Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Harvard Creek Post Acute during CMS and state inspections, most recent first.
A resident with pneumonia, type 2 DM, dysphagia, and severe cognitive impairment experienced a fever, after which the NP ordered monitoring of vital signs. The DON stated that following such a change in condition, staff should obtain vital signs every 2–4 hours. An LVN reported checking the resident's vital signs multiple times during the subsequent night shift but did not document them because they were within normal limits. Review of records showed no documented vital signs after the change in condition, despite facility policies requiring monitoring and documentation of objective observations, changes in condition, and responses to treatment.
A resident with hemiplegia and severe cognitive impairment did not receive passive range of motion (PROM) exercises to the left arm as required by the care plan and facility policy. Staff provided PROM to other limbs but omitted the left arm, resulting in pain and joint stiffness when PROM was eventually performed, indicating a decline in range of motion.
A resident with severe cognitive and physical impairments repeatedly crawled on the floor, a behavior observed by staff and another resident. Despite this, the care plan did not include interventions or goals to address the crawling, focusing only on general fall precautions. Staff confirmed the behavior was frequent, and the DON acknowledged the care plan should have been updated to include it.
A resident with a history of falls, confusion, and impaired mobility was not assessed for injury when found crawling on floor mats, and their care plan was not updated to address repeated crawling behavior. Staff, including a CNA and the DON, confirmed the resident frequently crawled on the floor and into the hallway, but this was not reflected in the care plan. An LVN also failed to document a wander guard device trial in the medical record, contrary to facility policy. These failures placed the resident at risk for harm.
A nurse did not document a wander guard trial for a resident with severe cognitive impairment and high fall risk, despite facility policy requiring such documentation. The omission led to incomplete medical records and risked miscommunication among the care team regarding the resident's condition and interventions.
A resident with acute respiratory failure and end-stage renal disease experienced diarrhea, prompting a physician's order for a stool sample to test for C. difficile. The facility failed to collect the sample, potentially delaying care. Interviews with the ADON and DON highlighted the importance of following physician orders, which was not done in this case.
The facility failed to ensure call lights were within reach for three residents, all of whom had severe cognitive impairments and were at high risk for falls. Observations revealed that the call lights were positioned out of reach, contrary to the facility's policy and care plans. Staff confirmed the inaccessibility and the importance of having call lights within reach for residents to request assistance.
The facility failed to follow its policy on the use of side rails for three residents, leading to deficiencies in care. A resident with a history of falls did not have alternative interventions attempted or informed consent obtained before bed rail installation. Another resident with severe cognitive impairment had side rails installed without documentation of alternative measures. A third resident, with intact cognition, had side rails installed without understanding their purpose, and no alternative interventions were documented.
The facility failed to label and date food items when opened, as observed in a refrigerator containing unlabeled tortillas. The Lead Cook and Dietary Supervisor confirmed the requirement for labeling to track food lifespan, as per the facility's policy.
A facility failed to obtain informed consent from a resident before administering an increased dosage of Mirtazapine, a psychoactive medication. The resident, who had the capacity to understand and make decisions, did not sign or date the consent form for the medication increase. The facility's policy required informed consent before administering or increasing the dosage of psychotropic medications, which was not followed in this case.
A resident with surgical aftercare and chronic kidney disease was inaccurately recorded in the MDS as discharged to an acute hospital, despite being discharged home with home health services. The MDS Coordinator admitted the error, and the DON highlighted the importance of accurate documentation for CMS reporting.
A resident with Parkinson's disease and dementia, assessed as high risk for falls, did not have bilateral landing mats properly positioned as ordered. The mats were intended to minimize injury in case of a fall, but one was found placed a foot away from the bed. Interviews with the ADON and DON confirmed the mats should be closer to the bed, as per the facility's fall risk policy.
A resident with respiratory failure was observed receiving five liters of oxygen per minute instead of the prescribed two liters. The facility staff failed to document the resident's oxygen usage as required, and the licensed nurse did not monitor the oxygen levels to ensure compliance with the physician's order. The facility's policy for oxygen administration was not followed, resulting in a deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident undergoing hemodialysis with a permacatheter, despite the facility's policy requiring EBP for residents with indwelling medical devices. The resident, with end-stage renal disease and other conditions, was not placed on EBP, which was confirmed by the ADON and acknowledged by the DON. This oversight had the potential to expose the resident to infection.
The facility did not meet the required 80 square feet per resident in multiple resident rooms for 18 out of 24 rooms. Despite this, staff reported being able to provide care without difficulty. A room waiver request was submitted, indicating compliance with care and privacy standards.
