Deficiency Records for West Covina Healthcare Center

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Updated as of April 01, 2024

A list of the most recent deficiencies for West Covina Healthcare 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?
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-01-31 2024-02-23 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-01-31 2024-02-23 Y
Provide and implement an infection prevention and control program. Health 2023-11-28 2023-12-27 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-10-13 2023-11-17 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 2023-10-13 2023-11-15 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 2023-10-13 2023-11-15 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-10-13 2023-11-15 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 2023-10-13 2023-11-06 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 2023-10-13 2023-11-06 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 2023-10-13 2023-11-06 N
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Fire Safety 2023-10-12 2023-11-03 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-10-13 2023-11-01 N
Provide activities to meet all resident's needs. Health 2023-10-13 2023-11-01 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-10-12 2023-10-23 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2023-10-13 2023-10-13 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-10-12 2023-10-13 N
Install an approved automatic sprinkler system. Fire Safety 2023-10-12 2023-10-13 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-10-12 2023-10-13 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-08-07 2023-08-25 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2023-05-30 2023-06-26 Y
Provide and implement an infection prevention and control program. Health 2023-05-30 2023-06-26 Y
Provide and implement an infection prevention and control program. Health 2023-05-26 2023-06-26 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-03-04 2023-04-24 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 2023-01-10 2023-01-26 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 2023-01-10 2023-01-20 Y
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2022-12-21 2023-01-04 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2022-12-29 2022-12-30 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-12-21 2022-12-28 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-12-13 2022-12-14 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-12-13 2022-12-14 Y
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2022-12-13 2022-12-14 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-12-13 2022-12-14 Y
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 2022-11-02 2022-11-10 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-09-28 2022-10-28 Y
Ensure that residents are free from significant medication errors. Health 2022-09-28 2022-10-28 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2022-09-01 2022-09-30 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 2022-09-01 2022-09-30 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-08-25 2022-09-27 Y
Ensure that residents are free from significant medication errors. Health 2022-08-25 2022-09-27 Y
Post nurse staffing information every day. Health 2022-08-30 2022-09-20 Y
Provide and implement an infection prevention and control program. Health 2022-07-13 2022-08-02 Y
Ensure staff are vaccinated for COVID-19 Health 2022-07-13 2022-08-02 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-05-19 2022-06-29 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-05-19 2022-06-29 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-05-19 2022-06-29 Y
Provide and implement an infection prevention and control program. Health 2022-06-18 2022-06-23 Y
Ensure that residents are free from significant medication errors. Health 2022-06-02 2022-06-16 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2022-01-13 2022-03-09 Y
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 2022-01-20 2022-02-07 Y
Provide and implement an infection prevention and control program. Health 2022-01-20 2022-02-07 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-12-07 2022-02-07 Y
Provide and implement an infection prevention and control program. Health 2021-09-16 2021-10-12 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2021-08-06 2021-08-26 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 2021-07-21 2021-08-19 Y
Provide and implement an infection prevention and control program. Health 2021-07-21 2021-08-19 Y
Reasonably accommodate the needs and preferences of each resident. Health 2021-07-27 2021-08-12 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-04-23 2021-05-21 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-04-23 2021-05-21 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2021-04-23 2021-05-21 N
Ensure each resident receives an accurate assessment. Health 2021-04-23 2021-05-21 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 2021-04-23 2021-05-21 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-04-23 2021-05-21 N
Assist a resident in gaining access to vision and hearing services. Health 2021-04-23 2021-05-21 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-04-23 2021-05-21 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 2021-04-23 2021-05-21 N
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2021-04-23 2021-05-21 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-04-23 2021-05-21 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-04-23 2021-05-21 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 2021-04-23 2021-05-21 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2021-04-23 2021-05-21 N
Ensure that residents are free from significant medication errors. Health 2021-04-14 2021-05-20 Y
Have properly located and lighted "Exit" signs. Fire Safety 2021-04-23 2021-05-20 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2021-04-23 2021-05-20 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2021-04-23 2021-05-20 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-04-23 2021-05-20 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-04-23 2021-05-20 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 2019-09-26 2019-11-25 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-09-26 2019-11-25 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-09-26 2019-11-25 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 2019-09-26 2019-11-25 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-09-26 2019-11-25 N
Provide enough food/fluids to maintain a resident's health. Health 2019-09-26 2019-11-25 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2019-09-26 2019-11-25 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2019-09-26 2019-11-25 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 2019-09-26 2019-11-25 N
Post nurse staffing information every day. Health 2019-09-26 2019-11-25 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-09-26 2019-11-25 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 2019-09-26 2019-11-25 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2019-09-26 2019-11-25 N
Provide and implement an infection prevention and control program. Health 2019-09-26 2019-11-25 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2019-09-26 2019-11-25 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2019-09-26 2019-10-28 N
Construct fire resistant interior walls. Fire Safety 2019-09-26 2019-10-28 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-09-26 2019-10-28 N