A list of the most recent deficiencies for West Covina Medical Center D/p Snf. 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 policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-22 | 2023-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-22 | 2023-12-16 | 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 | 2023-11-22 | 2023-12-16 | 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 | 2023-11-22 | 2023-12-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-11-22 | 2023-12-16 | N |
| 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 | 2023-11-22 | 2023-12-16 | 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 | 2023-11-22 | 2023-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-22 | 2023-12-16 | N |
| Keep all essential equipment working safely. | Health | 2023-11-22 | 2023-12-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-27 | 2023-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-27 | 2023-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-27 | 2023-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-27 | 2023-12-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-27 | 2023-12-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-27 | 2023-12-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-03 | 2023-01-19 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-01-03 | 2023-01-19 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-03 | 2023-01-19 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-09 | 2023-01-06 | 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 | 2022-12-09 | 2023-01-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-09 | 2023-01-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-09 | 2023-01-06 | 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 | 2022-12-09 | 2023-01-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-09 | 2023-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-09 | 2023-01-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-07 | 2023-01-06 | 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 | 2022-12-07 | 2023-01-06 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-07 | 2023-01-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-12-07 | 2023-01-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-12-07 | 2023-01-03 | N |
| 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 | 2022-05-04 | 2022-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-02 | 2022-06-01 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-01-27 | 2022-02-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-07 | 2020-03-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-07 | 2020-03-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-07 | 2020-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-07 | 2020-03-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-07 | 2020-03-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-07 | 2020-03-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-07 | 2020-03-19 | 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 | 2020-02-07 | 2020-03-19 | 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 | 2020-02-07 | 2020-03-19 | 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 | 2020-02-07 | 2020-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-07 | 2020-03-19 | 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 | 2020-02-06 | 2020-03-02 | N |
| Construct fire resistant interior walls. | Fire Safety | 2020-02-06 | 2020-03-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-06 | 2020-03-02 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-02-06 | 2020-03-02 | N |
