Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 West Covina Healthcare Center during CMS and state inspections, most recent first.
A resident with cerebral ischemia, type 2 DM, and moderately impaired cognition had a designated responsible party who requested the resident’s medical records through a legal services entity. The facility’s policy required resident access to records within 24 hours of request and photocopies within 48 hours, and staff reported an internal expectation to send records within seven working days. The MRD and DON stated that the chart was difficult to locate because it was stored in boxes, and the MRD had physical limitations, resulting in the records being sent after the required timeframe and violating the resident’s and responsible party’s right to timely access to medical records.
Two residents with cognitive impairments were involved in an unwitnessed physical altercation resulting in alleged facial injuries, but nursing staff did not initiate or document required neurological assessments as outlined in facility policy. Staff interviews and record reviews confirmed that neurological checks were not performed or recorded after the incident, despite clear protocols mandating such assessments following suspected head injuries.
A facility failed to report an alleged verbal abuse incident between two residents to the appropriate authorities within the required timeframe. A resident reported being called derogatory names by another resident, but the incident was not escalated to the Administrator or other required authorities as per the facility's policy. The Administrator was informed of the incident four days later by the resident's family member, highlighting a lapse in the facility's reporting procedures.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to call for assistance. One resident, with impaired cognition and mobility issues, mistook the bed remote for the call light, while another resident, requiring substantial assistance, could not locate or reach the call light. This was against the facility's policy, which mandates call lights be accessible to residents.
The facility failed to ensure that residents' Advance Directives (AD) were discussed, documented, and included in their medical charts, affecting three residents with varying medical conditions and cognitive abilities. Despite facility policy, ADs were not completed or signed, and there was no evidence of assistance offered to formulate them, as confirmed by staff interviews.
The facility failed to provide daily care for the gastrostomy tube (GT) sites of two residents, as ordered by physicians. One resident's dressing was not changed daily, risking infection, while another's dressing was observed to be unclean and falling off. Staff confirmed the need for daily dressing changes to prevent bacterial growth.
The facility failed to attempt alternatives before installing grab bars for two residents, risking entrapment and injury. One resident with hemiplegia and depression had grab bars installed without documented alternative attempts. Another resident with diabetes and heart failure had grab bars posing an accident hazard, with no record of alternative measures tried. The facility's policy mandates attempting alternatives before bed rail use, which was not followed.
The facility failed to create individualized care plans for two residents, one with dementia and another on high-risk medications. The absence of a care plan for dementia in a resident requiring substantial assistance and the lack of a plan for black box medications in another resident with End Stage Renal Disease and Congestive Heart Failure were noted. This oversight could lead to inconsistent care, as highlighted by the facility's staff and policies.
A facility failed to coordinate care with a hospice provider for a resident with Alzheimer's and CHF by not ensuring scheduled visits by the Hospice RN were documented. Despite the hospice sign-in sheet indicating visits occurred, there was no evidence of visit notes. The DON admitted responsibility for monitoring these visits and ensuring documentation, as per facility policy.
A resident developed and experienced worsening of Stage 2 pressure ulcers due to the facility's failure to adhere to the care plan, which required repositioning every two hours. Despite the care plan's instructions, the resident was frequently observed lying on his back, and CNAs admitted to not repositioning the resident due to being busy with other duties.
A facility failed to adhere to professional standards for a resident receiving IV antibiotics by not labeling the PICC line dressing with the date it was applied. The resident, who had sepsis and hypertension, was observed with an unlabeled dressing, contrary to the facility's policy requiring dressing changes every seven days and proper labeling. This oversight was confirmed by an RN Supervisor, highlighting a lapse in infection control measures.
A resident with Alzheimer's and heart failure was prescribed two liters per minute of oxygen but was observed receiving four liters per minute. An LVN admitted to not checking the flow rate, contrary to the facility's policy, risking respiratory complications.
A facility failed to conduct a post-hemodialysis assessment for a resident with ESRD, as required by their policy. The resident's Dialysis Communication Record was incomplete, lacking documentation of the post-dialysis evaluation. The DON confirmed the necessity of this assessment to ensure the dialysis site was free from bleeding and vital signs were stable, highlighting a lapse in following established care protocols.
