Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Covina Medical Center D/p Snf during CMS and state inspections, most recent first.
LVNs did not complete required narrative charting for a resident with chronic respiratory failure, Alzheimer's, COPD, tracheostomy, and gastrostomy on two shifts, resulting in missing and inaccurate medical records. Staff confirmed the absence of documentation, which was required by facility policy to ensure accurate assessment and care.
Failure to Revise Care Plans for Weight Loss and Pneumonia: The facility did not revise care plans for three residents when their conditions changed. One resident with chronic respiratory failure, COPD, and heart failure had a significant weight loss that was not reflected in the WL care plan. Another resident with gastrostomy, dysphagia, and quadriplegia developed pneumonia and received an ABX order, but the pneumonia care plan was not updated. A third resident with gastrostomy and tracheostomy had weight loss over two months, but the weight loss care plan was not revised. Staff stated the care plans needed to be updated to determine whether interventions were effective.
A resident’s refrigerator contained multiple food items that were not labeled with the resident’s name, room number, or expiration date, and expired items were mixed with non-expired items. Surveyors found pastries, yogurts, Ensure drinks, gelatin cups, and a soda bottle stored without proper labeling, while an LVN, DON, and IPN each confirmed that visitor-provided food should be labeled and expired food discarded. The resident had significant medical needs, including a pureed diet, thin liquids, and 1:1 feeding assistance with aspiration precautions.
A resident with tracheostomy care needs, UTI history, and quadriplegia was observed awake in bed when an RN pulled up the resident’s gown and checked the foley catheter tubing attachment without asking permission. The resident objected, and the RN later acknowledged that permission and an explanation should have been provided. The DON stated staff must introduce themselves, explain procedures before touching the resident, and ask consent to protect privacy and respect, consistent with the facility’s dignity policy.
Failure to complete a change-of-condition assessment after significant weight loss. A resident with chronic respiratory failure, COPD, and HF had severe cognitive impairment and was dependent for ADLs, yet the record showed no SBAR or comprehensive MDS assessment after a 24-lb. weight loss and an additional 11-lb. loss. Staff stated an SBAR should be completed for every change of condition, and the facility policy called for thorough assessment and evaluation of condition changes.
MDS Discharge Destination Coded Incorrectly: A resident with dependence on a ventilator, supplemental O2, and a gastrostomy was transferred to an acute hospital after a fever was not relieved by Tylenol and cooling measures, but the MDS coded the discharge destination as SNF instead of acute hospital. The MDSC and DON stated the assessment needed to be coded accurately for CMS reporting.
Failure to report Foley catheter change of condition: A resident with severe cognitive impairment, ADL dependence, and an indwelling Foley had white cloudiness/sediment observed in the catheter tubing. An LPN identified the finding as possible urine sediment and a sign of infection, but did not notify the MD, despite the facility’s policy requiring assessment and physician notification for changes in condition.
Failure to Carry Out RD Weekly Weight Recommendation: A resident with a gastrostomy, tracheostomy, anemia, and severely impaired cognition had a care plan for weight loss that included weekly weights. The RD documented a recommendation for weekly weights to monitor changes, but staff found no clinical documentation that the weights were completed and the primary MD was not notified. The RD noted the resident had lost 13 lbs in two months, and the DON confirmed the recommendation was not followed or communicated.
GT Medication Administration Without Required Flushes: An LVN administered a resident's morning meds via GT without flushing with water before or after each medication and did not flush after the meds were completed. The resident was NPO, receiving enteral feeding, and had severely impaired cognition. The LVN stated uncertainty about fluid restriction and believed flushing between meds was too much water, while the DON and facility P&P required water flushes before, after, and between GT medications.
A resident with chronic respiratory failure, sepsis due to streptococcus pneumonia, major depressive disorder, and paraplegia had a pharmacist MRR note asking the physician to specify the behavior to be monitored for routine Xanax use and to document it on the MAR. The OSR listed Xanax for anxiety, but the facility did not act on the pharmacist’s recommendation for months, and the DON stated the resident’s meds should be verified for a specific indication and monitored every shift to determine whether Xanax was effective.
