap water immediately after each use until the original content had been cleared, including the inside surface of the barrel, stopper, nozzle lumen, and outside, and then dry it before placing it into the pole bag. In a separate deficiency, Enhanced Barrier Precautions were not followed for another resident with a G-tube and a stage 2 coccyx pressure injury. The resident’s record showed severe cognitive impairment and dependence on staff for eating, hygiene, toileting, bathing, dressing, and personal hygiene. The resident’s orders and care plan required EBP related to the G-tube and pressure injury, with gowns and gloves to be used during high-contact care activities, including changing linens. During observation, an EBP sign was posted outside the resident’s room, but a CNA was observed making the bed without wearing a gown. The CNA stated that if a resident is on EBP, staff should wear gown, gloves, and mask when coming into contact with the resident, linens, or belongings. Other staff stated gowns and gloves were required for EBP, while the infection prevention nurse stated EBP is a precaution for close contact care and that staff must wear gown and gloves when touching the resident or items in the resident’s area.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain written informed consent for the use of a psychotropic medication for one sampled resident. Resident 4 was admitted and later readmitted with diagnoses including COPD, depression, and anxiety. The resident’s MDS dated 1/21/2025 indicated intact cognition for daily decision making, dependence on staff for toileting, showering, lower body dressing, and footwear, and maximum assistance for upper body dressing and personal hygiene. A physician’s order dated 12/1/2025 directed staff to administer Lexapro 10 mg by mouth daily for depression manifested by verbalization of sadness. During interview, Resident 4 stated nursing staff had not discussed Lexapro with him or asked him to consent to taking it. In a concurrent interview and record review, the ADON confirmed that the Informed Consent Psychoactive Medication form for Lexapro was not signed by Resident 4 or the physician. The ADON stated licensed nurses should have verified the medication upon admission with the ordering physician and ensured consent was obtained, and that the risks and benefits of psychotropic medications should have been discussed with Resident 4 upon admission.
Advance Directive Not Readily Accessible
Penalty
Summary
The facility failed to ensure the Advance Directive for one of two sampled residents was readily accessible in accordance with its Advance Directives policy. The resident was admitted with diagnoses including COPD and difficulty walking, and the MDS dated 11/26/2025 indicated intact cognition for daily decision making, with dependence on staff for showering, lower body dressing, and footwear, and maximum assistance needed for oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. During the 12/2/2025 interview and record review, RN 1 stated there was no Advance Directive in the resident's chart or in PCC and could not find an existing copy. The SSD also stated the facility had requested a copy but was unable to find it in the chart. The ADON stated the resident's Advance Directive should be uploaded in PCC and readily accessible by staff, and the facility's policy stated that copies of executed Advance Directives are to be obtained, maintained in the medical record, and readily retrievable by any facility staff.
Psychotropic Medication Monitoring Not Documented
Penalty
Summary
The facility failed to ensure Resident 4’s target behavior was monitored for the use of Lexapro, an antidepressant, as required by the facility’s Psychotropic Medication Use policy. Resident 4 was admitted and later readmitted with diagnoses including COPD, depression, and anxiety. The Minimum Data Set dated 1/21/2025 indicated the resident had intact cognition for daily decision making and required varying levels of assistance from staff for toileting, showering, dressing, and personal hygiene. A physician’s order dated 12/1/2025 directed staff to administer Lexapro 10 mg by mouth daily for depression manifested by verbalization of sadness. During a concurrent interview and record review on 12/3/2025, the ADON reviewed the resident’s active orders in PCC and found that the Order Summary Report did not identify a specific target behavior for Lexapro. The ADON stated that licensed nurses should monitor the target behavior every shift to determine whether the medication was effective. The facility’s Psychotherapeutic Medication Use policy stated that staff should monitor residents’ behavior using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication and should document behavioral triggers, episodes, symptoms, and the resident’s response to staff interventions.