A resident with COPD and asthma had a dusty electric fan at their bedside, which had not been cleaned for an unknown period. Interviews with staff indicated that equipment should be kept clean to prevent infection, but the facility failed to adhere to its policy on maintaining a clean environment.
The facility failed to meet the required square footage for 13 rooms, each housing multiple residents. Despite the deficiency, residents could move freely, and staff had adequate space to provide care. The administrator planned to submit a waiver, noting that the rooms accommodated necessary equipment and did not compromise resident safety. Residents did not express concerns about room size.
A resident with heart disease and dementia was observed with cheek discoloration, but the facility failed to document this change, notify the physician, or develop a care plan. Despite staff awareness, the necessary procedures were not followed, risking delayed care.
A resident with limited mobility and unable to self-administer medications had several medications stored at their bedside, contrary to the facility's policies. Interviews confirmed the resident's preference for bedside storage, but the facility's procedures required medications to be stored in locked compartments. This posed a risk of unauthorized access.
Two residents in the facility were unable to reach their call lights, potentially delaying care. One resident, with a fracture and muscle weakness, was found with the call light hanging off the bed, while another resident, with a stroke and epilepsy, reported the call light was often on the floor. Both residents were dependent on staff for assistance, and the facility's policy required call lights to be accessible, which was not followed.
The facility failed to develop and implement a person-centered care plan for a resident using an antipsychotic medication. The resident, who had diagnoses including heart disease, heart failure, and dementia, had physician orders for Seroquel but lacked a care plan to address its use, side effects, and effectiveness. The Assistant Director of Nursing confirmed the oversight, which was against the facility's policy for comprehensive care plans.
The facility failed to follow its policy for antipsychotic medication use by not attempting non-pharmacological interventions or conducting a psychiatric evaluation before prescribing and increasing the dosage of Seroquel for a resident with dementia and hallucinations.
A resident experienced severe adverse reactions and was hospitalized after an LVN administered Narcan nasal spray instead of Flonase. The LVN failed to follow the facility's policy of checking the medication label three times, leading to the error.
A resident experienced severe adverse effects and required hospitalization after an LVN administered the incorrect medication due to not checking the medication label. The LVN had not completed the required medication competency assessments, and the facility failed to adhere to its policies on competent staffing and medication management.
A resident experienced severe adverse reactions after an LVN mistakenly administered Narcan instead of Flonase and failed to document the error in the MAR. The resident, with a history of asthma and chronic pain managed with opioids, was transferred to a hospital for treatment. Interviews revealed the LVN did not verify the medication label and did not document the administration accurately, contrary to facility policy.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its policy and procedure titled "Release of Information" for one sampled resident, resulting in the resident’s responsible party not receiving timely access to the resident’s medical records. The resident had been re-admitted with diagnoses including cerebral ischemia and type 2 DM, had moderately impaired cognition per the MDS, and was later discharged and subsequently expired. The admission record identified the resident’s daughter as the responsible party. A written request for release of the resident’s medical records was submitted by a legal services entity and was documented as received by the facility. The facility’s policy stated that a resident may have access to records within 24 hours of a written or oral request and may obtain photocopies with at least 48 hours’ advance notice, excluding weekends and holidays. The Medical Records Director acknowledged that the request from the legal services entity was received and that the facility’s policy required records to be sent within seven working days, but stated that the records were not sent within that timeframe. The Medical Records Director reported difficulty retrieving the resident’s records because they were stored in boxes in the back of the facility and the director had physical limitations. The Director of Nursing confirmed that the facility could not easily locate the resident’s chart and that the records were released only after the chart was found. Both the Medical Records Director and the Director of Nursing stated that it was the right of the resident or responsible party to request and receive the resident’s medical records in a timely manner, and that the records could be needed for legal purposes and, if the resident were alive, for continuity of care.