An LVN left a MedCart unlocked and unattended in the hallway while going into a resident's room to administer medications. The LVN stated the cart should have been locked, and both another LVN and the DON confirmed that medication carts must be locked when outside the nurse's view. The resident involved had chronic respiratory failure and sepsis due to staphylococcus, and was severely cognitively impaired and dependent for multiple ADLs.
Failure to use required PPE for a resident on EBP: a resident with a trach and GT, severe cognitive impairment, and dependence for ADLs was observed during GT site care while an RN touched the bed and bedding without wearing a gown. The IPN stated staff needed gown, gloves, and mask before contact, and facility policy required gown and gloves for high-contact care for residents with indwelling devices such as trach and feeding tubes.
The facility failed to ensure call lights were within reach for two residents with chronic respiratory failure and ventilator dependence. Both residents required assistance with ADLs, and their care plans specified that call lights should be accessible. Observations revealed call lights were hanging on the wall, out of reach, which was confirmed by staff. The ADON acknowledged the need for call lights to be placed near the residents' strong extremities, as per facility policy.
The facility failed to provide Advance Directive (AD) information for three residents, violating its policy. A resident with severe cognitive impairment and another dependent on a ventilator lacked AD documentation, and a third resident with chronic respiratory failure also had no AD in their records. This failure to adhere to policy could lead to treatment against residents' wishes.
The facility failed to provide necessary care for the gastrostomy tube sites of two residents, leading to potential complications. One resident's GT site was found with a dislodged dressing and was dirty, while another's site lacked a dressing and was unclean. Both residents had orders for specific GT care that were not followed, as confirmed by staff interviews.
The facility failed to provide proper respiratory care for two residents. One resident's oxygen cannula was not connected to the tracheostomy T-bar as ordered, and another resident did not receive tracheostomy care with hydrogen peroxide as prescribed. These oversights were contrary to the facility's policies and placed the residents at risk for health complications.
The facility failed to follow proper food storage and labeling practices, leading to potential cross-contamination risks. Thawed meat was stored above uncovered bread, and several food items lacked labels and dates. Interviews confirmed these practices violated facility policies, posing a risk of foodborne illnesses.
A resident with a bladder disorder and UTI had their catheter bag left uncovered, contrary to the facility's policy requiring a dignity bag for privacy. The resident expressed a preference for the privacy bag, and the ADON acknowledged the need for it to maintain dignity.
A facility failed to notify the State LTC Ombudsman of a resident's emergency transfer to a hospital. The resident, with a tracheostomy and pneumonia, was transferred due to fluctuating oxygen saturation. The facility's policy required notification, but no Notice of Proposed Transfer/Discharge Form was completed, and the Ombudsman was not informed.
A resident with chronic respiratory failure and a gastrostomy had a Stage 2 pressure ulcer that was not treated according to the physician's order. The order required cleaning with normal saline, applying betadine, and covering with Tegaderm, but a foam dressing was used instead. This deviation from the prescribed treatment could hinder wound healing and increase infection risk.
A facility failed to provide RNA services as ordered for a resident with chronic respiratory failure and ventilator dependence. The resident's care plan required PROM exercises and the application of hand rolls and an elbow splint. However, the RNA did not apply these devices and incorrectly documented that they were provided. This was confirmed by the ADON, highlighting a failure to adhere to the facility's policy on accurate treatment documentation.
A facility failed to label and date an IV catheter for a resident with chronic respiratory failure and a gastrostomy, increasing the risk of infection. The resident's IV site was observed without a label, contrary to the facility's policy requiring labeling for infection control. The ADON acknowledged the oversight, which could worsen the resident's health condition.
A facility failed to act on a pharmacist's recommendation for a resident's medication regimen review. The resident, with chronic respiratory failure and a gastrostomy, was prescribed Enoxaparin for DVT prevention. The MRR suggested consulting the physician for the term of therapy, but this was not documented. The ADON admitted to missing the MRR and not contacting the physician, contrary to facility policy.
A resident on contact isolation for Candida auris was exposed to potential infection spread when the ADON entered the room without properly wearing an isolation gown, allowing their coat to touch the resident's clothes. The facility's P&P required proper PPE use to prevent contamination, which was not followed.