Inaccurate MDS Coding for Surgical Wound
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a surgical wound for one sampled resident. Resident 99 was admitted with diagnoses including spinal stenosis and an infection at the surgical site. The resident’s MDS, dated 9/8/2025, indicated clear speech, the ability to understand and make self-understood, intact cognitive skills for daily decision making, partial assistance with oral hygiene and personal hygiene, substantial assistance with toileting hygiene, showering, and transferring, and no surgical wounds. A concurrent review of the resident’s TAR for 9/4-9/8/2025 showed a surgical wound on the mid back, and TN 1 stated this was not acceptable because the MDS was inaccurate and could delay necessary care. The MDS Coordinator reviewed the assessment and stated it should have been coded Yes for surgical wound, confirming the MDS was not accurate. The facility’s policy stated that all persons completing any portion of the MDS must sign attesting to the accuracy of the information and that MDS information must consistently reflect progress notes, plans of care, and resident observations/interviews.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one sampled resident. Resident 4 was admitted with diagnoses including COPD, depression, anxiety, and GERD without esophagitis. The MDS dated 1/21/2025 indicated the resident had intact cognition for daily decision making and required varying levels of staff assistance with toileting, showering, dressing, and personal hygiene. During an observation and interview on 12/2/2025 at 9:36 a.m., Resident 4 was lying in bed receiving oxygen at 2.5 liters per minute via nasal cannula, and the IPN stated the resident was receiving continuous oxygen at that rate. During a later interview and record review on 12/3/2025 at 9:33 a.m., the ADON reviewed the resident's PCC records and stated there was no physician's order for the oxygen therapy, and that there should be a doctor's order for oxygen administration. The facility's Oxygen Administration policy, revised 2/2024, stated to verify that there is a physician's order for the procedure and to review the physician's orders or facility protocol for oxygen administration.
Failure to Complete Antibiotic Stewardship Screening
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol for one sampled resident who was receiving Azithromycin for cough with phlegm. The resident’s record showed an admission history that included COPD and depressive disorder, and the MDS dated 11/4/2025 indicated intact cognition for daily decision making and moderate assistance needed for toileting, showering, lower body dressing, and putting on/off footwear. The active order summary showed Azithromycin 250 mg by mouth once daily for four days, with an order date of 12/2/2025. During a concurrent interview and record review, the ADON stated the antibiotic screening evaluation had not been completed for the resident and that antibiotic stewardship should have been completed prior to administering antibiotics to determine whether the criteria for use were met. The IPN stated the resident did not meet the criteria to receive antibiotics and that the physician should have been notified whether to continue the antibiotic. RN 1 stated the infection screening form was thought to be completed by the Charge Nurse and also stated the resident did not meet the criteria for antibiotic therapy. The facility’s Antibiotic Stewardship policy stated antibiotics were to be prescribed and administered under the guidance of the stewardship program and that the nurse calling the physician/prescriber should have information available including signs and symptoms, when symptoms were first observed, hydration status, current medications, allergy information, infection type, warfarin/INR information, creatinine clearance or serum creatinine if available, and time of the last antibiotic dose.
Failure to Act on Pharmacy Consultant MRR Recommendation
Penalty
Summary
The facility failed to ensure that a medication regimen review irregularity identified by the Pharmacy Consultant was acted upon for one resident. The resident was admitted with diagnoses including COPD, depression, anxiety, and GERD without esophagitis. The resident's MDS dated 1/21/2025 indicated intact cognition for daily decision making and dependence on staff for toileting, showering, lower body dressing, and putting on/off footwear, with maximum assistance needed for upper body dressing and personal hygiene. The resident had an active order for Linzess 145 mcg by mouth once daily for bowel management, and the MAR showed the medication was administered at 9:00 a.m. on 12/1/2025, 12/2/2025, and 12/3/2025. The Consultant Pharmacist's Medication Regimen Review dated 10/28/2025 noted that Linzess should be given at least 30 minutes before the first meal of the day on an empty stomach. During interview, the ADON stated the monthly MRR recommendation was supposed to be carried out by licensed nurses and that there was no other clinical documentation showing the recommendation had been acted upon. The facility's policy stated that MRR recommendations are to be acted upon and documented by facility staff and/or the prescriber.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident in multiple resident rooms, specifically Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39. During the survey, the Administrator stated the facility wanted to request a room waiver for those rooms and confirmed that nothing had been changed in the number of bed occupancies in the 13 rooms. A review of the facility’s room waiver request letter stated there was ample room for wheelchairs and other medical equipment, space for mobility and movement of ambulatory residents, adequate space for nursing care, and that the health and safety of residents in those rooms were not in jeopardy. The Client Accommodations Analysis form showed the listed rooms had approximately 225.50 to 234.89 square feet with 3 beds in each room. During the Health Recertification Survey, surveyors observed that the rooms had adequate space, nursing care, comfort, and privacy, and residents were able to move freely with wheelchairs, walkers, and a Hoyer lift. Residents interviewed in affected rooms stated they had enough space and no problems with room size, and staff stated they were able to provide care and move equipment inside the rooms without issues. Despite these observations, the deficiency remained that the rooms did not meet the required square footage per resident.
