Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Beacon Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure privacy for two residents during incontinence care. One resident with moderate impaired cognition and another with intact cognition but dependent on staff for toileting hygiene were observed without closed privacy curtains during care. This was contrary to the facility's policies on dignity and quality of life, which require maintaining resident privacy during personal care.
The facility failed to ensure safe food handling practices, as surveyors found unlabeled and undated open bags of hamburger patties and eggrolls in the freezer. The Dietary Supervisor acknowledged that open food items should be labeled and dated according to the facility's policies, which were not followed, potentially risking foodborne illnesses for residents.
A facility failed to accurately complete the MDS for a resident, not reflecting their hearing impairment. Despite being noted as having adequate hearing in the MDS, observations and interviews with family and staff revealed the resident was hard of hearing and required close communication. The MDS Coordinator acknowledged the inaccuracy, and the facility's policy emphasized the importance of accurate assessments and effective communication for hearing-impaired residents.
A resident with highly impaired hearing did not receive necessary treatment to prevent decline in hearing abilities. Despite being cognitively intact, the resident struggled to hear and required close communication, yet no hearing aids or ENT consult were provided. Staff interviews confirmed the oversight, which contradicted the facility's policy on caring for hearing-impaired residents.
A resident with a pressure ulcer on the right heel had a pressure relief boot (PRB) applied incorrectly by an LVN, who had not received training on its proper application. The resident, dependent on staff for care, had multiple pressure injuries. The Treatment Nurse confirmed the need for proper PRB application to relieve pressure and aid healing. The facility's policy emphasized reviewing care plans and implementing interventions, which was not followed.
A resident receiving oxygen therapy did not have a cautionary sign posted on their door, as required by the facility's policy. This oversight was observed during a survey, where the resident was found connected to an oxygen machine without any signage indicating oxygen use, posing a safety risk. Staff interviews confirmed the necessity of such signage for fire safety.
A resident with dementia and anxiety was not properly assessed for pain during a medication pass. Despite the resident's complaint of a stomachache, the LVN did not evaluate the pain, attributing it to the resident's usual behavior. This was against the physician's order for pain evaluation and the facility's pain management policy, potentially affecting the resident's well-being.
The facility did not post actual worked nursing hours at the start of each shift as required by their policy. On a specific date, the actual CNA direct care service hours were less than projected due to staffing discrepancies. The DSD admitted that posted hours were projections and not updated when staff called off, leading to potential misinformation about staffing levels.
A resident with spastic quadriplegic cerebral palsy was prescribed Cefepime for sepsis without completing the McGeer's criteria, which is necessary to confirm true infections. The Infection Prevention Nurse noted that the admission nurse did not fill out the criteria, despite the facility's policy requiring it for antibiotic use.
The facility failed to serve black bean soup at the required temperature, with a test tray showing the soup at 120F, below the policy's minimum of 140F. This was confirmed by the Dietary Supervisor during a tray-line inspection, highlighting a deficiency in meal service standards.
A resident with cognitive impairments signed an Arbitration Agreement without understanding it, as confirmed by interviews and records. The resident's family member was in the process of obtaining Power of Attorney due to the resident's inability to make decisions. The facility's policy required capacity documentation, but the resident's impairment was noted, and the agreement was signed without proper authorization.
A facility failed to document complete discharge planning for a resident with chronic ulcer and diabetes. Although the Director of Social Services discussed the option of staying at the current facility with the resident's family, this was not recorded in the medical record. The facility's policy requires all services and changes to be documented to ensure effective communication among the care team.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The facility failed to ensure privacy for two residents during incontinence care, as observed by surveyors. Resident 7, who was admitted with diagnoses including encephalopathy, dysphagia, and contractures, was found to have moderate impaired cognition and depended on staff for activities of daily living (ADLs). During an observation, it was noted that Resident 7's privacy curtain was not completely closed during incontinence care, compromising their privacy. Similarly, Resident 15, who had diagnoses of dysphagia, abnormal posture, and unsteadiness on feet, was observed to have an intact cognition but also depended on staff for toileting hygiene. During incontinence care, Resident 15's privacy curtain was not closed, failing to protect their bodily privacy. The facility's policies on dignity and quality of life, revised in November 2023, emphasize the importance of maintaining resident privacy during personal care, which was not adhered to in these instances.
Deficient Food Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food handling practices in its kitchen. During an initial tour of the kitchen, surveyors observed one open bag of four hamburger patties and one open bag of eggrolls in the facility freezer that were unlabeled and undated. The Dietary Supervisor confirmed that open food items should be labeled and dated to identify the contents and determine their good-by date, as per the facility's policies and procedures. The facility's policies, titled 'Procedure for Frozen Storage: Freezer Storage' and 'Labeling and Dating of Foods,' both dated 2023, require all frozen food to be labeled and dated. This deficiency had the potential to result in foodborne illnesses for the residents.
