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 Medical Center D/p Snf during CMS and state inspections, most recent first.
LVNs did not complete required narrative charting for a resident with chronic respiratory failure, Alzheimer's, COPD, tracheostomy, and gastrostomy on two shifts, resulting in missing and inaccurate medical records. Staff confirmed the absence of documentation, which was required by facility policy to ensure accurate assessment and care.
The facility failed to ensure call lights were within reach for two residents with chronic respiratory failure and ventilator dependence. Both residents required assistance with ADLs, and their care plans specified that call lights should be accessible. Observations revealed call lights were hanging on the wall, out of reach, which was confirmed by staff. The ADON acknowledged the need for call lights to be placed near the residents' strong extremities, as per facility policy.
The facility failed to provide Advance Directive (AD) information for three residents, violating its policy. A resident with severe cognitive impairment and another dependent on a ventilator lacked AD documentation, and a third resident with chronic respiratory failure also had no AD in their records. This failure to adhere to policy could lead to treatment against residents' wishes.
The facility failed to provide necessary care for the gastrostomy tube sites of two residents, leading to potential complications. One resident's GT site was found with a dislodged dressing and was dirty, while another's site lacked a dressing and was unclean. Both residents had orders for specific GT care that were not followed, as confirmed by staff interviews.
The facility failed to provide proper respiratory care for two residents. One resident's oxygen cannula was not connected to the tracheostomy T-bar as ordered, and another resident did not receive tracheostomy care with hydrogen peroxide as prescribed. These oversights were contrary to the facility's policies and placed the residents at risk for health complications.
The facility failed to follow proper food storage and labeling practices, leading to potential cross-contamination risks. Thawed meat was stored above uncovered bread, and several food items lacked labels and dates. Interviews confirmed these practices violated facility policies, posing a risk of foodborne illnesses.
A resident with a bladder disorder and UTI had their catheter bag left uncovered, contrary to the facility's policy requiring a dignity bag for privacy. The resident expressed a preference for the privacy bag, and the ADON acknowledged the need for it to maintain dignity.
A facility failed to notify the State LTC Ombudsman of a resident's emergency transfer to a hospital. The resident, with a tracheostomy and pneumonia, was transferred due to fluctuating oxygen saturation. The facility's policy required notification, but no Notice of Proposed Transfer/Discharge Form was completed, and the Ombudsman was not informed.
A resident with chronic respiratory failure and a gastrostomy had a Stage 2 pressure ulcer that was not treated according to the physician's order. The order required cleaning with normal saline, applying betadine, and covering with Tegaderm, but a foam dressing was used instead. This deviation from the prescribed treatment could hinder wound healing and increase infection risk.
A facility failed to provide RNA services as ordered for a resident with chronic respiratory failure and ventilator dependence. The resident's care plan required PROM exercises and the application of hand rolls and an elbow splint. However, the RNA did not apply these devices and incorrectly documented that they were provided. This was confirmed by the ADON, highlighting a failure to adhere to the facility's policy on accurate treatment documentation.
A facility failed to label and date an IV catheter for a resident with chronic respiratory failure and a gastrostomy, increasing the risk of infection. The resident's IV site was observed without a label, contrary to the facility's policy requiring labeling for infection control. The ADON acknowledged the oversight, which could worsen the resident's health condition.
A facility failed to act on a pharmacist's recommendation for a resident's medication regimen review. The resident, with chronic respiratory failure and a gastrostomy, was prescribed Enoxaparin for DVT prevention. The MRR suggested consulting the physician for the term of therapy, but this was not documented. The ADON admitted to missing the MRR and not contacting the physician, contrary to facility policy.
A resident on contact isolation for Candida auris was exposed to potential infection spread when the ADON entered the room without properly wearing an isolation gown, allowing their coat to touch the resident's clothes. The facility's P&P required proper PPE use to prevent contamination, which was not followed.
A facility failed to maintain an electric fan in a safe and sanitary condition for a resident with chronic respiratory failure and ventilator dependence. The fan was unstable, dusty, and broken, posing a risk to the resident's health. The ADON noted that housekeeping should clean equipment daily, and maintenance should repair broken items, as per facility policy.