Failure to Report Alleged Verbal Abuse in a Timely Manner
Penalty
Summary
The facility failed to adhere to its policy and procedure for abuse investigation and reporting by not reporting an alleged verbal abuse incident involving two residents to the appropriate authorities within the required timeframe. Resident 1, who has the capacity to understand and make decisions, reported that Resident 2 called them derogatory names in Spanish at the doorway of their room. This incident was reported by a Certified Nurse Assistant (CNA) to a Licensed Vocational Nurse (LVN), but it was not escalated to the Administrator (ADM) or other required authorities as per the facility's policy. The ADM was only made aware of the incident four days later by Resident 1's family member. Interviews with staff, including a Registered Nurse (RN) and the Assistant Director of Nursing (ADON), confirmed that the incident should have been reported immediately to the ADM, the Ombudsman, the California Department of Public Health (CDPH), and local law enforcement. The failure to report the incident promptly had the potential to subject Resident 1 to further abuse and compromised the safety of the residents, as the facility did not implement necessary interventions to prevent recurrence.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were within reach and appropriate to their physical abilities. Resident 29, who was admitted with peripheral vascular disease and osteoarthritis, had moderately impaired cognition and required assistance with various activities. During an observation, it was noted that Resident 29 was unable to reach the call light, mistaking the bed remote control for it. The call light was placed on the upper part of the bed, out of reach, contrary to the care plan that required it to be within reach for safety. Similarly, Resident 80, who had hypertension and lack of coordination, required substantial assistance for toilet hygiene and transfers. During an observation, Resident 80 was unable to locate or reach the call light, which was coiled on the wall behind the bed. This placement prevented the resident from calling for help, as confirmed by a treatment nurse. The facility's policy required call lights to be within reach, but this was not adhered to, potentially delaying necessary care for the residents.
Failure to Document and Discuss Advance Directives
Penalty
Summary
The facility failed to ensure that the residents' Advance Directives (AD) were discussed, documented, and included in their medical charts, as per the facility's policy. This deficiency was identified for three residents, each with varying medical conditions and cognitive abilities. Resident 12, who had intact cognition and required assistance with daily activities, did not have an AD documented, and there was no evidence that assistance was offered or declined to formulate one. The admission coordinator confirmed that an AD should be completed upon each admission to determine the resident's preferences for end-of-life care. Resident 54, diagnosed with diabetes mellitus and dementia, was found to have severely impaired cognition and was dependent on assistance for most activities. Despite this, the resident's AD acknowledgment form was not signed by the conservator since admission, indicating a lack of compliance with the facility's policy that requires the AD to be filled out and signed with each admission. The Director of Nursing reiterated the importance of having an AD completed to guide the care and treatment preferences of the resident. Resident 78, who had impaired cognition and was dependent on assistance for daily activities, also lacked documentation of an AD. The Social Service Director stated that the facility relied on the POLST form to identify if a resident had an AD, but there was no documentation for Resident 78. The facility's policy requires the social services director to inquire about the existence of any written advance directives during the initial assessment, which was not adhered to in this case.