Failure to Initiate Neurological Assessments After Unwitnessed Resident Altercation
Penalty
Summary
The facility failed to initiate neurological assessments for two residents following an unwitnessed resident-to-resident physical altercation involving alleged head injuries. Both residents had cognitive impairments and complex medical histories, including dementia and encephalopathy. After the incident, one resident was observed crying and covering a reddened left eye, while the other was noted to be in emotional distress. Both residents reported being struck in the face with a sandal during the altercation, but no neurological assessments were performed or documented for either individual. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required immediate neurological assessments for any unwitnessed head or facial injury, regardless of visible trauma. The staff acknowledged that neurological checks should have been initiated and documented according to the facility's protocols, which specify frequent monitoring intervals and comprehensive documentation in the medical record. However, record reviews revealed that no such assessments were conducted or recorded for either resident following the incident. The facility's own policies, including the Neurological Assessment and Fall Management Program, outlined the necessity and frequency of neurological checks after suspected head injuries. Despite these clear guidelines, the required assessments were not performed, and the absence of documentation was confirmed through both record review and staff interviews. This failure to follow established procedures constituted a deficiency in the standard of care provided to the residents involved in the altercation.
Failure to Report Alleged Verbal Abuse in a Timely Manner
Penalty
Summary
The facility failed to adhere to its policy and procedure for abuse investigation and reporting by not reporting an alleged verbal abuse incident involving two residents to the appropriate authorities within the required timeframe. Resident 1, who has the capacity to understand and make decisions, reported that Resident 2 called them derogatory names in Spanish at the doorway of their room. This incident was reported by a Certified Nurse Assistant (CNA) to a Licensed Vocational Nurse (LVN), but it was not escalated to the Administrator (ADM) or other required authorities as per the facility's policy. The ADM was only made aware of the incident four days later by Resident 1's family member. Interviews with staff, including a Registered Nurse (RN) and the Assistant Director of Nursing (ADON), confirmed that the incident should have been reported immediately to the ADM, the Ombudsman, the California Department of Public Health (CDPH), and local law enforcement. The failure to report the incident promptly had the potential to subject Resident 1 to further abuse and compromised the safety of the residents, as the facility did not implement necessary interventions to prevent recurrence.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were within reach and appropriate to their physical abilities. Resident 29, who was admitted with peripheral vascular disease and osteoarthritis, had moderately impaired cognition and required assistance with various activities. During an observation, it was noted that Resident 29 was unable to reach the call light, mistaking the bed remote control for it. The call light was placed on the upper part of the bed, out of reach, contrary to the care plan that required it to be within reach for safety. Similarly, Resident 80, who had hypertension and lack of coordination, required substantial assistance for toilet hygiene and transfers. During an observation, Resident 80 was unable to locate or reach the call light, which was coiled on the wall behind the bed. This placement prevented the resident from calling for help, as confirmed by a treatment nurse. The facility's policy required call lights to be within reach, but this was not adhered to, potentially delaying necessary care for the residents.
Failure to Document and Discuss Advance Directives
Penalty
Summary
The facility failed to ensure that the residents' Advance Directives (AD) were discussed, documented, and included in their medical charts, as per the facility's policy. This deficiency was identified for three residents, each with varying medical conditions and cognitive abilities. Resident 12, who had intact cognition and required assistance with daily activities, did not have an AD documented, and there was no evidence that assistance was offered or declined to formulate one. The admission coordinator confirmed that an AD should be completed upon each admission to determine the resident's preferences for end-of-life care. Resident 54, diagnosed with diabetes mellitus and dementia, was found to have severely impaired cognition and was dependent on assistance for most activities. Despite this, the resident's AD acknowledgment form was not signed by the conservator since admission, indicating a lack of compliance with the facility's policy that requires the AD to be filled out and signed with each admission. The Director of Nursing reiterated the importance of having an AD completed to guide the care and treatment preferences of the resident. Resident 78, who had impaired cognition and was dependent on assistance for daily activities, also lacked documentation of an AD. The Social Service Director stated that the facility relied on the POLST form to identify if a resident had an AD, but there was no documentation for Resident 78. The facility's policy requires the social services director to inquire about the existence of any written advance directives during the initial assessment, which was not adhered to in this case.