Failure to Document Resident Assessments Per Shift
Penalty
Summary
Licensed Vocational Nurses (LVNs) failed to accurately document daily narrative charting during each shift for a resident with complex medical needs, specifically on two dates. The facility's policy and procedure required documentation during each shift, including patient assessment and the status of medical devices such as IV lines, tracheostomy, and gastrostomy tubes. However, record review and staff interviews confirmed that narrative charting was missing for both the night and day shifts on the specified dates. Staff, including LVNs and the Charge Nurse, acknowledged the absence of required documentation and emphasized the importance of maintaining accurate records for resident care. The resident involved had a medical history of chronic respiratory failure, Alzheimer's disease, COPD, and had both a tracheostomy and gastrostomy in place. During observation, the resident was found awake, resting, and appeared confused, with fluctuating capacity to understand. The lack of documentation resulted in the resident's medical record containing inaccurate information regarding patient assessment, which had the potential to affect the provision of care. The deficiency was identified through interviews, record review, and observation, confirming non-compliance with the facility's documentation policy.
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 123, who had chronic respiratory failure and was dependent on a ventilator, was found to have a call light hanging on the wall, out of reach. This resident had severely impaired cognition and was dependent on assistance for activities of daily living (ADLs), as indicated in their care plan, which specified that the call light should be within reach at all times. During an observation, a Certified Nurse Assistant confirmed that the call light was not placed near the resident's strong arm or hand, which was necessary for the resident to call for help in case of an emergency. Similarly, Resident 2, who also had chronic respiratory failure and was ventilator-dependent, was observed with a call light hanging on the wall, not within reach. This resident had intact cognition but was dependent on assistance for ADLs, as noted in their care plan. A Licensed Vocational Nurse confirmed that the call light should have been placed near the resident's strong arm or hand to enable them to call for help. The Assistant Director of Nursing acknowledged that both residents had touch-sensitive call lights due to their medical conditions and reiterated the importance of placing the call lights within easy reach, as per the facility's policy and procedure.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information on Advance Directives (AD) for three residents, which is a violation of the facility's policy. Resident 20 was admitted with severe cognitive impairment and was dependent on assistance for daily activities. During a review of Resident 20's medical records, the Assistant Director of Nursing (ADON) could not find the Advance Directive Acknowledgement Form, and there was no documentation that AD was discussed or identified if Resident 20 had a previous AD. This lack of documentation meant that the staff could not determine Resident 20's healthcare wishes. Similarly, Resident 6, who was dependent on a ventilator and had severely impaired cognition, did not have an AD documented in their records. The ADON 2 confirmed that there was no evidence that the resident or their responsible party was provided with information on formulating an AD. Resident 14, who had chronic respiratory failure and was dependent on a gastrostomy, also lacked an AD in their medical records. The facility's policy requires that upon admission, the presence of an AD should be identified, and if absent, the resident should be given the opportunity to formulate one. The absence of these documents in the residents' records indicates a failure to adhere to this policy, potentially leading to medical treatment against the residents' wishes.
Failure to Provide Proper Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for the gastrostomy tube (GT) sites of two residents, leading to potential complications. Resident 123, who was admitted with chronic respiratory failure and dependence on a ventilator, had a physician's order for gastrostomy care that included cleaning with half-strength hydrogen peroxide and normal saline, patting dry, and applying a drain sponge every shift. However, during an observation, it was noted that Resident 123's GT site had a dislodged drain sponge dressing, was red, and dirty, indicating that the care plan was not followed as ordered. Similarly, Resident 2, also admitted with chronic respiratory failure and dependence on a ventilator, had a physician's order for similar gastrostomy care. An observation revealed that Resident 2's GT site lacked a drain sponge dressing and was not clean, contrary to the care plan that required the site to be kept clean and dry at all times. Interviews with the LVN and the Assistant Director of Nursing confirmed that the GT sites should be kept clean and covered to prevent skin irritation and infection, as per the facility's policy and procedure.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to potential health risks. For Resident 4, the oxygen cannula was not connected to the tracheostomy T-bar as ordered by the physician. This oversight was observed during a visit, where the resident was found lying in bed without the necessary oxygen connection. The facility's policy indicated that oxygen therapy should be administered as per the physician's order, which was not followed in this case. The resident had a history of respiratory issues, including pneumonia and impaired cognition, making the proper administration of oxygen crucial. For Resident 16, the facility did not adhere to the physician's order for tracheostomy care. The order specified the use of hydrogen peroxide and normal saline for cleaning the tracheostomy site, but the respiratory therapist only used normal saline. The therapist was unaware of the specific order, which was crucial for preventing infection. The resident, who had chronic respiratory failure and was dependent on a ventilator, was at risk due to this oversight. The facility's policy also required the use of hydrogen peroxide for cleaning, which was not followed, potentially exposing the resident to infection risks.