West Covina Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to provide timeliness diagnostic services to meet the needs for two of three sampled residents (Resident 7 and Resident 8) by failing to: 1. Ensure Resident 7 received a PET scan (Positron Emission Tomography imaging scans- use a radioactive tracer to check for signs of cancer, heart disease and brain disorders) as ordered on 5/21/2026.2. Ensure Resident 8 received a CT scan (A Computerized Tomography scan- is a type of imaging that uses X-ray techniques to create detailed images of the body) for abdominal pain as indicated in the physician's order dated 7/12/2026. These deficient practices resulted in delays in diagnoses services for Resident 7 and 8 and had the potential in worsening Resident 7 and 8's anxiety that could cause emotional and psychosocial distress.a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 4) was not given six medications (vitamin D3- a supplement, amlodipine- used to treat high blood pressure and chest pain [angina], atenolol- used to treat high blood pressure, angina and improve survival after a heart attack, levetiracetam- used to control partial-onset seizures, zinc- a supplement, vitamin C- a supplement) which were not ordered for Resident 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record for one of three sampled residents (Resident 7) was accurately documented when the nurse documented Resident 7's PET scan (Positron Emission Tomography imaging scans- use a radioactive tracer to check for signs of cancer, heart disease and brain disorders) was done in Resident 7's Progress Notes (PN) on 6/3/2026 instead of not being done in fact. This deficient practice resulted in inaccurate documentation in Resident 7's medical record and had the potential for delaying interventions and services for Resident 7. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan for Resident 1's pain in the left shoulder. This deficient practice had the potential for Resident 1 receiving delayed, inadequate and/or inappropriate care and treatment and to not maintaining Resident 1's highest practicable physical, mental, and psychosocial well-being. During a review of Resident 1's admission Record (AR), dated 5/8/2026, the AR indicated Resident 1 was originally admitted to the facility on [DATE]. The AR indicated Resident 1's diagnoses included morbid obesity (a chronic disease in which a person weighs 100 pounds or more over his/her ideal body weight), chronic pain syndrome (a condition where persistent pain lasts for more than 3 to 6 months), and spinal stenosis (the narrowing of the tunnel in a person's spine that contains the spinal cord and nerves). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Release of Information, for one of four sampled residents (Resident 1). This failure violated the rights of Resident 1's responsible party (RP- a relative or friend who handles the patient's finances and helps with medical decisions) to obtain a copy of Resident 1's medical records within the time frame indicated in the facility's P&P on release of medical records.

Inspectors wroteBased on interview and record review, the facility failed to initiate neurological assessment (a check of how well the brain, nerves, and muscles work often performed after a suspected head injury) for two of eight sampled residents (Residents 1 and 2) after a resident-to-resident physical altercation (a fight or struggle where people used physical force, contact, or aggression against each other) that involved allegations of unwitnessed head injuries on 12/20/2025. These failures had the potential to compromise Residents 1's and Resident 2's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a specific and person - centered care plans for two of two sampled residents (Resident 73 and Resident 99). These deficient practices had the potential for Resident 73 and Resident 99 to not receive appropriate care, treatment, and/or services related to their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage and handling practices by failing to label and discard expired food items stored in the facility's kitchen and residents' refrigerator. The facility failed to ensure:1. The kitchen staff removed expired food items from the kitchen refrigerator: a total of five [5] individually packaged peanut butter and jelly (PBJ) half sandwiches inside a white plastic container and a pack of flour tortillas.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (harmful germs entered and grew in the body) control measures for two of two sampled residents (Residents 73 and Resident 103) by failing to: a. Rinse off the syringe used for administering gastrostomy-tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly into the stomach. It is commonly used for people with swallowing problems) medication for Resident 73. b. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain written informed consent for one of five sampled residents (Resident 4) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. This deficient practice had the potential for Resident 4 not to receive adequate or sufficient information regarding psychotropic medications necessary to make an informed health care decision.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Advance Directive (AD, a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) for one of two sampled residents (Resident 46) was readily accessible in accordance with the facility's Policy and Procedure (P&P) titled Advance Directives. This failure had the potential for facility staff to provide medical treatment and services against the resident's will.