A facility failed to maintain an electric fan in a safe and sanitary condition for a resident with chronic respiratory failure and ventilator dependence. The fan was unstable, dusty, and broken, posing a risk to the resident's health. The ADON noted that housekeeping should clean equipment daily, and maintenance should repair broken items, as per facility policy.
Failure to Document Resident Assessments Per Shift
Penalty
Summary
Licensed Vocational Nurses (LVNs) failed to accurately document daily narrative charting during each shift for a resident with complex medical needs, specifically on two dates. The facility's policy and procedure required documentation during each shift, including patient assessment and the status of medical devices such as IV lines, tracheostomy, and gastrostomy tubes. However, record review and staff interviews confirmed that narrative charting was missing for both the night and day shifts on the specified dates. Staff, including LVNs and the Charge Nurse, acknowledged the absence of required documentation and emphasized the importance of maintaining accurate records for resident care. The resident involved had a medical history of chronic respiratory failure, Alzheimer's disease, COPD, and had both a tracheostomy and gastrostomy in place. During observation, the resident was found awake, resting, and appeared confused, with fluctuating capacity to understand. The lack of documentation resulted in the resident's medical record containing inaccurate information regarding patient assessment, which had the potential to affect the provision of care. The deficiency was identified through interviews, record review, and observation, confirming non-compliance with the facility's documentation policy.
Failure to Revise Care Plans for Weight Loss and Pneumonia
Penalty
Summary
The facility failed to revise care plans for three residents when their conditions changed. The facility’s policy stated care plans were to be reviewed quarterly and revised as needed, but the care plans for Residents 4, 15, and 22 were not updated after significant changes in condition were documented in the records and discussed with staff. Resident 4 was admitted with chronic respiratory failure, COPD, and heart failure, and had severely impaired cognition and dependence for ADLs. Weekly weights showed a decline from 229 lbs. to 205 lbs. and then to 194 lbs., and the resident’s weight loss care plan was initiated after a 24-lb. loss. The care plan was not revised after the additional 11-lb. loss was documented. An LVN stated the care plan had not been updated after the later weight loss and that licensed staff were supposed to update the care plan to determine whether care was effective and whether the MD or RD needed to be informed. Resident 15 had diagnoses including gastrostomy, dysphagia, and quadriplegia, with intact cognition but dependence on staff for multiple ADLs. A radiology report showed bilateral multifocal pneumonia with a right-sided effusion, and an antibiotic order for pneumonia was entered the next day. The pneumonia care plan that had been initiated earlier was not revised to reflect the new pneumonia episode. Resident 22 had diagnoses including gastrostomy and tracheostomy, severely impaired cognition, and dependence on staff for multiple ADLs. Monthly weights showed 188 lbs. in one month and 181 lbs. in the next, but the weight loss care plan was not revised to reflect those losses. The DON stated care plans should have been revised when there was a change of condition such as recurrent pneumonia or weight loss.
Unlabeled and Expired Food Kept in Resident Refrigerator
Penalty
Summary
The facility failed to follow its food storage handling practices for food kept in one resident’s refrigerator inside the supply room at the nurse’s station. During observation, surveyors found one box of pastries without the resident’s name, room number, or expiration date, two blueberry yogurts without the resident’s name or room number, six Ensure drinks without the resident’s name or room number, five assorted flavored gelatin cups in a white plastic bag dated 12/08/2025 with the resident’s name, and one soda bottle dated 10/29 for the same resident. The facility staff did not label the food items with the resident’s name and current date, and expired food items were not removed from the refrigerator. During interview, an LVN stated food placed in a resident’s refrigerator should include the resident’s name and the date received and expire date, and that expired food should be thrown away because it could make residents sick. The DON stated family and friends could bring food for residents, but it needed the resident’s name, date received, and expiration date, and expired food should be removed from the refrigerator. The IPN stated food brought by family should be labeled with the resident’s room number and expiration date, and that food without an expiration date was not safe to give to a resident. Resident 1’s record showed diagnoses including chronic respiratory failure, sepsis due to streptococcus pneumonia, major depressive disorder, and paraplegia, and the resident required a pureed diet, thin liquids, and 1:1 feeding assistance with aspiration precautions.