Failure to Provide Daily GT Site Care
Penalty
Summary
The facility failed to provide necessary care and services for the gastrostomy tube (GT) sites of two residents, as ordered by the physician and indicated in their care plans. Resident 45, who was admitted with diagnoses including dementia and required a feeding tube for nutrition, had a physician's order for daily cleansing and dressing of the GT site. However, the Treatment Administration Record (TAR) showed that the dressing was only changed on two specific dates, and an observation revealed that the dressing was not changed daily as required. The Infection Preventionist Nurse confirmed that the dressing should be changed daily to prevent infection. Similarly, Resident 54, who had diagnoses including diabetes mellitus and dementia, also had a physician's order for daily cleansing and dressing of the GT site. The TAR indicated that the dressing was changed on two specific dates, but an observation showed that the dressing was not clean and was falling off. The Certified Nurse Assistants and the Treatment Nurse confirmed that the dressing should be changed daily, including weekends, to prevent bacterial growth. The Director of Nursing also stated that the GT site should be checked daily for signs of infection and the dressing changed as ordered.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives to grab bars before their installation for two residents, placing them at risk for entrapment and injury. Resident 35, who was admitted with conditions including hemiplegia, hemiparesis, and depression, was observed with grab bars on both sides of the bed without documented evidence of alternative measures being attempted. The Director of Nursing (DON) confirmed that no less restrictive alternatives were tried before the installation of the grab bars, which is against the facility's policy. Similarly, Resident 14, who was readmitted with diabetes mellitus and heart failure, was found with grab bars on the bed frame, which he did not use and was unaware of their purpose. The DON acknowledged that the grab bars posed an accident hazard and that the resident's medical record lacked documentation of attempts to use alternatives before the grab bars were applied. The facility's policy requires that alternatives be attempted and evaluated before the use of bed rails, which was not adhered to in these cases.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop specific and individualized person-centered care plans for two residents, leading to potential inconsistencies in care. Resident 45, who was admitted with dementia, anxiety, and depression, did not have a care plan addressing dementia despite having severely impaired cognition and requiring substantial assistance with daily activities. The Registered Nurse Supervisor acknowledged the absence of a care plan for dementia and emphasized the need for one to monitor the effectiveness of interventions. The Director of Nursing confirmed that care plans should be developed upon admission and updated as needed. Similarly, Resident 55, diagnosed with End Stage Renal Disease and Congestive Heart Failure, was prescribed high-risk medications with black box warnings, including Furosemide and Tylenol with Codeine #3. However, the care plan did not address these medications, which are crucial for monitoring potential side effects and ensuring proper interventions. The Registered Nurse Supervisor and the Director of Staff Development both highlighted the necessity of care plans for such medications to guide staff in providing appropriate care. The facility's policy on comprehensive person-centered care plans, revised in March 2023, mandates the development of care plans within seven days of the MDS assessment and no more than 21 days after admission. These care plans should include measurable objectives and timetables to meet residents' needs and reflect recognized standards of practice. The lack of care plans for Residents 45 and 55 indicates a failure to adhere to these policies, potentially impacting the residents' well-being.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate care with a hospice provider for a resident, identified as Resident 34, by not ensuring that the Hospice Registered Nurse (HRN) visited the resident on three scheduled dates. This deficiency was identified through observation, interview, and record review. Resident 34 was readmitted to the facility with diagnoses including Alzheimer's disease and congestive heart failure (CHF), and had an order for hospice care due to CHF. Despite the hospice sign-in sheet indicating that the HRN visited on the scheduled dates, there was no documented evidence of visit notes for these dates. The Director of Nursing (DON) acknowledged the lack of documentation and stated that it was their responsibility to monitor and audit the scheduled visits of hospice staff to ensure that visit notes were completed. The facility's policy and procedures designated the DON to coordinate care provided by hospice staff to residents. The absence of documented visit notes meant that the assessed care needs of Resident 34 were not recorded, and collaboration with facility staff regarding hospice services was not documented.
Failure to Reposition Resident Leads to Worsening Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care to prevent and manage pressure ulcers for a resident, identified as Resident 14. Upon readmission to the facility, Resident 14 did not have any pressure ulcers. However, a subsequent assessment revealed the development of Stage 2 pressure ulcers on the left buttock, which initially healed but later reopened, along with a new ulcer on the right buttock. The care plan for Resident 14 specified the need for repositioning every two hours to alleviate pressure on the ulcers, a critical step in promoting healing and preventing further deterioration. Observations and interviews conducted over several days revealed that Resident 14 was consistently found lying on his back, contrary to the care plan's instructions. Certified Nursing Assistants (CNAs) acknowledged the failure to reposition the resident as required, citing workload and time constraints as reasons for the oversight. This lack of adherence to the care plan resulted in the worsening of the pressure ulcers, as evidenced by the increase in size and redness of the wounds upon subsequent examination.