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 4's target behavior was monitored for the use Lexapro (antidepressant - antidepressant - a medication that change the way the brain uses certain chemicals to regulate mood and behavior) for one of five sampled residents (Resident 4) as indicated in the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately coded for surgical wound for one of one sampled resident (Resident 99). This failure had the potential to place Resident 99 at risk of not receiving necessary care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sample resident (Resident 4) had a physician's order for the use of oxygen (a medical treatment used to help a person to breathe more easily) at two and a half liters per minute through nasal cannula (a medical device used for oxygen therapy). This failure had the potential to place Resident 4 at risk for complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its protocol for antibiotic (a substance used to kill bacteria and to treat infections) use for one of one sampled resident (Resident 36), who had received and was receiving antibiotics from 12/2/2025. This deficient practice had the potential for Resident 36 to develop antibiotic resistance and to receive antibiotics without justification.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a medication regimen review (MRR) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sample resident (Resident 4). This deficient practice had the potential for harm due to the missed opportunity by the physician and the licensed staff to act upon the reported irregularities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., a unit of measurement) per resident area for fourteen (13) out of thirty-eight (38) resident rooms (Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39). This deficient practice had the potential to impact on the ability to provide safe nursing care and maintain the privacy of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff response/answer to Residents' call lights in a timely manor for three of three sampled Residents (Residents 1, 2, and 3). These deficient practice violated Residents 1, 2 and 3's rights, delayed in care and services and had the potential to affect Residents 1, 2, and 3's health.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse Investigation and Reporting, by failing to report an alleged verbal abuse to the facility's Abuse Coordinator, California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individual's complaints and assists in resolution of concerns), and the local law enforcement immediately and within 2 hours on 12/19/2024 for one of five sampled residents (Resident 2) when Resident 2 allegedly called Resident 1 derogatory words. This failure had the potential to subject Resident 1 to potential further abuse from Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Residents 29 and 80) by failing to ensure the resident's call lights (an alerting device for nurses or other nursing personnel to assist a patient when in need) were within reach and appropriate to the resident's physical ability. These deficient practices had the potential for Residents 29 and 80 not to receive necessary care or delayed services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) was discussed, written information was provided to the residents and/or responsible parties and current copy was in the medical chart for three of three sampled residents (Residents 12, 54 and 78) consistent with the facility's policy and procedure on advance directives. These failures had the potential for facility staff to provide medical treatment and services against the resident's will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for two of two sampled residents (Residents 45 and 54). These failures had the potential for complications related to tube feedings for Residents 45 and 54.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt the use of appropriate alternatives to grab bars before its installation for two of two sampled residents (Residents 35 and 14). These deficient practices placed Residents 35 and 14 at risk for entrapment and injury from the use of bedrails.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a specific and individualized person-centered care plan to meet the resident's needs for two of two sampled residents (Residents 45 and 55). a. A care plan was not developed for Resident 45 with dementia (a progressive state of decline in mental abilities). b. A care plan was not developed for Resident 55 for the use of black box medications - Furosemide (water pill that treats fluid retention) and Tylenol #3 with Codeine 3 (a combination narcotic drug that is used to relieve mild to moderate pain). These failures had the potential to result in inconsistent implementation of the care to Residents 45 and 55.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate care with hospice (compassionate care for people near the end of life) provider for one of two sampled residents (Resident 34) by failing to ensure the Hospice Registered Nurse (HRN) visited Resident 34 on 9/19/24, 9/23/24 and 9/30/24, as scheduled. This deficient practice placed Resident 34 at risk of not receiving appropriate care in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote healing and prevent development of pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of one sampled resident (Resident 14) by failing to ensure Resident 14 was not lying on the site of the pressure ulcer and was repositioned every two hours while in bed. This deficient practice placed Resident 14 at risk for further skin breakdown, prevent healing of the wound and/or worsen the pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure one of one sampled resident (Resident 185) received care and service for parenteral antibiotic (a drug used to treat infections caused by bacteria and other microorganisms) consistent with professional standards of practice. The PICC line dressing was not labeled with date indicating when the dressing was applied. This failure had the potential to result in infection to the resident and worsen the resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for one of one sampled resident (Resident 34) on oxygen therapy (treatment that provides supplemental, or extra oxygen) consistent with professional standards of practice, by failing to follow the physician's order to provide two liters of oxygen through nasal cannula (a flexible soft tube that delivers extra oxygen through a tube and into the nose) to Resident 34. This deficient practice placed Resident 34 at risk for difficulty of breathing and respiratory complications.