Failure to Ask Permission Before Providing Care
Penalty
Summary
The facility failed to promote one sampled resident’s right to dignity, privacy, and self-determination when staff did not ask permission before providing care. Resident 15 was admitted with diagnoses including encounter for attention to tracheostomy, history of UTI, and quadriplegia. The resident’s MDS dated 9/12/2025 indicated intact cognition for daily decision making and dependence on staff for eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, and personal hygiene. During an observation on 12/16/2025 at 9:20 AM, RN 1 was in Resident 15’s room while the resident was awake and lying in bed. RN 1 pulled up the resident’s gown, checked the foley catheter tubing attachment, and did not ask permission before doing so. Resident 15 stated, “Oh, wait wait, you did not ask permission. No!” RN 1 later stated that permission should have been asked and the procedure explained, and that the resident had the right to refuse care and treatment. The DON stated staff needed to introduce themselves, explain the procedure before touching the resident, and ask consent to provide privacy and respect. The facility’s P&P titled Promoting/Maintaining Resident Dignity/Quality of Life stated to explain care or procedures to the resident before initiating the activity.
Failure to Complete Change-of-Condition Assessment After Significant Weight Loss
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days after a significant change in condition for one resident. The resident was admitted with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, and heart failure. The resident's H&P indicated the resident lacked capacity to make medical decisions, and the MDS showed severely impaired cognition and dependence for ADLs. The resident had weekly weight orders due to weight loss, and the record showed weights of 229 lbs. on 10/23/25, 205 lbs. on 11/4/25, and 194 lbs. on 12/8/25. During a concurrent interview and record review, there was no SBAR completed, and the LVN stated there should be an SBAR for every change of condition. The record also did not contain a change of condition comprehensive assessment MDS for the resident's 24-lb. weight loss and additional 11-lb. weight loss. The facility policy stated that changes in a resident's condition must be thoroughly assessed and evaluated, and that SBAR may be used to assess and evaluate the change of condition.
MDS Discharge Destination Coded Incorrectly
Penalty
Summary
The facility failed to ensure that one sampled resident’s discharge destination was coded accurately in the MDS. Resident 28 was admitted with diagnoses including dependence on a respiratory ventilator, dependence on supplemental oxygen, and encounter for attention to gastrostomy. On 11/13/2025, the physician ordered staff to call 911 because the resident’s fever was not relieved by Tylenol and cooling measures, and the progress note at 6:09 a.m. documented that the resident was transferred to an acute hospital at 6:20 a.m. The resident’s MDS, however, coded the discharge destination as a nursing home/SNF. During interview and record review, the MDS Coordinator stated the resident was discharged to an acute care hospital and not to a SNF, and that the MDS needed to be coded as discharged to an acute hospital. The DON also stated the MDS assessment needed to be coded accurately to ensure the facility was not sending wrong information to CMS.
Failure to Report Foley Catheter Change of Condition
Penalty
Summary
The facility failed to report a change of condition for signs of a possible urinary tract infection in a resident with an indwelling Foley catheter. The resident was admitted with diagnoses including chronic respiratory failure, COPD, and heart failure, and the record showed the resident lacked capacity to make medical decisions, had severely impaired cognition, was dependent for ADLs, and had a Foley catheter. The order summary directed staff to monitor the catheter for hematuria, sediments, foul-smelling urine, and urine color. During observation, white cloudiness was seen in the tubing of the resident’s Foley catheter, and the licensed nurse identified it as possible urine sediment and stated it could be a sign of infection. The nurse stated the tubing should be flushed or changed and the physician notified, but also stated the finding had not been reported to the MD. The infection preventionist stated nursing staff should have reported the cloudiness, and the nurse later stated the physician was not notified because other tasks were being completed. The facility policy required changes in condition to be thoroughly assessed and evaluated with physician notification, and SBAR could be used for that process.