Failure to Label PICC Line Dressing
Penalty
Summary
The facility failed to provide care and service for a resident receiving parenteral antibiotics consistent with professional standards of practice. The deficiency was identified when the PICC line dressing for a resident was observed without a label indicating the date it was applied. This oversight was noted during an observation in the resident's room, where the resident was sitting in a wheelchair with a PICC line at the right upper arm covered by dressing gauze. The absence of a date label on the dressing was confirmed during an interview with the Registered Nurse Supervisor, who acknowledged that the dressing should be changed and labeled with the date to ensure timely dressing changes and infection control. The resident involved had been admitted with diagnoses including sepsis and hypertension and was receiving daily intravenous Cefazolin Sodium due to sepsis. The facility's policy required that the PICC line dressing be changed every seven days or as needed when soiled, and that the dressing be labeled with the date, time, and nurse's initials. The failure to label the dressing as per the facility's policy and procedure had the potential to result in infection and worsen the resident's health condition.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide necessary care and services for a resident on oxygen therapy by not adhering to the physician's order. The resident, who was readmitted with diagnoses including Alzheimer's disease and heart failure, was prescribed two liters per minute of oxygen through a nasal cannula continuously for shortness of breath. However, observations revealed that the resident was receiving four liters per minute of oxygen, which was not in accordance with the physician's order. Licensed Vocational Nurse 4 admitted to forgetting to check the oxygen flow rate during rounds, resulting in the resident receiving excessive oxygen. This oversight was contrary to the facility's policy and procedure for oxygen administration, which mandates that oxygen therapy be administered as ordered by the physician. The failure to follow the prescribed oxygen flow rate placed the resident at risk for respiratory complications due to potential oxygen toxicity.
Failure to Perform Post-Dialysis Assessment
Penalty
Summary
The facility failed to perform a post-hemodialysis assessment for a resident, identified as Resident 186, who required dialysis care. Resident 186 was admitted with diagnoses including End Stage Renal Disease (ESRD) and hypotension, necessitating regular hemodialysis treatments. A review of the resident's Dialysis Communication Record (DCR) dated 9/30/2024 revealed that the post-dialysis assessment section was left blank, indicating that the necessary evaluation was not conducted upon the resident's return to the facility. During an interview, the Director of Nursing (DON) confirmed that the DCR should be completed immediately after the resident's return to ensure the dialysis access site was free from bleeding and that the resident's vital signs were stable. The facility's policy on the care of residents with ESRD emphasized the importance of staff being trained to perform assessments before and after dialysis sessions. The lack of documentation and assessment posed a potential risk for complications related to the hemodialysis site for Resident 186.
Failure to Maintain Cleanliness of Resident's Electric Fan
Penalty
Summary
The facility failed to maintain an electric fan in a safe and sanitary condition for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and asthma. The resident, who required substantial assistance with daily activities, had a dusty electric fan at their bedside. During an observation and interview, the resident confirmed the fan blades were dusty and could not recall the last time it was cleaned. Interviews with housekeeping staff and the maintenance supervisor revealed that equipment inside residents' rooms should be kept clean to prevent infection and maintain a comfortable environment. The facility's policy on maintaining a homelike environment emphasized the importance of a clean, sanitary, and orderly setting. However, the dusty fan in the resident's room indicated a lapse in adhering to these standards.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 out of 38 rooms met the required square footage of 80 square feet per resident in multiple resident rooms. During an observation, it was noted that Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39 did not meet this requirement. Despite this, residents were able to ambulate freely and nursing staff had sufficient space to provide care with dignity and privacy. The rooms contained necessary furniture and medical equipment, and there was space for mobility and movement of ambulatory residents. The facility's administrator acknowledged the deficiency and indicated that a room waiver would be submitted for these rooms. The waiver request stated that there was ample room for wheelchairs and other medical equipment, and that the health and safety of residents were not compromised. The waiver detailed that the rooms were in accordance with the special needs of the residents and did not adversely affect their health and safety. However, the square footage for these 3-bed rooms was below the minimum requirement of 240 square feet, with each room ranging from 225.50 to 234.89 square feet. Residents interviewed did not express concerns about the size of their rooms.
