West Covina Medical Center D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin (the source of the injury was not witnessed by any person and the source of the injury could not be explained by the resident and the injury is suspicious because of its extent, location, the number of injuries at a time, or the number of injuries over time) to the California Department of Public Health (CDPH), Adult Protective Services (APS, the county agency responsible for investigating reports of abuse, neglect, or exploitation of elders and dependent adults), and the Ombudsman (an impartial advocate who investigates and helps resolve complaints between patients and healthcare organizations) within 24 hours for one of three sampled residents (Resident 1) in accordance with state law and the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurses accurately documented during each shift on 12/4/25 and 12/22/2025 as per facility's policy and procedures for one of three sampled residents (Resident 1) investigated under quality of care. This deficient practice resulted in Resident 1's medical record containing inaccurate documentation of patient assessment, which had the potential to affect Resident 1's provision of care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to revise a plan of care for three of three sampled residents (Residents 4, 15 and 22), as indicated in the facility's policy and procedure titled Care Planning by failing to:a. Revise Resident 4's care plan following an unintended and significant 35 lbs. weight loss.b. Revise Resident 15's care plan who had Pneumonia on 11/25/2025.c. Revise Resident 22's care plan who had a weight loss in 10/2025 and 11/2025. These deficient practices had the potential for Residents 4, 15 and 22 to not receive appropriate care treatment and/or services specific to their individual needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to label and discard expired food items stored in one of one resident's refrigerator located inside the supply room at the nurse's station. The facility staff did not label food items with resident's name and current date. The facility staff did not remove expired food items from the resident's refrigerator. These deficient practices had the potential to result in foodborne illness (illness caused by consuming contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote one of one sampled resident (Resident 15) with respect, privacy and dignity in accordance to facility's Policy and Procedure(P&P) titled Promoting/Maintaining Resident Dignity/Quality of Life. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline and lowered self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment within 14 days after a change of condition for one of one sampled resident (Resident 4). This deficient practice placed Resident 4 at risk for delayed implementation of clinical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 28)'s discharge destination was coded accurately in the Minimum Data Set (MDS - a federally mandated resident assessment tool). Resident 28 was discharged to a general acute care hospital but was coded as being discharged to Skilled Nursing Facility (SNF - an inpatient rehabilitation and medical treatment center staffed with medical professionals). This deficient practice resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 28 not receiving interventions to address specific care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a change of condition (COC) for symptoms of a urinary tract infection (UTI) to the physician (MD) for one of three sampled residents (Resident 4) with foley catheter (a flexible tube that passes through the urethra and inserted into the bladder to drain urine). Resident 4's foley catheter tubing had cloudy, white urine sediments (bacteria and white blood cells are shed into the urine). This failure had the potential to result in delay of care and treatment of urinary tract infection (UTI) and unmanaged UTI pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Registered Dietitian's (RD) recommendation for one of one sampled resident (Resident 22) to start weekly weights on 11/5/2025 was implemented/carried out and communicated to the physician. This deficient practice had the potential to result in adverse consequences for Resident 22.

Inspectors wroteBased on observation, interview and record review, one of one License Vocational Nurse (LVN 3) did not flush Resident 23's Gastrostomy Tube (GT- a feeding tube placed directly into the stomach through the abdominal wall, used to deliver nutrition, fluids, and medicine) with water before and after giving medication, to prevent the GT from clogging, to ensure the medication passes, and ensure patency of the GT for future use. This deficient practice had the potential to result in negative consequences for Resident 23.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) recommendation for one of five sampled residents (Resident 1) to specify the behavior manifestation to be monitored for Resident 1's routine Xanax (a medication used for the short-term treatment of anxiety disorders and panic disorders) 0.5 milligrams (mg- unit of measurement) QHS (every night at bedtime) for anxiety, ordered on 9/13/2025, for the months of October and November 2025. This deficient practice had the potential for Resident 1 to receive unnecessary medications and result in undesirable or non-therapeutic effect of the medication to the resident.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse 5 (LVN 5) failed to ensure medications were kept secure by failing to lock one of one medication cart (MedCart) that was left unattended and outside of LVN 5's view while providing medication to Resident 3. This deficient practice had the potential for the residents' medications to be accessible to others not authorized to have access to drugs (medications) and biologicals (drugs derived from natural sources) and increased the risk for loss and medication diversion (illegally redirecting prescription medications from intended patient for personal use).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for one of five sampled residents (Resident 24) by failing to wear proper personal protective equipment (PPE, equipment that protects people from injury or illness in hazardous environments) while providing care to Resident 24 who was placed on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with an multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing a MDRO, such as, residents with wounds or indwelling medical devices). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Residents 2 and 123) by failing to ensure the residents' call lights were within reach and appropriate to the resident's physical ability. These deficient practices had the potential for Residents 2 and 123 not to receive necessary care or received delayed services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to provide information on Advance Directive (AD- a process of communication between individuals and their healthcare agents for future healthcare decisions when individuals are no longer able to make their own healthcare decisions) for three of three sampled residents (Residents 6,14, and 20) in accordance with the facility's policy on Advance Directives. These failures had the potential for facility staff to provide medical treatment against the residents' 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 three sampled residents (Residents 2 and 123 ). These failures had the potential for complications related to tube feedings for Residents 2 and 123.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Ensure the oxygen cannula (tubing used to deliver oxygen) was connected to the tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe) with a T-Bar (a T shaped device) for one of one sampled resident (Resident 4). b. Follow the physician's order for tracheostomy care for one of one sampled resident (Resident 16) These deficient practices placed Residents 4 and 16 at risk for complications of shortness of breath and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow it's policy and procedure on storing, preparing, distributing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure: 1. Thawed meat was stored on the top shelf in one of one refrigerator. 2. Stored food items were labeled and dated when it was first opened, in one of three kitchen freezers. These deficient practices had the potential risk for food borne illnesses (infections caused by ingesting contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's indwelling catheter (foley catheter - thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) bag was covered and provided the resident privacy in accordance with the facility's policy on Urinary Catheter, Insertion and Care for one of one sampled resident (Resident 17). This deficient practice had the potential to result in psychosocial (mental and emotional well-being) decline and lowered self-esteem and self-worth for the resident.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Long Term Care Ombudsman (public advocate) of the Notice of Proposed Transfer and Discharge for one of three sampled resident's (Resident 22) transfer to the General Acute Hospital (GACH) on 8/8/2024 in accordance with facility's policy on Transfer and Discharge (Including Against Medical Advice [AMA].) This deficient practice had the potential to violate Resident 22's right to ensure for an appropriate discharge/transfer from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to promote healing of pressure ulcer/injury (PU/PI, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of one sampled resident (Resident 14), as ordered by the physician. This failure had the potential to result in worsening or re occurrence of pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nurse Assistant (RNA, a specialized role for certified nursing assistants that involves training in rehabilitation skills) services was provided to one of one sampled resident (Resident 123) as ordered by the physician. This deficient practice had the potential for a decline in range of motion (ROM, measure of joint flexibility and functionality), stiffness and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) for Resident 123.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 14) 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 to label and date a peripherally inserted intravenous (IV) catheter. This failure had the potential to result in infection to the resident and worsen the resident's overall health condition.