Inspectors wroteBased on interview and record review, the facility failed to perform post (after) hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed to function) assessment for one of two sampled residents on HD (Resident 186). This failure had the potential to placed Resident 186 at risk for complications from the hemodialysis site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe and sanitary condition for one of one sampled resident (Resident 12). This failure had the potential to affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 13 out of 38 rooms (Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38 and 39) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential to adversely affect the residents' health, safety, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services as indicated in the facility's policies and procedures (P&P) titled, Change in a Resident's Condition or Status and Goals and Objectives, Care Plans for one of three sampled residents (Resident 1) by failing to: 1. Ensure assigned Licensed Vocational Nurses (LVNs) assessed, monitored, and documented Resident 1's left cheek discoloration as a change of condition (COC - clinical change from a resident's baseline in physical, cognitive, behavioral, or functional status) in Resident 1's clinical record. 2. Ensure assigned LVNs developed a care plan (CP - a formal process that outlines the goals, objectives, and evaluation of the nursing care provided for a patient) regarding Resident 1's left cheek discoloration. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure storage of medications for one of three sampled residents (Resident 2) as indicated in the facility's policies and procedures (P&P) titled, Self-Administration of Medications, and Medication Labeling and Storage. This deficient practice had the potential for other residents and unauthorized persons to access Resident 2's medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of three sampled residents (Residents 2 and 3). This deficient practice had the potential to result in the delay of care for Residents 2 and 3 when Residents 2 and 3 were unable to reach their call lights to call staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan for the use of an antipsychotic medication (medication used to treat psychotic [having severe mental illness] disorders]) for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to not receive the type of care and services necessary for the use of an antipsychotic medication.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Antipsychotic Medication Use, for one of three sampled residents (Resident 1) by: 1. Failing to attempt to provide non-pharmacological interventions (referring to treatments that do not involve the use of medications) before starting an antipsychotic (a medication used to treat psychotic [having severe mental illness] disorders) medication. 2. Failing to provide a psychiatric evaluation (a clinical assessment of an individual ' s mental state) for the use of the antipsychotic medication. These deficient practices had the potential to result in the use of an unnecessary medication for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication error (medication error which causes the resident discomfort or jeopardizes the resident health and safety) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 administered fluticasone furoate suspension (Flonase- nasal [nose] spray medication used to treat nasal congestion, sneezing, and runny nose caused by seasonal allergies [body's reaction to normally harmless substances]) instead of Narcan nasal liquid (nasal spray medication used to rapidly reverse the effects of opioid [class of drugs used to treat moderate to severe pain] overdose) to Resident 1 on 3/14/2024 at 7:00 pm. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all nursing staff had the appropriate skills and competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics an individual needed to perform work roles or occupational functions successfully) necessary to provide nursing care safely to one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, and Administering Medication by failing to: Ensure Licensed Vocational Nurse (LVN) 1 had demonstrated the skills and proper techniques necessary to care for Resident 1 with regards to medication management and/or medication administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurately documented medical record for one of three sampled residents (Resident 1) by failing to: Ensure Licensed Vocational Nurse (LVN) 1 documented the administration of Narcan nasal liquid (Naloxone Hydrochloride [HCl]- nasal [nose] spray medication used to rapidly reverse the effects of opioid [class of drugs used to treat moderate to severe pain] overdose) instead of fluticasone furoate suspension (Flonase- nasal spray medication used to treat nasal congestion, sneezing, and runny nose caused by seasonal allergies [body's reaction to normally harmless substances) to Resident 1 on 3/14/2024 at 7 pm. This failure had the potential for Resident 1 to not receive appropriate care and treatment due to an incomplete/inaccurate medical record and could lead to more medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a resident-centered comprehensive care plan to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of five sampled residents (Resident 1) by failing to: Ensure Certified Nursing Assistant (CNA) 1 provided two-person physical assistance (help from two person) when CNA 1 turned Resident 1 to one side while bathing Resident 1 on the bed as indicated in Resident 1's Care Plan titled, Activities of Daily Living (ADL)/Self-Care Deficits, initiated on 10/6/2023, and the facility's policies and procedures titled, Fall and Fall Risk, Managing, and Care Plans, Comprehensive Person-Centered. As a result, on 12/12/2023 at 10:30 AM, Resident 1 fell from Resident 