Failure to Carry Out RD Weekly Weight Recommendation
Penalty
Summary
The facility failed to ensure the RD's recommendation for Resident 22 to start weekly weights was carried out and communicated to the physician. Resident 22 was admitted with diagnoses including encounter for attention to gastrostomy, encounter for attention to tracheostomy, and anemia. The MDS dated 9/25/2025 indicated severely impaired cognition for daily decision making and dependence on staff for eating, oral hygiene, toileting, showering/bathing, dressing, and personal hygiene. The care plan for weight loss, revised on 2/11/2025, identified Resident 22 as at risk for weight loss secondary to a chronic medical condition and directed nursing staff to monitor weight as ordered, obtain RD consults to adjust diet as needed, and weigh the resident every week as ordered. The Monthly Nutritional Review dated 11/5/2025 documented a recommendation to weigh Resident 22 weekly to monitor changes, but during interview the LVN stated there was no clinical documentation that weekly weights were done and the primary physician was not notified of the recommendation. The RD stated Resident 22 had lost 13 lbs in two months and that the weekly weight recommendation for November 2025 was not carried out or communicated to the primary physician. The DON also stated the recommendation was not followed and the physician was not notified. The facility policy stated that the RDN's recommendations for changes in the nutrition plan of care would be communicated to the licensed nursing team and dining services director via the summary recommendation sheet.
GT Medication Administration Without Required Water Flushes
Penalty
Summary
Failure to provide pharmaceutical services to meet the needs of each resident occurred when one LVN did not flush Resident 23's GT with water before and after administering medications. Resident 23 was admitted with chronic respiratory failure, dysphagia, and attention to a GT, and the MDS indicated severely impaired cognition and dependence on staff for multiple activities of daily living. The OSR showed the resident was NPO and receiving enteral feeding, with an order allowing licensed staff to give an additional 30 ml of water during medication pass. During medication administration observation, the LVN gave the morning medications through the GT without flushing the tube with water before or after each medication and did not flush the GT after all medications were given. The LVN stated not knowing whether the resident was on fluid restriction and thought giving water between medications was too much. The DON stated medications given through the GT were to be flushed with water before and after each individual medication, and the facility P&P titled Medication Administration (Nasogastric, Gastric and Jejunostomy) indicated to flush the tube with approximately 30 ml of water before and after medication administration and to flush in between medication administration with 5 ml to 10 ml of water.
Failure to Act on Pharmacist Recommendation for Xanax Monitoring
Penalty
Summary
The facility failed to act on the consultant pharmacist’s Medication Regimen Review recommendation for one resident regarding routine Xanax use. The resident was admitted and readmitted with diagnoses including chronic respiratory failure, sepsis due to streptococcus pneumonia, major depressive disorder, and paraplegia. The MDS dated 9/16/2025 indicated the resident had intact cognitive skills and was dependent for eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Record review showed the OSR dated 10/10/2025 listed Xanax 0.25 mg by mouth at bedtime for anxiety, while the MRR for October and November 2025 included the pharmacist’s note asking the physician to specify the behavior manifestation to be monitored for the resident’s routine Xanax 0.5 mg q HS for anxiety and to monitor the behavior every shift on the MAR and add it to the Xanax order. During interview, the DON stated the resident’s medications should be verified by the doctor for a specific indication to monitor behaviors, that licensed staff should monitor the resident every shift to determine whether Xanax was effective, and that the pharmacist’s recommendation should have been acknowledged and communicated to the physician. The DON stated it should not take three months to act on the recommendation.
Unlocked Medication Cart During Medication Pass
Penalty
Summary
LVN 5 failed to keep a medication cart secured while administering medications to Resident 3. During a medication pass observation in the hallway outside Resident 3's room, LVN 5 left the MedCart unlocked and unattended while going inside the resident's room to give medications. During an interview shortly afterward, LVN 5 stated the MedCart should have been locked and not left unlocked for safety. Resident 3's record showed the resident was originally admitted and later re-admitted to the facility with diagnoses including chronic respiratory failure and sepsis due to staphylococcus. The resident's MDS dated 10/13/2025 indicated severely impaired cognitive skills and dependence for eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. Interviews with another LVN and the DON confirmed that medication carts must be locked when the nurse walks away or when the cart is outside the nurse's view, and the facility policy stated that medication rooms, carts, and medication supplies are locked or attended by authorized persons.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow infection prevention procedures for one sampled resident who was on Enhanced Barrier Precautions. The resident was admitted with diagnoses including attention to gastrostomy and attention to tracheostomy, and the order summary directed staff to place the resident on EBP because of the tracheostomy. The resident’s MDS indicated severely impaired cognition and dependence on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The care plan identified the resident as having a tracheostomy and gastrostomy and directed nursing staff to observe infection prevention and control at all times, including frequent handwashing and proper PPE as necessary. During an observation, the resident was awake and lying in bed while an RN assessed the GT site. The RN touched the resident’s bed and bedding while providing care but did not wear a gown, and stated that a protective gown was not worn during the assessment. The Infection Preventionist stated staff needed to wear gown, gloves, and mask before touching the resident because the resident was on EBP, and the facility policy required gown and gloves for high-contact care activities for residents with wounds or indwelling medical devices, including tracheostomy and feeding tubes.
