Deficiency Records for Covina Rehabilitation Center

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Updated as of March 01, 2024

A list of the most recent deficiencies for Covina Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-01-10 2024-01-29 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-12-01 2024-01-03 Y
Provide and implement an infection prevention and control program. Health 2023-12-01 2024-01-03 Y
Post nurse staffing information every day. Health 2023-09-11 2023-09-12 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-08-11 2023-08-18 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-08-11 2023-08-18 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-07-11 2023-08-01 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-11 2023-08-01 Y
Provide and implement an infection prevention and control program. Health 2023-03-03 2023-03-03 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-02-16 2023-02-24 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-01-25 2023-02-10 Y
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2023-01-25 2023-02-10 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-01-25 2023-02-10 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-11-09 2022-11-25 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2022-11-09 2022-11-25 Y
Provide and implement an infection prevention and control program. Health 2022-11-09 2022-11-25 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-08-25 2022-09-17 Y
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-08-25 2022-09-17 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-08-25 2022-09-17 Y
Provide and implement an infection prevention and control program. Health 2022-08-24 2022-09-03 Y
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2022-05-13 2022-05-23 Y
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2022-05-13 2022-05-23 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-05-03 2022-05-03 Y
Respond appropriately to all alleged violations. Health 2022-05-03 2022-05-03 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-03-30 2022-04-30 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-04-08 2022-04-26 Y
Respond appropriately to all alleged violations. Health 2022-04-08 2022-04-26 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-04-08 2022-04-26 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-01-05 2022-03-14 Y
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2022-01-05 2022-03-14 Y
Conduct testing and exercise requirements. Fire Safety 2021-10-29 2022-01-04 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-10-29 2022-01-04 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2021-10-29 2022-01-04 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-10-29 2022-01-04 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-10-29 2021-12-15 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2021-10-29 2021-12-15 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2021-10-29 2021-12-15 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2021-10-29 2021-12-15 N
Ensure each resident receives an accurate assessment. Health 2021-10-29 2021-12-15 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-10-29 2021-12-15 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2021-10-29 2021-12-15 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-10-29 2021-12-15 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-10-29 2021-12-15 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-10-29 2021-12-15 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2021-10-29 2021-12-15 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2021-10-29 2021-12-15 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-10-29 2021-12-15 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2021-10-29 2021-12-15 N
Post nurse staffing information every day. Health 2021-10-29 2021-12-15 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-10-29 2021-12-15 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2021-10-29 2021-12-15 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-10-29 2021-12-15 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-10-29 2021-12-15 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2021-10-29 2021-12-15 N
Provide and implement an infection prevention and control program. Health 2021-10-29 2021-12-15 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-10-29 2021-12-15 Y
Provide and implement an infection prevention and control program. Health 2021-09-07 2021-10-07 N
Provide and implement an infection prevention and control program. Health 2021-09-29 2021-09-29 Y
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2021-09-13 2021-09-29 Y
Provide and implement an infection prevention and control program. Health 2021-09-13 2021-09-29 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2020-01-10 2020-02-12 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2020-01-10 2020-02-12 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2020-01-10 2020-02-12 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2020-01-10 2020-02-12 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2020-01-10 2020-02-12 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-01-10 2020-02-12 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2020-01-10 2020-02-12 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2020-01-10 2020-02-12 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2020-01-10 2020-02-12 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2020-01-10 2020-02-12 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-01-10 2020-02-12 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2020-01-10 2020-02-12 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2020-01-10 2020-02-12 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2020-01-10 2020-02-12 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2020-01-10 2020-02-12 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2020-01-10 2020-02-12 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2020-01-10 2020-02-12 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-01-10 2020-02-12 N
Implement a program that monitors antibiotic use. Health 2020-01-10 2020-02-12 N
Keep all essential equipment working safely. Health 2020-01-10 2020-02-12 N
Have properly located and lighted "Exit" signs. Fire Safety 2020-01-09 2020-01-27 N
Ensure proper usage of power strips and extension cords. Fire Safety 2020-01-09 2020-01-27 N
Ensure that sources of ignition are removed from patients receiving respiratory therapy. Fire Safety 2020-01-09 2020-01-27 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2018-12-20 2019-02-08 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-12-20 2019-02-08 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2018-12-20 2019-02-08 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2018-12-20 2019-02-08 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2018-12-20 2019-02-08 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2018-12-20 2019-02-08 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2018-12-20 2019-02-08 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2018-12-20 2019-02-08 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2018-12-20 2019-02-08 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2018-12-20 2019-02-08 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2018-12-20 2019-02-08 N
Ensure medication error rates are not 5 percent or greater. Health 2018-12-20 2019-02-08 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-12-20 2019-02-08 N
Implement a program that monitors antibiotic use. Health 2018-12-20 2019-02-08 N
Construct fire resistant interior walls. Fire Safety 2019-01-03 2019-01-30 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-01-03 2019-01-30 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-01-03 2019-01-30 N