Failure to Document and Address Change in Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not assessing, monitoring, and documenting a change in the resident's condition, specifically a discoloration on the left cheek. The resident, who was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia, was observed with purple discoloration on the cheek. Despite this observation, there was no documentation of a change of condition report or a care plan addressing the discoloration. A Certified Nursing Assistant reported the discoloration to an LVN, who acknowledged the report but did not document it or notify the physician. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that the change of condition should have been reported and documented promptly. The facility's policies and procedures require notifying the physician of changes in a resident's condition and developing care plans based on comprehensive assessments. The failure to adhere to these procedures resulted in the resident's condition not being monitored, which could potentially delay necessary care and services.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for one resident, as per the facility's policies and procedures. The resident, who was admitted with diagnoses of hypothyroidism, essential hypertension, and type 2 diabetes mellitus, required substantial assistance with daily activities and was unable to self-administer medications. Despite this, several medications, including Laxaclear, Senokot, vitamin C tablets, and MiraFIBER gummies, were found at the resident's bedside during an observation. Interviews with the Infection Preventionist Nurse and the Administrator confirmed that the resident preferred having medications at the bedside, but was unable to self-administer them due to limited mobility. The facility's policies indicated that medications not authorized for self-administration should be returned to the nurse in charge, and all medications should be stored in locked compartments. The presence of medications at the resident's bedside posed a risk of access by other residents or unauthorized persons.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential delay in care. Resident 2, who was admitted with a fracture of the right femur, muscle weakness, and dysphagia, was observed lying in bed unable to reach the call light, which was hanging off the bed. The resident expressed hunger and was dependent on staff for various activities, including toileting hygiene and personal hygiene. A Licensed Vocational Nurse (LVN) adjusted the call light to be within reach, acknowledging that Resident 2 usually used the call light for assistance. Similarly, Resident 3, admitted with cerebral infarction, epilepsy, and dysphagia, reported that the call light was often not within reach, sometimes found on the floor. This resident was dependent on staff for toileting hygiene and showering. During an interview, Resident 3 stated that they had to shout for assistance when the call light was unreachable. The facility's policy indicated that call lights should be accessible to residents from their bed, toilet, shower, or floor, but this was not adhered to in these instances.
Failure to Implement Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for the use of an antipsychotic medication for one of the residents. The resident was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia. The resident's Minimum Data Set indicated that the resident was understood by others and had the ability to understand others, and also had hallucinations. The resident had physician orders for Seroquel, an antipsychotic medication, but there was no care plan in place to address the use of this medication, including how to provide care, monitor side effects, and assess the medication's effectiveness. During an interview, the Assistant Director of Nursing confirmed that the resident should have had a care plan for the use of the antipsychotic medication. The facility's policy and procedure for comprehensive, person-centered care plans, which was revised in March 2022, indicated that such care plans should include measurable objectives and timeframes to meet the resident's needs. However, this was not implemented for the resident in question, leading to the deficiency noted in the report.
Failure to Follow Antipsychotic Medication Policy
Penalty
Summary
The facility failed to follow its policy and procedure for antipsychotic medication use for one resident. Specifically, the facility did not attempt non-pharmacological interventions before starting the resident on Seroquel, an antipsychotic medication. Additionally, the facility did not conduct a psychiatric evaluation before initiating or increasing the dosage of Seroquel. The resident was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia, and exhibited behaviors such as hallucinations. Despite these symptoms, there was no documentation of non-pharmacological interventions or a psychiatric evaluation before the medication was prescribed and increased. The Assistant Director of Nursing confirmed that a psychiatric evaluation should have been conducted and that non-pharmacological interventions should have been documented. The facility's policy required the attending physician and staff to gather and document information about the resident's behavior, mood, function, and medical condition, and to attempt non-pharmacological interventions unless contraindicated. However, these steps were not followed, leading to the potential use of unnecessary medication for the resident.