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 123, who had chronic respiratory failure and was dependent on a ventilator, was found to have a call light hanging on the wall, out of reach. This resident had severely impaired cognition and was dependent on assistance for activities of daily living (ADLs), as indicated in their care plan, which specified that the call light should be within reach at all times. During an observation, a Certified Nurse Assistant confirmed that the call light was not placed near the resident's strong arm or hand, which was necessary for the resident to call for help in case of an emergency. Similarly, Resident 2, who also had chronic respiratory failure and was ventilator-dependent, was observed with a call light hanging on the wall, not within reach. This resident had intact cognition but was dependent on assistance for ADLs, as noted in their care plan. A Licensed Vocational Nurse confirmed that the call light should have been placed near the resident's strong arm or hand to enable them to call for help. The Assistant Director of Nursing acknowledged that both residents had touch-sensitive call lights due to their medical conditions and reiterated the importance of placing the call lights within easy reach, as per the facility's policy and procedure.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information on Advance Directives (AD) for three residents, which is a violation of the facility's policy. Resident 20 was admitted with severe cognitive impairment and was dependent on assistance for daily activities. During a review of Resident 20's medical records, the Assistant Director of Nursing (ADON) could not find the Advance Directive Acknowledgement Form, and there was no documentation that AD was discussed or identified if Resident 20 had a previous AD. This lack of documentation meant that the staff could not determine Resident 20's healthcare wishes. Similarly, Resident 6, who was dependent on a ventilator and had severely impaired cognition, did not have an AD documented in their records. The ADON 2 confirmed that there was no evidence that the resident or their responsible party was provided with information on formulating an AD. Resident 14, who had chronic respiratory failure and was dependent on a gastrostomy, also lacked an AD in their medical records. The facility's policy requires that upon admission, the presence of an AD should be identified, and if absent, the resident should be given the opportunity to formulate one. The absence of these documents in the residents' records indicates a failure to adhere to this policy, potentially leading to medical treatment against the residents' wishes.
Failure to Provide Proper Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for the gastrostomy tube (GT) sites of two residents, leading to potential complications. Resident 123, who was admitted with chronic respiratory failure and dependence on a ventilator, had a physician's order for gastrostomy care that included cleaning with half-strength hydrogen peroxide and normal saline, patting dry, and applying a drain sponge every shift. However, during an observation, it was noted that Resident 123's GT site had a dislodged drain sponge dressing, was red, and dirty, indicating that the care plan was not followed as ordered. Similarly, Resident 2, also admitted with chronic respiratory failure and dependence on a ventilator, had a physician's order for similar gastrostomy care. An observation revealed that Resident 2's GT site lacked a drain sponge dressing and was not clean, contrary to the care plan that required the site to be kept clean and dry at all times. Interviews with the LVN and the Assistant Director of Nursing confirmed that the GT sites should be kept clean and covered to prevent skin irritation and infection, as per the facility's policy and procedure.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to potential health risks. For Resident 4, the oxygen cannula was not connected to the tracheostomy T-bar as ordered by the physician. This oversight was observed during a visit, where the resident was found lying in bed without the necessary oxygen connection. The facility's policy indicated that oxygen therapy should be administered as per the physician's order, which was not followed in this case. The resident had a history of respiratory issues, including pneumonia and impaired cognition, making the proper administration of oxygen crucial. For Resident 16, the facility did not adhere to the physician's order for tracheostomy care. The order specified the use of hydrogen peroxide and normal saline for cleaning the tracheostomy site, but the respiratory therapist only used normal saline. The therapist was unaware of the specific order, which was crucial for preventing infection. The resident, who had chronic respiratory failure and was dependent on a ventilator, was at risk due to this oversight. The facility's policy also required the use of hydrogen peroxide for cleaning, which was not followed, potentially exposing the resident to infection risks.