Failure to Monitor and Document Vital Signs After Change in Condition
Penalty
Summary
Facility nurses failed to provide treatment and care in accordance with professional standards of practice when they did not monitor and document a resident's vital signs after a documented change in condition. The resident was admitted with pneumonia, type 2 diabetes mellitus, and dysphagia, and had severe cognitive impairment and dependence on staff for most activities of daily living. On 2/28/2026 at 6:21 PM, the resident had an elevated temperature of 100.2°F, and the nurse practitioner was contacted. The SBAR form and progress note indicated that the nurse practitioner ordered monitoring of the resident's vital signs following this elevated temperature. The DON stated that nurses normally monitor residents' vital signs once a day, but when instructed to monitor vital signs after a change in condition, staff should check them every 2–4 hours. The nurse practitioner confirmed that orders included monitoring vital signs. An LVN reported checking the resident's vital signs 2–3 times during the night shift following the fever but acknowledged not documenting them because they were within normal limits. The DON stated that if vital signs were not documented, then staff did not monitor them. Review of facility policies on acute condition changes and charting/documentation showed that staff were required to monitor and document the resident's progress, responses to treatment, and any changes in condition, including objective observations and services performed.
Failure to Provide PROM to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to provide appropriate treatment to prevent further decrease in range of motion (ROM) for a resident with a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left side. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living, was not given passive range of motion (PROM) exercises to the left arm as required by the care plan and the facility's policies. Record reviews and staff interviews confirmed that PROM was only provided to the resident's right arm, right leg, and left leg, omitting the left arm despite documented impaired mobility in the left shoulder. During an observation, when PROM was finally provided to the resident's left shoulder, the resident exhibited pain and joint stiffness, indicating a decline in ROM. The care plan specifically identified the risk for decline in ROM and included interventions for PROM to both arms and legs, but these interventions were not implemented for the left arm. The facility's own policies required that residents with limited ROM receive appropriate treatment to prevent further decline, which was not followed in this case.
Failure to Address Crawling Behavior in Resident Care Plan
Penalty
Summary
The facility failed to update and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting the resident's behavior of crawling on the floor. Despite multiple assessments and staff observations indicating that the resident had a history of confusion, impaired cognition, decreased coordination, and required extensive assistance with mobility and activities of daily living, the care plan only addressed general fall risk interventions such as floor mats and call light accessibility. The care plan did not include specific interventions or goals related to the resident's repeated behavior of crawling on the floor, which was observed and reported by both staff and another resident as occurring multiple times daily, including instances where the resident crawled into the hallway and attempted to pull himself up using hallway rails. Interviews with staff, including a CNA and LVN, confirmed that the resident frequently crawled out of bed and onto the floor, requiring staff assistance to return him to bed or his wheelchair. The DON acknowledged that the care plan should have been updated to reflect this behavior, in accordance with facility policy, but it was not. As a result, there were no nursing interventions in place to address the resident's crawling behavior, which was a significant omission given the resident's cognitive and physical impairments.
Failure to Implement Fall Risk Policy and Update Care Plan for Resident with Repeated Crawling Behavior
Penalty
Summary
The facility failed to implement its Falls and Fall Risk Management Policy and Procedure for one resident who was at high risk for falls due to a history of falls, confusion, impaired gait and balance, and use of antihypertensive medication. The resident's care plan included interventions such as providing bilateral floor mats, keeping the call light within reach, and maintaining a safe environment. However, staff did not assess the resident for injury whenever he was found crawling on the floor mats, as required by the care plan. Additionally, the resident's care plan was not updated to reflect his repeated behavior of crawling on the floor, despite multiple staff observations and reports from a roommate that the resident crawled out of bed and around the room several times a day. Staff, including a CNA and the DON, confirmed that the resident frequently crawled on the floor and sometimes into the hallway, but the care plan did not address this specific behavior. Furthermore, an LVN failed to document the use of a wander guard device trial in the resident's medical record, contrary to facility policy. The DON acknowledged that documentation and care plan updates were not completed as required, and that staff did not consistently follow procedures for monitoring and assisting the resident when found on the floor. These failures placed the resident at risk for harm and injury.
Failure to Document Wander Guard Trial for High-Risk Resident
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to document a wander guard trial for one resident in the medical record, as required by the facility's Charting and Documentation policy. The resident, who had a history of cerebral infarction, cognitive communication deficit, and was assessed as a high fall risk due to confusion, balance problems, and use of antihypertensive medication, was admitted with multiple care interventions in place to prevent falls. Despite these risks and the use of a wander guard device, LVN 1 did not record the trial in the resident's medical record during assigned shifts. This omission was confirmed during interviews with LVN 1 and the Director of Nursing (DON), both of whom acknowledged that documentation and staff endorsement of the wander guard trial should have occurred according to facility policy. The lack of documentation resulted in incomplete medical records for the resident and created a risk of miscommunication among the interdisciplinary team regarding the resident's condition and response to care.