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the proper storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. During an initial tour of the kitchen, it was observed that thawed meat was improperly stored on the top shelf of a refrigerator, directly above uncovered sliced bread, posing a risk of cross-contamination. Dietary Aid 1 acknowledged that thawed meat should not be placed above bread due to the potential for blood to drip onto the bread. Additionally, several food items in the kitchen freezer, including a bag of whole corn kernel, penne pasta, and liquid marinade, were found without labels or dates indicating when they were first opened, contrary to the facility's policy. Interviews with the Dietary Supervisor and Kitchen District Manager confirmed the improper practices observed. The Dietary Supervisor stated that bread should not be stored below raw meat to prevent cross-contamination, and all food items should be labeled and dated to track their usage. The Kitchen District Manager reiterated that uncooked meat should not be mixed with ready-to-eat food due to the risk of cross-contamination. A review of the facility's policies and procedures indicated that food should be thawed in a drip-proof container to prevent cross-contamination and that all foods should be stored in covered containers, labeled, and dated. These deficiencies in food handling practices had the potential to cause foodborne illnesses.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident with an indwelling catheter, as required by their policy. The resident, who had been admitted with a bladder disorder and urinary tract infection, had a care plan that included the use of a dignity bag to cover the catheter bag. However, during an observation, the catheter bag was found uncovered, hanging on the side of the bed without the dignity bag in place. The Assistant Director of Nursing confirmed that the catheter bag should have been covered to maintain the resident's dignity. The resident expressed a desire for the catheter bag to be inside the privacy bag, indicating awareness and preference for privacy. The facility's policy on urinary catheter care, revised earlier in the year, also stipulated the use of a dignity bag for the drainage bag, which was not adhered to in this instance.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of the Notice of Proposed Transfer and Discharge for a resident who was transferred to a General Acute Hospital. The resident, who had been admitted with diagnoses including attention to tracheostomy and pneumonia, was transferred via emergency services due to fluctuating oxygen saturation. The facility's policy required notification of the Ombudsman in such cases, but this was not done. During the review of the resident's medical records, it was found that there was no completed Notice of Proposed Transfer/Discharge Form, and the Ombudsman was not notified of the transfer. Interviews with the facility's Medical Records staff and Assistant Director of Nursing confirmed the lack of notification. The facility's policy indicated that for emergency transfers, notice should be provided as soon as practicable, but this procedure was not followed.
Failure to Follow Physician's Order for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care and services to promote the healing of a pressure ulcer for a resident, as ordered by the physician. The resident, who was readmitted to the facility with chronic respiratory failure and a gastrostomy, was dependent on staff for personal hygiene and bathing. The physician's order specified that the resident's Stage 2 pressure ulcer on the right middle back should be cleaned with normal saline, painted with betadine, and covered with Tegaderm every three days for 21 days. During an observation of a dressing change, it was noted that a foam dressing was used instead of Tegaderm, contrary to the physician's order. LVN 3 confirmed that the previous dressing change did not follow the physician's order, which could affect wound healing and increase the risk of infection. The facility's policy and procedure for wound care emphasized the importance of following physician orders to ensure effective treatment and promote healing.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to provide Restorative Nurse Assistant (RNA) services as ordered by the physician for a resident, identified as Resident 123. The resident, who was admitted with chronic respiratory failure and ventilator dependence, had severely impaired cognition and was dependent on assistance for daily activities. The care plan for the resident included a maintenance program for range of motion (ROM) and the use of splints to aid mobility, with specific orders for passive range of motion (PROM) exercises and the application of hand rolls and an elbow splint five times a week. However, during an observation and interview, it was found that the RNA did not apply the hand rolls and elbow splint as documented in the restorative record. The RNA admitted to only performing PROM exercises and incorrectly signing the record to indicate that all ordered services were provided. This discrepancy was confirmed by the Assistant Director of Nursing, who emphasized the importance of implementing RNA services as ordered to prevent further contractures and decrease in ROM. The facility's policy required accurate documentation of treatments provided, which was not adhered to in this case.