Failure to Ensure Resident was Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, a Licensed Vocational Nurse (LVN) administered Narcan nasal spray instead of Flonase nasal spray to a resident. This error occurred because the LVN did not check the medication label three times as required by the facility's policy and procedure for administering medications. The resident experienced severe adverse reactions, including chest pain, a burning sensation, and feelings of impending death, and was subsequently transferred to a hospital for treatment of acute opioid withdrawal induced by the accidental Narcan administration. The resident had a history of asthma, allergic rhinitis, and chronic pain managed with Percocet and occasionally Morphine. The resident's physician had prescribed Flonase for nasal congestion and Narcan for emergency use in case of opioid overdose. On the day of the incident, the LVN retrieved a box labeled with the resident's name but did not verify the medication inside. Despite the resident's protest that the medication did not look familiar, the LVN insisted it was correct and administered it. Immediately after administration, the resident experienced severe symptoms and was transferred to the hospital. Interviews with the LVN, the Pharmacist Consultant, and the Director of Nursing revealed that the LVN did not follow the five rights of medication administration, which include verifying the right medication, dose, time, route, and patient. The facility's policy and procedure for administering medications also emphasized the importance of checking the medication label three times to prevent errors. The LVN admitted to not following these protocols, which led to the medication error and the resident's subsequent adverse reaction.
Medication Error Due to Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that all nursing staff had the appropriate skills and competencies necessary to provide nursing care safely, resulting in a medication error that caused significant harm to a resident. Licensed Vocational Nurse (LVN) 1 administered the incorrect medication to a resident, leading to the resident experiencing severe adverse effects and requiring hospitalization. The error occurred because LVN 1 did not check the medication label before administration, mistakenly giving Narcan instead of the prescribed Flonase nasal spray. The resident, who had intact cognition and required supervision for various activities, was admitted with diagnoses including asthma, allergic rhinitis, and phantom limb syndrome with pain. The resident had a physician's order for Flonase nasal spray and Narcan nasal liquid for opioid overdose. On the day of the incident, LVN 1 administered Narcan instead of Flonase, causing the resident to experience chest pain, a burning sensation, and a feeling of impending death. The resident was subsequently transferred to a general acute care hospital for treatment of acute opioid withdrawal induced by the accidental Narcan administration. Interviews and record reviews revealed that LVN 1 did not follow the facility's policy and procedure for medication administration, which includes checking the medication label and ensuring the five rights of medication administration. Additionally, LVN 1 had not completed the required medication competency assessments before administering medications independently. The Director of Staffing Development and the Director of Nursing confirmed that the facility did not adhere to its policies on competent staffing and medication management, which contributed to the medication error and subsequent harm to the resident.
Failure to Document Medication Administration Accurately
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for a resident by not ensuring that an LVN documented the administration of Narcan nasal liquid instead of fluticasone furoate suspension. The incident occurred when the LVN administered Narcan to the resident, who immediately experienced severe adverse reactions, including chest pain, a burning sensation, and acute withdrawal symptoms. The resident was subsequently transferred to an emergency department for treatment, where it was confirmed that Narcan had been administered instead of the prescribed Flonase nasal spray. The resident, who had a history of asthma, allergic rhinitis, and chronic pain managed with opioids, was admitted to the facility with specific medication orders, including Flonase for nasal congestion and Narcan for opioid overdose. On the day of the incident, the LVN mistakenly administered Narcan, believing it to be Flonase, and failed to document this administration in the Medication Administration Record (MAR). The resident's immediate adverse reactions led to an emergency transfer to a hospital, where the error was identified and treated. Interviews with the resident, the LVN, and the Director of Nursing (DON) revealed that the LVN did not verify the medication label before administration and did not document the error in the MAR. The facility's policy required accurate documentation of all administered medications to ensure safety and communication among the care team. The failure to document the administration of Narcan accurately could lead to further medication errors and adverse effects, as noted by the DON.
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 6,080 citations issued within 25 miles in the last 12 months — including the 22 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 West Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victoria Care Center | 0.5 mi | ★★★★★ | 13 | 0 |
| West Covina Medical Center D/p Snf | 0.6 mi | ★★★★★ | 15 | 0 |
| Garden View Post Acute Rehabilitation | 0.6 mi | ★★★★★ | 20 | 0 |
| West Haven Healthcare | 0.6 mi | ★★★★★ | 17 | 0 |
| Clara Baldwin Stocker Home For Women | 1.2 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for West Covina Healthcare Center.
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.