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the proper storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. During an initial tour of the kitchen, it was observed that thawed meat was improperly stored on the top shelf of a refrigerator, directly above uncovered sliced bread, posing a risk of cross-contamination. Dietary Aid 1 acknowledged that thawed meat should not be placed above bread due to the potential for blood to drip onto the bread. Additionally, several food items in the kitchen freezer, including a bag of whole corn kernel, penne pasta, and liquid marinade, were found without labels or dates indicating when they were first opened, contrary to the facility's policy. Interviews with the Dietary Supervisor and Kitchen District Manager confirmed the improper practices observed. The Dietary Supervisor stated that bread should not be stored below raw meat to prevent cross-contamination, and all food items should be labeled and dated to track their usage. The Kitchen District Manager reiterated that uncooked meat should not be mixed with ready-to-eat food due to the risk of cross-contamination. A review of the facility's policies and procedures indicated that food should be thawed in a drip-proof container to prevent cross-contamination and that all foods should be stored in covered containers, labeled, and dated. These deficiencies in food handling practices had the potential to cause foodborne illnesses.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident with an indwelling catheter, as required by their policy. The resident, who had been admitted with a bladder disorder and urinary tract infection, had a care plan that included the use of a dignity bag to cover the catheter bag. However, during an observation, the catheter bag was found uncovered, hanging on the side of the bed without the dignity bag in place. The Assistant Director of Nursing confirmed that the catheter bag should have been covered to maintain the resident's dignity. The resident expressed a desire for the catheter bag to be inside the privacy bag, indicating awareness and preference for privacy. The facility's policy on urinary catheter care, revised earlier in the year, also stipulated the use of a dignity bag for the drainage bag, which was not adhered to in this instance.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of the Notice of Proposed Transfer and Discharge for a resident who was transferred to a General Acute Hospital. The resident, who had been admitted with diagnoses including attention to tracheostomy and pneumonia, was transferred via emergency services due to fluctuating oxygen saturation. The facility's policy required notification of the Ombudsman in such cases, but this was not done. During the review of the resident's medical records, it was found that there was no completed Notice of Proposed Transfer/Discharge Form, and the Ombudsman was not notified of the transfer. Interviews with the facility's Medical Records staff and Assistant Director of Nursing confirmed the lack of notification. The facility's policy indicated that for emergency transfers, notice should be provided as soon as practicable, but this procedure was not followed.
Failure to Follow Physician's Order for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care and services to promote the healing of a pressure ulcer for a resident, as ordered by the physician. The resident, who was readmitted to the facility with chronic respiratory failure and a gastrostomy, was dependent on staff for personal hygiene and bathing. The physician's order specified that the resident's Stage 2 pressure ulcer on the right middle back should be cleaned with normal saline, painted with betadine, and covered with Tegaderm every three days for 21 days. During an observation of a dressing change, it was noted that a foam dressing was used instead of Tegaderm, contrary to the physician's order. LVN 3 confirmed that the previous dressing change did not follow the physician's order, which could affect wound healing and increase the risk of infection. The facility's policy and procedure for wound care emphasized the importance of following physician orders to ensure effective treatment and promote healing.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to provide Restorative Nurse Assistant (RNA) services as ordered by the physician for a resident, identified as Resident 123. The resident, who was admitted with chronic respiratory failure and ventilator dependence, had severely impaired cognition and was dependent on assistance for daily activities. The care plan for the resident included a maintenance program for range of motion (ROM) and the use of splints to aid mobility, with specific orders for passive range of motion (PROM) exercises and the application of hand rolls and an elbow splint five times a week. However, during an observation and interview, it was found that the RNA did not apply the hand rolls and elbow splint as documented in the restorative record. The RNA admitted to only performing PROM exercises and incorrectly signing the record to indicate that all ordered services were provided. This discrepancy was confirmed by the Assistant Director of Nursing, who emphasized the importance of implementing RNA services as ordered to prevent further contractures and decrease in ROM. The facility's policy required accurate documentation of treatments provided, which was not adhered to in this case.