Inaccurate MDS Assessment of Resident's Hearing Abilities
Penalty
Summary
The facility failed to ensure an accurate completion of the Minimum Data Set (MDS) for a resident, which did not accurately reflect the resident's hearing abilities and limitations. The resident was admitted with diagnoses including intestinal obstruction, hydronephrosis, atelectasis, and lack of coordination. The MDS indicated the resident was cognitively intact and had adequate hearing without the use of hearing aids. However, observations and interviews revealed that the resident was hard of hearing, requiring individuals to speak close to their ear for effective communication. Family members and staff, including a CNA, Activities Director, MDS Coordinator, RN, and LVN, confirmed the resident's hearing impairment, noting the absence of hearing aids or devices. The MDS Coordinator acknowledged the inaccuracy in the MDS assessment, which was crucial for providing quality care. The facility's policy and procedure for hearing-impaired residents emphasized maintaining effective communication and evaluating the resident's preferred communication method. Despite this, the resident's physician was not informed of the hearing impairment, and no ENT consult was ordered. The facility's policy required accurate MDS completion, and the MDS Coordinator's job description included evaluating residents' conditions and completing accurate MDS coding based on medical records, observations, and interviews.
Failure to Address Hearing Impairment in Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 99, received necessary treatment to prevent a decline in hearing abilities and maintain quality of life. Upon admission, Resident 99 was noted to have highly impaired hearing, yet the Minimum Data Set (MDS) indicated the resident was cognitively intact and had adequate hearing without the use of hearing aids. Observations and interviews revealed that Resident 99 struggled to hear and required others to speak very close to their ear or rely on lip reading for communication. Despite these challenges, no hearing aids or devices were provided, and there was no documentation of an Ear, Nose, and Throat (ENT) consult being ordered. Interviews with staff, including a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), and a Registered Nurse (RN), confirmed that Resident 99 was hard of hearing and that the necessary steps to address this issue, such as informing the physician or arranging for an ENT consult, were not taken. The facility's policy on the care of hearing-impaired residents emphasized the importance of maintaining effective communication and utilizing available resources, yet these procedures were not followed. This oversight had the potential to negatively impact Resident 99's social interaction and overall quality of life.
Improper Application of Pressure Relief Boot
Penalty
Summary
The facility failed to properly apply a pressure relief boot (PRB) for a resident with a pressure ulcer on the right heel. The resident, who was admitted with diagnoses including pressure-induced deep tissue damage, type 2 diabetes mellitus, and cognitive communication deficit, was dependent on staff for daily activities and had multiple pressure injuries. During an observation, a Licensed Vocational Nurse (LVN) was found to have incorrectly applied the PRB upside-down on the resident's right foot. The LVN admitted to not having received training on how to apply the PRB and was unaware of who had initially applied it incorrectly. Further observations and interviews revealed that the Treatment Nurse (TN) confirmed the presence of a deep tissue injury on the resident's right heel and emphasized the importance of the PRB in relieving pressure to aid in healing. The Director of Nursing (DON) reviewed the resident's care plan, which indicated the need for heel protection to offload pressure. The facility's policy on the prevention of pressure injuries highlighted the need to review care plans and implement interventions to reduce modifiable risk factors, which was not adhered to in this case.
Failure to Post Oxygen Use Signage
Penalty
Summary
The facility failed to ensure the safety of a resident receiving oxygen therapy by not posting a cautionary sign on the resident's door indicating that oxygen was in use. This oversight was identified during an observation where the resident was found asleep in bed, connected to an oxygen machine via a nasal cannula, without any signage to alert others of the oxygen use. The absence of a sign posed a risk to the resident's safety, as it did not remind visitors or other residents to be cautious and avoid smoking near the oxygen source. The resident in question had been admitted with diagnoses including a compression fracture of the vertebra, hypertension, and hyperlipidemia, and was receiving oxygen therapy to maintain oxygen saturation above 93%. The facility's policy and procedure on oxygen administration, revised in March 2024, clearly stated the need for 'No Smoking/Oxygen in Use' signs as part of the equipment and supplies necessary for safe oxygen administration. Interviews with staff, including an LVN and the Director of Staff Development, confirmed the requirement for such signage to ensure fire safety, as oxygen is combustible.
Failure to Assess and Manage Pain for a Resident
Penalty
Summary
The facility failed to properly assess and manage pain for a resident during a medication pass observation. The resident, who was admitted with diagnoses including dementia and anxiety, was observed by a Licensed Vocational Nurse (LVN) complaining of a stomachache. Despite the complaint, the LVN did not assess the resident's pain, attributing the complaint to the resident's usual behavior of complaining about back pain when sitting in a wheelchair. This inaction was contrary to the physician's order for pain evaluation every shift and the facility's policy on pain assessment and management. The facility's policy, revised in November 2024, outlines a comprehensive approach to pain management, including recognizing, assessing, and identifying the cause of pain, as well as defining goals and implementing strategies for pain management. However, during the incident, the LVN failed to follow these procedures, potentially affecting the resident's physical comfort and psychosocial well-being. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for moderate to maximal assistance with daily activities, highlighting the importance of proper pain assessment and management for this resident.