Failure to Provide Daily GT Site Care
Penalty
Summary
The facility failed to provide necessary care and services for the gastrostomy tube (GT) sites of two residents, as ordered by the physician and indicated in their care plans. Resident 45, who was admitted with diagnoses including dementia and required a feeding tube for nutrition, had a physician's order for daily cleansing and dressing of the GT site. However, the Treatment Administration Record (TAR) showed that the dressing was only changed on two specific dates, and an observation revealed that the dressing was not changed daily as required. The Infection Preventionist Nurse confirmed that the dressing should be changed daily to prevent infection. Similarly, Resident 54, who had diagnoses including diabetes mellitus and dementia, also had a physician's order for daily cleansing and dressing of the GT site. The TAR indicated that the dressing was changed on two specific dates, but an observation showed that the dressing was not clean and was falling off. The Certified Nurse Assistants and the Treatment Nurse confirmed that the dressing should be changed daily, including weekends, to prevent bacterial growth. The Director of Nursing also stated that the GT site should be checked daily for signs of infection and the dressing changed as ordered.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives to grab bars before their installation for two residents, placing them at risk for entrapment and injury. Resident 35, who was admitted with conditions including hemiplegia, hemiparesis, and depression, was observed with grab bars on both sides of the bed without documented evidence of alternative measures being attempted. The Director of Nursing (DON) confirmed that no less restrictive alternatives were tried before the installation of the grab bars, which is against the facility's policy. Similarly, Resident 14, who was readmitted with diabetes mellitus and heart failure, was found with grab bars on the bed frame, which he did not use and was unaware of their purpose. The DON acknowledged that the grab bars posed an accident hazard and that the resident's medical record lacked documentation of attempts to use alternatives before the grab bars were applied. The facility's policy requires that alternatives be attempted and evaluated before the use of bed rails, which was not adhered to in these cases.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop specific and individualized person-centered care plans for two residents, leading to potential inconsistencies in care. Resident 45, who was admitted with dementia, anxiety, and depression, did not have a care plan addressing dementia despite having severely impaired cognition and requiring substantial assistance with daily activities. The Registered Nurse Supervisor acknowledged the absence of a care plan for dementia and emphasized the need for one to monitor the effectiveness of interventions. The Director of Nursing confirmed that care plans should be developed upon admission and updated as needed. Similarly, Resident 55, diagnosed with End Stage Renal Disease and Congestive Heart Failure, was prescribed high-risk medications with black box warnings, including Furosemide and Tylenol with Codeine #3. However, the care plan did not address these medications, which are crucial for monitoring potential side effects and ensuring proper interventions. The Registered Nurse Supervisor and the Director of Staff Development both highlighted the necessity of care plans for such medications to guide staff in providing appropriate care. The facility's policy on comprehensive person-centered care plans, revised in March 2023, mandates the development of care plans within seven days of the MDS assessment and no more than 21 days after admission. These care plans should include measurable objectives and timetables to meet residents' needs and reflect recognized standards of practice. The lack of care plans for Residents 45 and 55 indicates a failure to adhere to these policies, potentially impacting the residents' well-being.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate care with a hospice provider for a resident, identified as Resident 34, by not ensuring that the Hospice Registered Nurse (HRN) visited the resident on three scheduled dates. This deficiency was identified through observation, interview, and record review. Resident 34 was readmitted to the facility with diagnoses including Alzheimer's disease and congestive heart failure (CHF), and had an order for hospice care due to CHF. Despite the hospice sign-in sheet indicating that the HRN visited on the scheduled dates, there was no documented evidence of visit notes for these dates. The Director of Nursing (DON) acknowledged the lack of documentation and stated that it was their responsibility to monitor and audit the scheduled visits of hospice staff to ensure that visit notes were completed. The facility's policy and procedures designated the DON to coordinate care provided by hospice staff to residents. The absence of documented visit notes meant that the assessed care needs of Resident 34 were not recorded, and collaboration with facility staff regarding hospice services was not documented.
Failure to Reposition Resident Leads to Worsening Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care to prevent and manage pressure ulcers for a resident, identified as Resident 14. Upon readmission to the facility, Resident 14 did not have any pressure ulcers. However, a subsequent assessment revealed the development of Stage 2 pressure ulcers on the left buttock, which initially healed but later reopened, along with a new ulcer on the right buttock. The care plan for Resident 14 specified the need for repositioning every two hours to alleviate pressure on the ulcers, a critical step in promoting healing and preventing further deterioration. Observations and interviews conducted over several days revealed that Resident 14 was consistently found lying on his back, contrary to the care plan's instructions. Certified Nursing Assistants (CNAs) acknowledged the failure to reposition the resident as required, citing workload and time constraints as reasons for the oversight. This lack of adherence to the care plan resulted in the worsening of the pressure ulcers, as evidenced by the increase in size and redness of the wounds upon subsequent examination.