Failure to Label and Date IV Catheter
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident, specifically in the labeling and dating of a peripherally inserted intravenous (IV) catheter. This deficiency was identified during an observation of a resident who had an IV site on the left hand that was not labeled with the insertion date. The Assistant Director of Nursing (ADON) confirmed that the IV site should have been labeled with the date of insertion to facilitate proper infection control and maintenance of IV patency. The absence of labeling could lead to an increased risk of infection, potentially worsening the resident's health condition. The resident involved had been readmitted to the facility with chronic respiratory failure and a gastrostomy. The resident's Minimum Data Set (MDS) indicated significant communication limitations and dependency on assistance for personal hygiene and bathing. The facility's policy and procedure for intravenous infusion, reviewed in January 2022, required that a sterile dressing be applied over the IV site and that the site be initialed, dated, and timed. The failure to adhere to this policy was observed during a survey, highlighting a lapse in following professional standards of practice for IV care.
Failure to Act on Pharmacist's Recommendation for Medication Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's Medication Regimen Review (MRR) recommendation for a resident, identified as Resident 8. The resident was admitted with chronic respiratory failure and had a gastrostomy. The resident's Minimum Data Set (MDS) indicated unclear speech and dependency on others for personal hygiene and bathing. The resident was prescribed Enoxaparin for Deep Vein Thrombosis (DVT) prevention. The MRR recommended consulting the resident's physician to determine the term of therapy for Enoxaparin use. However, there was no documentation in the resident's medical record indicating that the MRR recommendation was followed. During an interview, the Assistant Director of Nursing (ADON 1) admitted to not acting on the pharmacist's recommendation and acknowledged missing the MRR, which led to not contacting the physician for the term of therapy. The facility's policy required that recommendations be acted upon and documented, but this was not done, potentially leading to unnecessary medication use.
Improper Use of PPE in Contact Isolation
Penalty
Summary
The facility failed to ensure that staff used Personal Protection Equipment (PPE) in accordance with its Policy and Procedure (P&P) on infection prevention and control for a resident who was on contact isolation due to a diagnosis of Candida auris, a communicable disease. The resident, who was readmitted with chronic respiratory failure and a gastrostomy, was dependent on staff for personal hygiene and bathing. During an observation, the Assistant Director of Nursing (ADON) entered the resident's room without properly wearing the isolation gown, as their arms were not inside the sleeves, and made direct contact with the resident, allowing their coat to touch the resident's clothes. The Infection Preventionist Nurse confirmed that proper PPE, including mask, gown, and gloves, should be worn by anyone entering a room with contact isolation, and that arms should be inside the gown sleeves to prevent the transmission of bacteria. The facility's P&P on Infection Prevention and Control, revised in July 2022, indicated that gowns are to be worn to prevent direct contamination from patients' secretions, excretions, or other body fluids. The failure to adhere to these guidelines had the potential to spread infection and communicable diseases within the facility.
Unsafe and Unsanitary Electric Fan in Resident's Room
Penalty
Summary
The facility failed to maintain an electric fan in a safe, operating, and sanitary condition for a resident with chronic respiratory failure and dependence on a ventilator. The resident, who had severely impaired cognition and was dependent on assistance for daily activities, had a black electric fan at their bedside that was observed to be wiggly and unstable when moved. The fan's vents were dusty and covered with lint, and it was described as broken by a Licensed Vocational Nurse (LVN) during an observation and interview. The Assistant Director of Nursing (ADON) stated that housekeeping staff were responsible for cleaning equipment in residents' rooms daily to prevent infection, and maintenance staff were required to fix broken equipment for resident safety. The facility's policy on Physical Environment and Space Equipment emphasized maintaining all mechanical, electrical, and patient care equipment in a safe operational condition. This deficiency had the potential to affect the resident's quality of life and overall health, particularly given their respiratory condition.
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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.
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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) |
|---|---|---|---|---|
| West Haven Healthcare | 0.2 mi | ★★★★★ | 16 | 0 |
| West Covina Healthcare Center | 0.6 mi | ★★★★★ | 17 | 0 |
| Clara Baldwin Stocker Home For Women | 0.7 mi | ★★★★★ | 24 | 0 |
| Victoria Care Center | 0.7 mi | ★★★★★ | 13 | 0 |
| Garden View Post Acute Rehabilitation | 1.2 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.