Failure to Post Actual Nursing Hours
Penalty
Summary
The facility failed to post the actual worked nursing hours at the start of each shift for one specific date, as required by their policy and procedure titled 'Consumer Information.' On November 14, 2024, the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) indicated that the actual total Certified Nursing Assistant (CNA) direct care service hours were 92.34 hours, whereas the Projection of Nursing Hours had scheduled 97.5 hours. This discrepancy was due to the fact that only three CNAs worked the entire second shift, and one CNA worked only three hours during that shift, contrary to the projection of four CNAs working the full shift. The Director of Staff Development (DSD) acknowledged that the posted nursing hours were merely projections and were not updated when a staff member called off. The facility's policy requires that the actual number of nursing staff on duty for each shift be posted daily at the beginning of each shift, in a clear and readable format, and in a prominent place accessible to residents and visitors. The failure to update the posted hours to reflect actual staffing levels could lead to inaccurate information being available to residents and visitors, potentially misrepresenting the level of care provided.
Failure to Review Antibiotic Necessity for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics, as required by their antibiotic stewardship program. Resident 149, who was admitted with spastic quadriplegic cerebral palsy and multiple joint contractures, was prescribed Cefepime Hydrochloride for sepsis. However, the necessary McGeer's criteria, which are used to confirm true infections, were not completed for this resident, indicating a lack of proper review for the necessity of the antibiotic. During an interview and record review, the Infection Prevention Nurse acknowledged that the admission nurse did not fill out the McGeer's criteria for Resident 149, despite the resident being prescribed antibiotics in the hospital. The facility's policy on antibiotic stewardship requires that antibiotics be prescribed and administered under specific guidelines, including meeting the McGeer's criteria for active infection or suspected sepsis. The failure to complete this criteria review suggests a lapse in adherence to the facility's policy and procedure.
Deficient Food Temperature in Meal Service
Penalty
Summary
The facility failed to prepare and serve food at a safe and appetizing temperature, as observed during a tray-line inspection. Specifically, the black bean soup served during dinner was found to be at 120 degrees Fahrenheit, which is below the facility's policy requirement of a minimum holding temperature of 140 degrees Fahrenheit for hot foods. This observation was made during a test tray tasting with the Dietary Supervisor, who confirmed that the soup was lukewarm and not within acceptable temperature ranges. The deficiency was identified during an initial facility tour where complaints about the food's texture, flavor, and temperature were noted. The facility's policy and procedure for meal service, dated 2023, mandates that meals meet the nutritional needs of residents and are served at appropriate temperatures, with hot foods like soups expected to be between 170F to 190F. The failure to adhere to these standards had the potential to result in meal dissatisfaction and decreased intake, placing residents at risk for unplanned weight loss.
Resident Signed Arbitration Agreement Without Capacity
Penalty
Summary
The facility failed to ensure that a resident, who signed an Arbitration Agreement, had the capacity to understand and make an informed decision. The resident was admitted with diagnoses including pressure-induced deep tissue damage, type 2 diabetes mellitus, and a cognitive communication deficit. The Minimum Data Set (MDS) indicated the resident was moderately impaired in cognitive skills, requiring supervision for decisions and assistance with daily activities. During an interview, the resident was unable to explain what an arbitration agreement was and did not recall being informed about it by the facility. The resident's family member, who was present during the interview, confirmed the resident's confusion and stated they were in the process of obtaining Power of Attorney due to the resident's inability to make medical decisions. The Case Manager claimed to have explained the arbitration agreement to the resident, who signed it despite documented cognitive impairments. The facility's policy stated that residents are presumed to have capacity unless otherwise documented, and consents should be signed by the resident or a legally authorized representative if the resident lacks capacity. However, the resident's cognitive impairment was documented, and the family member indicated the resident should not make decisions independently.
Incomplete Documentation of Discharge Planning
Penalty
Summary
The facility failed to ensure complete documentation regarding discharge planning for a resident, which was identified during a review of the resident's medical records. The resident was admitted with diagnoses including a non-pressure chronic ulcer, local infection of the skin and subcutaneous tissue, and type 2 diabetes mellitus. The Minimum Data Set (MDS) indicated the resident was dependent on assistance for certain activities of daily living. A late entry Social Service Note (SSN) documented a meeting between the resident's family member and the interdisciplinary team to discuss discharge plans, where assistance with long-term placement to another skilled nursing facility was requested. However, the SSN did not document whether the option to remain at the current facility was offered or discussed. Interviews with the Director of Social Services (DSS) revealed that the option for the resident to stay at the current facility was indeed discussed with the family member, but this was not documented in the resident's medical record. The facility's policy on charting and documentation requires that all services, progress, and changes in the resident's condition be documented to facilitate communication among the interdisciplinary team. The DSS acknowledged the importance of documentation, stating that if it was not documented, it did not happen, highlighting the deficiency in maintaining complete and accurate records.
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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) |
|---|---|---|---|---|
| Garden View Post Acute Rehabilitation | 1.1 mi | — | 18 | 0 |
| West Covina Healthcare Center | 1.4 mi | — | 16 | 0 |
| West Haven Healthcare | 1.6 mi | — | 16 | 0 |
| West Covina Medical Center D/p Snf | 1.7 mi | — | 15 | 0 |
| Victoria Care Center | 1.8 mi | — | 13 | 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 August 2026) and official state health department websites.