1's bed to the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of five sampled residents (Resident 1) by failing to: Ensure CNA 1 provided two-person physical assistance (help from two person) when CNA 1 turned Resident 1 to one side while bathing Resident 1 on the bed as indicated in Resident 1 ' s Care Plan titled, Activities of Daily Living (ADL)/Self-Care Deficits, initiated on 10/6/2023, and the facility's policies and procedures titled, Fall and Fall Risk, Managing, and Care Plans, Comprehensive Person-Centered. As a result, on 12/12/2023 at 10:30 AM, Resident 1 fell from Resident 1's bed to the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the spread of infection during a Coronavirus-19 (COVID-19 an illness caused by a virus that can spread from person to person) outbreak (the occurrence of disease cases more than normal expectancy) in the facility, which started on 11/17/2023, by failing to: 1. Ensure Resident 2 was assessed for COVID-19 symptoms and Resident 2's vital signs (measurement of essential body functions, including pulse rate, respiration [breathing] rate, body temperature, and blood pressure) were monitored at least every 24 hours during the facility's COVID-19 outbreak (OB). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent the development of pressure ulcers/pressure injuries (PU/PI- refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of two sampled residents (Resident 22), who was assessed as high risk for developing pressure ulcers, by failing to: 1. Assess Resident 22's skin condition on the buttocks (bottom), coccyx (tail bone), sacral (a triangular shape bone at the bottom of the spine) area, and feet for redness or open sores (injuries that involve a break in the skin and leave the internal tissue exposed) during resident care as indicated in Resident 22's care plan on prevention of pressure ulcer/pressure injury, and the facility's Policy and Procedures titled, Prevention of Pressure Injuries. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four residents (Residents 8 and 11) reviewed for Bowel and Bladder Incontinence and Catheter use, was provided the necessary care and services to prevent the possible development of Urinary Tract Infection (UTI, is an infection in any part of the urinary system). a. For Resident 11, the facility failed to monitor the urine output in the resident's indwelling urinary catheter for sediments and cloudiness. b. For Resident 8, the facility failed to provide incontinent care after each episode in accordance with the plan of care. These failures had the potential risk for Residents 8 and 11 to develop UTI.

Inspectors wroteBased on interview and record review, the facility failed to provide written information on the right to formulate an advance directive (a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care] ) to one of three sampled residents (Resident 238). This deficient practice had the potential for Resident 238 to not make health care decision in advance to prepare for the time when the resident becomes unable to make decisions.

Inspectors wroteBased on observation, interview and record review the facility failed to provide necessary services to promote oral hygiene for one of one sampled resident (Resident 238.) This deficient practice had the potential to affect Resident 238's sense of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide in-room activities based on the resident's activity assessment for one of two residents (Resident 63.) This deficient practice can lead to low stimulation which can affect Resident 63's physical, emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide rehabilitative treatment and services in accordance with the physician's order for one of three sampled resident (Resident 8). This deficient practice had the potential to lead to further contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives to bed rails before its installation for two of two sampled residents (Residents 46 and 63). This deficient practice placed Residents 46 and 63 at risk for entrapment and injury from the use of bed rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was available to provide nursing and nursing related services to two of three sampled residents (Resident 8 and Resident 63) when; a. Certified Nursing Assistant 3 (CNA3) failed to provide incontinent care to Resident 8 after each episode of bladder incontinence (unable to hold urine). b. Licensed Vocational Nurse 3 (LVN3) prepared medications on 10/12/23 at 11:06 am for the 9 a.m. scheduled medication for Resident 63. This deficient practice resulted in the failure to provide incontinent care to Resident 8 and administer medications timely to Resident 63.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents reviewed for unnecessary medications, was administered antibiotic (medication to treat infection) with an adequate indication for its use (Resident 61). For Resident 61, there was no antibiotic stewardship done before administering Ciprofloxacin (an antibiotic medication) to ensure Resident 61 met the criteria and has adequate indication for its use. This failure had the potential for the use of antibiotics without adequate indication of use and placed the resident at risk for untoward reactions to medications

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 13 of 38 resident bedrooms met the minimum requirement measurement of 80 square feet (sq. ft.) per resident in multi-bed occupancy resident bedrooms. Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39 measured less than 80 sq. ft. per resident in multi-bed occupancy bedrooms as indicated in the facility's Client Accommodation Analysis (square footage measurement of the residents' rooms), signed and dated by the administrator (Admin) on 10/12/23. This deficient practice had the potential to result in inadequate space needed to provide nursing care to the residents.