Failure to Follow Physician's Order for Stool Sample Collection
Penalty
Summary
The facility failed to follow a physician's order to collect a stool sample for a resident, which had the potential to delay care and services. The resident, who was admitted with acute respiratory failure with hypoxia, end-stage renal disease, and dependence on renal dialysis, was experiencing signs and symptoms of diarrhea. A physician's order was issued for a stool sample to be collected to test for C. difficile, but this order was not completed by the facility staff. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the importance of following physician orders to provide proper care and interventions. The facility's policy and procedure for stool specimen collection, which includes verifying physician orders and documenting the procedure, was not adhered to. This oversight was identified during a review of the resident's records and interviews with facility staff.
Call Lights Inaccessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident 17, who had severe cognitive impairment and required assistance with daily activities, was found to have their call light positioned behind the headboard, making it inaccessible. This was confirmed during an observation and interview with the Activity Director, who acknowledged that the call light should be within easy reach to allow the resident to request help. Similarly, Resident 13, who had severe cognitive impairment and was assessed as high risk for falls, was observed with their call light clipped to the upper right side of the bed, out of reach. A Certified Nursing Assistant confirmed that the resident could not reach the call light and emphasized the importance of having it accessible for the resident to call for assistance. The resident's care plan also indicated the need for the call light to be within easy reach. Resident 35, who also had severe cognitive impairment and was at high risk for falls, was found with their call light hanging on top of the headboard, making it unreachable. The Assistant Director of Nursing confirmed the inaccessibility of the call light and reiterated the necessity for it to be within reach. The facility's policy on answering call lights also stated that call lights should be within easy reach when residents are in bed or confined to a chair.
Failure to Implement Bed Rail Policy for Three Residents
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of side rails for three residents, leading to deficiencies in care. For Resident 21, the facility did not ensure that appropriate alternative interventions were attempted before installing side rails. Additionally, there was no assessment for the risk of entrapment, nor was informed consent obtained prior to the installation of the bed rails. Resident 21 had a history of falls and was capable of giving informed consent, yet the necessary evaluations and consents were not documented. For Resident 33, the facility did not document any attempts at alternative interventions before the automatic installation of side rails upon readmission. Resident 33 had severely impaired cognition and was dependent on staff for various activities of daily living. Despite these conditions, the facility failed to follow its policy of attempting less restrictive measures before resorting to side rails. Similarly, for Resident 48, there was no documentation of alternative interventions being attempted before the installation of side rails. Resident 48, who had intact cognition, was not using the side rails and was unaware of their purpose. The facility's policy required an assessment of the resident's symptoms, risk of entrapment, and the reason for using side rails, along with obtaining consent after discussing potential benefits and risks, none of which were documented for Resident 48.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to adhere to proper food handling practices by not labeling and dating food items when they were first opened, as observed in one of the facility's refrigerators. During an inspection, an unlabeled bag of tortillas and a 2-pound open bag of corn tortillas were found without any labels or dates indicating when they were opened. The Lead Cook acknowledged that the tortillas were not labeled or dated and stated that the staff responsible for opening food items should label them with the date opened to track their duration. The Dietary Supervisor confirmed that all food items should be labeled with the date opened to determine their use-by date and lifespan. The facility's Policy and Procedure on Labeling and Dating of Goods, dated 2020, requires newly opened food items to be closed and labeled with a delivery and open date, as well as a use-by date.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident was informed in advance about the risks and benefits of a psychoactive medication, specifically Mirtazapine, which was prescribed to treat depression. The resident, who had the capacity to understand and make decisions, was admitted with diagnoses including diabetes mellitus, anemia, and dysphagia. Despite having moderately impaired cognition, the resident was capable of making informed decisions. However, the informed consent for the increased dosage of Mirtazapine from 30 mg to 45 mg was neither signed nor dated by the resident, indicating a lack of informed consent. The facility's policy required that informed consent be obtained and documented before administering psychotropic medications or increasing their dosage. The Assistant Director of Nursing acknowledged that the resident should have consented prior to the medication use, emphasizing the importance of informed consent for psychotropic medications. The facility's failure to obtain and document informed consent before administering the increased dosage of Mirtazapine violated the resident's right to make an informed decision regarding their treatment.