Failure to Label PICC Line Dressing
Penalty
Summary
The facility failed to provide care and service for a resident receiving parenteral antibiotics consistent with professional standards of practice. The deficiency was identified when the PICC line dressing for a resident was observed without a label indicating the date it was applied. This oversight was noted during an observation in the resident's room, where the resident was sitting in a wheelchair with a PICC line at the right upper arm covered by dressing gauze. The absence of a date label on the dressing was confirmed during an interview with the Registered Nurse Supervisor, who acknowledged that the dressing should be changed and labeled with the date to ensure timely dressing changes and infection control. The resident involved had been admitted with diagnoses including sepsis and hypertension and was receiving daily intravenous Cefazolin Sodium due to sepsis. The facility's policy required that the PICC line dressing be changed every seven days or as needed when soiled, and that the dressing be labeled with the date, time, and nurse's initials. The failure to label the dressing as per the facility's policy and procedure had the potential to result in infection and worsen the resident's health condition.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide necessary care and services for a resident on oxygen therapy by not adhering to the physician's order. The resident, who was readmitted with diagnoses including Alzheimer's disease and heart failure, was prescribed two liters per minute of oxygen through a nasal cannula continuously for shortness of breath. However, observations revealed that the resident was receiving four liters per minute of oxygen, which was not in accordance with the physician's order. Licensed Vocational Nurse 4 admitted to forgetting to check the oxygen flow rate during rounds, resulting in the resident receiving excessive oxygen. This oversight was contrary to the facility's policy and procedure for oxygen administration, which mandates that oxygen therapy be administered as ordered by the physician. The failure to follow the prescribed oxygen flow rate placed the resident at risk for respiratory complications due to potential oxygen toxicity.
Failure to Perform Post-Dialysis Assessment
Penalty
Summary
The facility failed to perform a post-hemodialysis assessment for a resident, identified as Resident 186, who required dialysis care. Resident 186 was admitted with diagnoses including End Stage Renal Disease (ESRD) and hypotension, necessitating regular hemodialysis treatments. A review of the resident's Dialysis Communication Record (DCR) dated 9/30/2024 revealed that the post-dialysis assessment section was left blank, indicating that the necessary evaluation was not conducted upon the resident's return to the facility. During an interview, the Director of Nursing (DON) confirmed that the DCR should be completed immediately after the resident's return to ensure the dialysis access site was free from bleeding and that the resident's vital signs were stable. The facility's policy on the care of residents with ESRD emphasized the importance of staff being trained to perform assessments before and after dialysis sessions. The lack of documentation and assessment posed a potential risk for complications related to the hemodialysis site for Resident 186.
Failure to Maintain Cleanliness of Resident's Electric Fan
Penalty
Summary
The facility failed to maintain an electric fan in a safe and sanitary condition for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and asthma. The resident, who required substantial assistance with daily activities, had a dusty electric fan at their bedside. During an observation and interview, the resident confirmed the fan blades were dusty and could not recall the last time it was cleaned. Interviews with housekeeping staff and the maintenance supervisor revealed that equipment inside residents' rooms should be kept clean to prevent infection and maintain a comfortable environment. The facility's policy on maintaining a homelike environment emphasized the importance of a clean, sanitary, and orderly setting. However, the dusty fan in the resident's room indicated a lapse in adhering to these standards.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 out of 38 rooms met the required square footage of 80 square feet per resident in multiple resident rooms. During an observation, it was noted that Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39 did not meet this requirement. Despite this, residents were able to ambulate freely and nursing staff had sufficient space to provide care with dignity and privacy. The rooms contained necessary furniture and medical equipment, and there was space for mobility and movement of ambulatory residents. The facility's administrator acknowledged the deficiency and indicated that a room waiver would be submitted for these rooms. The waiver request stated that there was ample room for wheelchairs and other medical equipment, and that the health and safety of residents were not compromised. The waiver detailed that the rooms were in accordance with the special needs of the residents and did not adversely affect their health and safety. However, the square footage for these 3-bed rooms was below the minimum requirement of 240 square feet, with each room ranging from 225.50 to 234.89 square feet. Residents interviewed did not express concerns about the size of their rooms.