Failure to Label and Date IV Catheter
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident, specifically in the labeling and dating of a peripherally inserted intravenous (IV) catheter. This deficiency was identified during an observation of a resident who had an IV site on the left hand that was not labeled with the insertion date. The Assistant Director of Nursing (ADON) confirmed that the IV site should have been labeled with the date of insertion to facilitate proper infection control and maintenance of IV patency. The absence of labeling could lead to an increased risk of infection, potentially worsening the resident's health condition. The resident involved had been readmitted to the facility with chronic respiratory failure and a gastrostomy. The resident's Minimum Data Set (MDS) indicated significant communication limitations and dependency on assistance for personal hygiene and bathing. The facility's policy and procedure for intravenous infusion, reviewed in January 2022, required that a sterile dressing be applied over the IV site and that the site be initialed, dated, and timed. The failure to adhere to this policy was observed during a survey, highlighting a lapse in following professional standards of practice for IV care.
Failure to Act on Pharmacist's Recommendation for Medication Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's Medication Regimen Review (MRR) recommendation for a resident, identified as Resident 8. The resident was admitted with chronic respiratory failure and had a gastrostomy. The resident's Minimum Data Set (MDS) indicated unclear speech and dependency on others for personal hygiene and bathing. The resident was prescribed Enoxaparin for Deep Vein Thrombosis (DVT) prevention. The MRR recommended consulting the resident's physician to determine the term of therapy for Enoxaparin use. However, there was no documentation in the resident's medical record indicating that the MRR recommendation was followed. During an interview, the Assistant Director of Nursing (ADON 1) admitted to not acting on the pharmacist's recommendation and acknowledged missing the MRR, which led to not contacting the physician for the term of therapy. The facility's policy required that recommendations be acted upon and documented, but this was not done, potentially leading to unnecessary medication use.
Improper Use of PPE in Contact Isolation
Penalty
Summary
The facility failed to ensure that staff used Personal Protection Equipment (PPE) in accordance with its Policy and Procedure (P&P) on infection prevention and control for a resident who was on contact isolation due to a diagnosis of Candida auris, a communicable disease. The resident, who was readmitted with chronic respiratory failure and a gastrostomy, was dependent on staff for personal hygiene and bathing. During an observation, the Assistant Director of Nursing (ADON) entered the resident's room without properly wearing the isolation gown, as their arms were not inside the sleeves, and made direct contact with the resident, allowing their coat to touch the resident's clothes. The Infection Preventionist Nurse confirmed that proper PPE, including mask, gown, and gloves, should be worn by anyone entering a room with contact isolation, and that arms should be inside the gown sleeves to prevent the transmission of bacteria. The facility's P&P on Infection Prevention and Control, revised in July 2022, indicated that gowns are to be worn to prevent direct contamination from patients' secretions, excretions, or other body fluids. The failure to adhere to these guidelines had the potential to spread infection and communicable diseases within the facility.
Unsafe and Unsanitary Electric Fan in Resident's Room
Penalty
Summary
The facility failed to maintain an electric fan in a safe, operating, and sanitary condition for a resident with chronic respiratory failure and dependence on a ventilator. The resident, who had severely impaired cognition and was dependent on assistance for daily activities, had a black electric fan at their bedside that was observed to be wiggly and unstable when moved. The fan's vents were dusty and covered with lint, and it was described as broken by a Licensed Vocational Nurse (LVN) during an observation and interview. The Assistant Director of Nursing (ADON) stated that housekeeping staff were responsible for cleaning equipment in residents' rooms daily to prevent infection, and maintenance staff were required to fix broken equipment for resident safety. The facility's policy on Physical Environment and Space Equipment emphasized maintaining all mechanical, electrical, and patient care equipment in a safe operational condition. This deficiency had the potential to affect the resident's quality of life and overall health, particularly given their respiratory condition.
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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) |
|---|---|---|---|---|
| West Haven Healthcare | 0.2 mi | — | 16 | 0 |
| West Covina Healthcare Center | 0.6 mi | — | 16 | 0 |
| Clara Baldwin Stocker Home For Women | 0.7 mi | — | 24 | 0 |
| Victoria Care Center | 0.7 mi | — | 13 | 0 |
| Garden View Post Acute Rehabilitation | 1.2 mi | — | 18 | 0 |
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