Inspectors wroteBased on interview and record review, the facility failed to act upon the consultant pharmacist's Medication Regimen Review (MRR) recommendation for one of five sampled residents (Resident 8). This failure had the potential to result in undesirable or non-therapeutic effect of the medication to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility staff used Personal Protection Equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) in accordance with the facility's Policy and Procedure (P&P) on infection prevention and control for one of five sampled residents (Resident 14). This deficient practice had the potential to spread infection and transmission of communicable diseases.

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, operating, and sanitary condition for one of one sampled resident (Resident 123). This failure had the potential to affect Resident's 123 quality of life and overall health.

Inspectors wroteBased in interview and record review, three of four sampled staff (Pharmacy Technician 1[PTech 1], Licensed Vocational Nurse 1 [LVN 1] and Registered Nurse 1 [RN 1]) did not know to report allegation of abuse to the state agency as indicated in the facility's Policy and Procedure titled Elder and Dependent Adult Abuse. This deficient practice had the potential for employees not to report an abuse incident to the state agency, which could lead to possible harm and risk of further abuse of the residents.

Inspectors wroteb. During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/22/2022 with diagnoses that included elevated white blood cell count (WBC - part of body's immune system that helps to fight infection), and dementia (long term and often gradual decrease in the ability to think and remember, severe enough to affect a person's daily functioning). During a review of Resident 1's MDS dated [DATE], the MDS indicated, Resident 1's cognition for daily decision making was severely impaired. The MDS indicated Resident 1 required total dependence with two-person physical assistance with bed mobility, transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), dressing, and toilet use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for two of two sampled residents (Residents 8 and 22 ) with indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's Policy and Procedure, titled Urinary Catheter, Insertion and Care and the resident's care plan for foley catheter. This deficient practice had the potential for Residents 8 and 22 to receive no care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system).

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) feeding as ordered by the physician and as indicated in the facility's Policy and Procedure (P&P) and plan of care for two of five sampled residents (Residents 11 and 12) by failing to: a. Ensure Resident 11 received the recommended tube feeding formula and amount of gastrostomy tube feeding. b. Ensure to apply drain sponge to the gastrostomy site and anchor the gastrostomy tube of Resident 12. These failures had the potential for complications related to tube feedings for Residents 11 and 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products.) for three out of three sampled residents (Resident 21, 20 and 7). These failures had the potential to result in infection to the residents and worsen the residents' health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure competent nursing staff for two of five staff (Licensed Vocational Nurse 7 [LVN 7], and Registered Nurse Supervisor 3 [RN Sup 3]) by failing to ensure the Department Manager completed and validated the performance evaluation as indicated in the facility's Policy and Procedure titled Evaluation Process. This deficient practice had the potential for residents not to receive appropriate nursing care and services.

Inspectors wroteBased on interview and record review, the facility failed to obtain a consent for psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) use for two of five sampled residents (Residents 1 and 18). This failure had the potential for Resident 1 and 18 to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe, and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another) for three of three sampled residents (Residents 1, 20 and 21) by failing to ensure: a. Registered Nurse Supervisor 2 (RN Sup 2) performed hand hygiene before contact with Resident 1. b. Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before contact with Resident 20. c. Resident 21's nasal cannula ( tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) tubing was labeled and dated. These deficient practices placed the residents at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain patient care equipment in safe operating condition for one of two beds inspected and the facility staff did not communicate with the facility Maintenance Department when the bed indicators flashed. This failure had the potential to result in compromised resident's safety.