Failure to Document and Address Change in Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not assessing, monitoring, and documenting a change in the resident's condition, specifically a discoloration on the left cheek. The resident, who was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia, was observed with purple discoloration on the cheek. Despite this observation, there was no documentation of a change of condition report or a care plan addressing the discoloration. A Certified Nursing Assistant reported the discoloration to an LVN, who acknowledged the report but did not document it or notify the physician. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that the change of condition should have been reported and documented promptly. The facility's policies and procedures require notifying the physician of changes in a resident's condition and developing care plans based on comprehensive assessments. The failure to adhere to these procedures resulted in the resident's condition not being monitored, which could potentially delay necessary care and services.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for one resident, as per the facility's policies and procedures. The resident, who was admitted with diagnoses of hypothyroidism, essential hypertension, and type 2 diabetes mellitus, required substantial assistance with daily activities and was unable to self-administer medications. Despite this, several medications, including Laxaclear, Senokot, vitamin C tablets, and MiraFIBER gummies, were found at the resident's bedside during an observation. Interviews with the Infection Preventionist Nurse and the Administrator confirmed that the resident preferred having medications at the bedside, but was unable to self-administer them due to limited mobility. The facility's policies indicated that medications not authorized for self-administration should be returned to the nurse in charge, and all medications should be stored in locked compartments. The presence of medications at the resident's bedside posed a risk of access by other residents or unauthorized persons.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential delay in care. Resident 2, who was admitted with a fracture of the right femur, muscle weakness, and dysphagia, was observed lying in bed unable to reach the call light, which was hanging off the bed. The resident expressed hunger and was dependent on staff for various activities, including toileting hygiene and personal hygiene. A Licensed Vocational Nurse (LVN) adjusted the call light to be within reach, acknowledging that Resident 2 usually used the call light for assistance. Similarly, Resident 3, admitted with cerebral infarction, epilepsy, and dysphagia, reported that the call light was often not within reach, sometimes found on the floor. This resident was dependent on staff for toileting hygiene and showering. During an interview, Resident 3 stated that they had to shout for assistance when the call light was unreachable. The facility's policy indicated that call lights should be accessible to residents from their bed, toilet, shower, or floor, but this was not adhered to in these instances.
Failure to Implement Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for the use of an antipsychotic medication for one of the residents. The resident was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia. The resident's Minimum Data Set indicated that the resident was understood by others and had the ability to understand others, and also had hallucinations. The resident had physician orders for Seroquel, an antipsychotic medication, but there was no care plan in place to address the use of this medication, including how to provide care, monitor side effects, and assess the medication's effectiveness. During an interview, the Assistant Director of Nursing confirmed that the resident should have had a care plan for the use of the antipsychotic medication. The facility's policy and procedure for comprehensive, person-centered care plans, which was revised in March 2022, indicated that such care plans should include measurable objectives and timeframes to meet the resident's needs. However, this was not implemented for the resident in question, leading to the deficiency noted in the report.
Failure to Follow Antipsychotic Medication Policy
Penalty
Summary
The facility failed to follow its policy and procedure for antipsychotic medication use for one resident. Specifically, the facility did not attempt non-pharmacological interventions before starting the resident on Seroquel, an antipsychotic medication. Additionally, the facility did not conduct a psychiatric evaluation before initiating or increasing the dosage of Seroquel. The resident was admitted with diagnoses including atherosclerotic heart disease, heart failure, and dementia, and exhibited behaviors such as hallucinations. Despite these symptoms, there was no documentation of non-pharmacological interventions or a psychiatric evaluation before the medication was prescribed and increased. The Assistant Director of Nursing confirmed that a psychiatric evaluation should have been conducted and that non-pharmacological interventions should have been documented. The facility's policy required the attending physician and staff to gather and document information about the resident's behavior, mood, function, and medical condition, and to attempt non-pharmacological interventions unless contraindicated. However, these steps were not followed, leading to the potential use of unnecessary medication for the resident.