Inaccurate MDS Discharge Coding for a Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the discharge status of a resident, identified as Resident 51. The resident was admitted with diagnoses including surgical aftercare following digestive system surgery and chronic kidney disease. According to the Physician's Order, the resident was scheduled to be discharged home with home health services, including nursing, physical therapy, occupational therapy, and mobility aids. However, the MDS inaccurately recorded the resident's discharge status as being transferred to an acute hospital. During a review of the Licensed Personnel Progress Notes, it was confirmed that the resident was discharged home in stable condition. The MDS Coordinator acknowledged the error, stating that the discharge status was incorrectly coded in the MDS. The Director of Nursing emphasized the importance of accurate assessments and documentation for proper reporting to the Centers for Medicare and Medicaid Services (CMS). The facility's policy on resident assessments requires the interdisciplinary team to conduct timely and appropriate assessments, which was not adhered to in this case.
Failure to Properly Position Fall Prevention Mats
Penalty
Summary
The facility failed to utilize bilateral landing mats as ordered for a resident with a history of falls. The resident, who was admitted with diagnoses including Parkinson's disease and unspecified dementia, was assessed as being at high risk for falls due to disorientation, being chair-bound, and requiring assistive devices. The resident's care plan and order summary report both indicated the need for bilateral floor mats as a fall precaution. However, during an observation, it was noted that one of the floor mats was placed approximately one foot away from the resident's bed, which was not in accordance with the care plan. Interviews with the facility's Assistant Director of Nursing and Director of Nursing confirmed that the floor mats needed to be placed closer to the resident's bed to effectively minimize injury in the event of a fall. The facility's policy and procedure on fall risk assessment emphasized the importance of using landing mats to minimize potential injuries. The failure to properly position the floor mats as ordered had the potential to result in serious consequences for the resident, who had severely impaired cognition and was dependent on staff for daily activities.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility staff failed to ensure that a resident received the prescribed two liters of oxygen per minute as needed, according to the physician's order. Instead, the resident was observed receiving five liters per minute of oxygen through a nasal cannula on multiple occasions. The resident, who was admitted with diagnoses including sepsis, respiratory failure, and a urinary tract infection, had an order to maintain oxygen saturation above 92% for acute respiratory failure with hypoxia. Despite this, there was no documentation in the Medication Administration Record (MAR) for the use of two liters per minute of oxygen as needed for the month of December. Interviews with the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) revealed that the licensed nurse was responsible for monitoring the resident's oxygen levels to ensure compliance with the physician's order. The ADON emphasized the necessity of monitoring the resident's oxygen levels to check for respiratory distress and determine the effectiveness of interventions. The facility's policy and procedure for oxygen administration required reviewing the physician's orders, adjusting the oxygen delivery device to the proper flow, and recording oxygen administration in the resident's medical record. However, these procedures were not followed, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions for Resident on Hemodialysis
Penalty
Summary
The facility failed to ensure a safe and sanitary environment to prevent the transmission of communicable diseases for a resident undergoing hemodialysis with an indwelling medical device. The resident, who was admitted with end-stage renal disease and other conditions, required hemodialysis through a permacatheter in the right upper chest. The facility's care plan for the resident included monitoring the dialysis access site for signs of infection. However, during an observation, it was noted that the resident was not placed on Enhanced Barrier Precautions (EBP), which are necessary to prevent the spread of multidrug-resistant organisms. The Assistant Director of Nursing confirmed that the resident was not on EBP, and the Director of Nursing acknowledged that the resident should have been placed on EBP due to the presence of a central line. The facility's policy on infection control clearly stated that EBP should be used for residents with indwelling medical devices, such as central lines. This oversight had the potential to expose the resident to infection, as the necessary precautions were not implemented as per the facility's policy.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to meet the regulatory requirement of providing at least 80 square feet per resident in multiple resident rooms for 18 out of 24 rooms. Specifically, rooms 101, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, and 122 did not meet the minimum space requirement. The deficiency was identified through observations, interviews, and record reviews. During observations, it was noted that rooms with two beds had only 154 square feet instead of the required 160 square feet, and rooms with four beds had 280 square feet instead of the required 320 square feet. Interviews with the facility's Administrator confirmed the deficiency, and a room waiver request was submitted, indicating that the rooms had enough space for care and did not negatively affect residents' dignity or privacy. Further interviews with Certified Nurse Assistants revealed that despite the space deficiency, staff were able to move equipment and provide care without difficulty. However, the facility's failure to meet the square footage requirement had the potential to affect residents' privacy and the adequacy of space for nursing care and emergency services.
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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 Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rowland | 0.5 mi | — | 5 | 0 |
| Covina Rehabilitation Center | 0.6 mi | — | 0 | 0 |
| Emanate Health Inter-community Hospital- D/p Snf | 0.6 mi | — | 0 | 0 |
| Glendora Grand, Inc | 1.8 mi | — | 3 | 0 |
| Clara Baldwin Stocker Home For Women | 2.2 mi | — | 24 | 0 |
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