Failure to Ensure Resident was Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, a Licensed Vocational Nurse (LVN) administered Narcan nasal spray instead of Flonase nasal spray to a resident. This error occurred because the LVN did not check the medication label three times as required by the facility's policy and procedure for administering medications. The resident experienced severe adverse reactions, including chest pain, a burning sensation, and feelings of impending death, and was subsequently transferred to a hospital for treatment of acute opioid withdrawal induced by the accidental Narcan administration. The resident had a history of asthma, allergic rhinitis, and chronic pain managed with Percocet and occasionally Morphine. The resident's physician had prescribed Flonase for nasal congestion and Narcan for emergency use in case of opioid overdose. On the day of the incident, the LVN retrieved a box labeled with the resident's name but did not verify the medication inside. Despite the resident's protest that the medication did not look familiar, the LVN insisted it was correct and administered it. Immediately after administration, the resident experienced severe symptoms and was transferred to the hospital. Interviews with the LVN, the Pharmacist Consultant, and the Director of Nursing revealed that the LVN did not follow the five rights of medication administration, which include verifying the right medication, dose, time, route, and patient. The facility's policy and procedure for administering medications also emphasized the importance of checking the medication label three times to prevent errors. The LVN admitted to not following these protocols, which led to the medication error and the resident's subsequent adverse reaction.
Medication Error Due to Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that all nursing staff had the appropriate skills and competencies necessary to provide nursing care safely, resulting in a medication error that caused significant harm to a resident. Licensed Vocational Nurse (LVN) 1 administered the incorrect medication to a resident, leading to the resident experiencing severe adverse effects and requiring hospitalization. The error occurred because LVN 1 did not check the medication label before administration, mistakenly giving Narcan instead of the prescribed Flonase nasal spray. The resident, who had intact cognition and required supervision for various activities, was admitted with diagnoses including asthma, allergic rhinitis, and phantom limb syndrome with pain. The resident had a physician's order for Flonase nasal spray and Narcan nasal liquid for opioid overdose. On the day of the incident, LVN 1 administered Narcan instead of Flonase, causing the resident to experience chest pain, a burning sensation, and a feeling of impending death. The resident was subsequently transferred to a general acute care hospital for treatment of acute opioid withdrawal induced by the accidental Narcan administration. Interviews and record reviews revealed that LVN 1 did not follow the facility's policy and procedure for medication administration, which includes checking the medication label and ensuring the five rights of medication administration. Additionally, LVN 1 had not completed the required medication competency assessments before administering medications independently. The Director of Staffing Development and the Director of Nursing confirmed that the facility did not adhere to its policies on competent staffing and medication management, which contributed to the medication error and subsequent harm to the resident.
Failure to Document Medication Administration Accurately
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for a resident by not ensuring that an LVN documented the administration of Narcan nasal liquid instead of fluticasone furoate suspension. The incident occurred when the LVN administered Narcan to the resident, who immediately experienced severe adverse reactions, including chest pain, a burning sensation, and acute withdrawal symptoms. The resident was subsequently transferred to an emergency department for treatment, where it was confirmed that Narcan had been administered instead of the prescribed Flonase nasal spray. The resident, who had a history of asthma, allergic rhinitis, and chronic pain managed with opioids, was admitted to the facility with specific medication orders, including Flonase for nasal congestion and Narcan for opioid overdose. On the day of the incident, the LVN mistakenly administered Narcan, believing it to be Flonase, and failed to document this administration in the Medication Administration Record (MAR). The resident's immediate adverse reactions led to an emergency transfer to a hospital, where the error was identified and treated. Interviews with the resident, the LVN, and the Director of Nursing (DON) revealed that the LVN did not verify the medication label before administration and did not document the error in the MAR. The facility's policy required accurate documentation of all administered medications to ensure safety and communication among the care team. The failure to document the administration of Narcan accurately could lead to further medication errors and adverse effects, as noted by the DON.
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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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Illustrative
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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) |
|---|---|---|---|---|
| Victoria Care Center | 0.5 mi | — | 13 | 0 |
| West Covina Medical Center D/p Snf | 0.6 mi | — | 15 | 0 |
| Garden View Post Acute Rehabilitation | 0.6 mi | — | 18 | 0 |
| West Haven Healthcare | 0.6 mi | — | 16 | 0 |
| Clara Baldwin Stocker Home For Women | 1.2 mi | — | 24 | 0 |
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