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Deficiency Records for Covina Rehabilitation Center
A list of the most recent deficiencies for Covina Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Covina Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-06-06 | 2024-06-06 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-10 | 2024-06-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-10 | 2024-06-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-10 | 2024-06-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-10 | 2024-06-03 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-05-10 | 2024-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-10 | 2024-06-03 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-05-10 | 2024-06-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-05-10 | 2024-06-03 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-05-10 | 2024-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-10 | 2024-06-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-05-10 | 2024-05-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-05-14 | 2024-05-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-14 | 2024-05-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-14 | 2024-05-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-14 | 2024-05-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-14 | 2024-05-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-14 | 2024-05-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-10 | 2024-01-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-01 | 2024-01-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-01-03 | Y |
| Post nurse staffing information every day. | Health | 2023-09-11 | 2023-09-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-11 | 2023-08-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-11 | 2023-08-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-11 | 2023-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-11 | 2023-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-06 | 2023-03-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-16 | 2023-02-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-25 | 2023-02-10 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-25 | 2023-02-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-25 | 2023-02-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-09 | 2022-11-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-09 | 2022-11-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-09 | 2022-11-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-09-17 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-25 | 2022-09-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-25 | 2022-09-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-09-03 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-05-13 | 2022-05-23 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-05-13 | 2022-05-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-03 | 2022-05-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-03 | 2022-05-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-30 | 2022-04-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-08 | 2022-04-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-08 | 2022-04-26 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-08 | 2022-04-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-05 | 2022-03-14 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-01-05 | 2022-03-14 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-29 | 2022-01-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-29 | 2022-01-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-29 | 2022-01-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-29 | 2022-01-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-29 | 2021-12-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-29 | 2021-12-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-10-29 | 2021-12-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-10-29 | 2021-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-29 | 2021-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-29 | 2021-12-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-10-29 | 2021-12-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-29 | 2021-12-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-29 | 2021-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-29 | 2021-12-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-29 | 2021-12-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-10-29 | 2021-12-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-29 | 2021-12-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-29 | 2021-12-15 | N |
| Post nurse staffing information every day. | Health | 2021-10-29 | 2021-12-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-29 | 2021-12-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-29 | 2021-12-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-29 | 2021-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-29 | 2021-12-15 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-10-29 | 2021-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-29 | 2021-12-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-29 | 2021-12-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-01-10 | 2020-02-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-10 | 2020-02-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-01-10 | 2020-02-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-01-10 | 2020-02-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-10 | 2020-02-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-10 | 2020-02-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-10 | 2020-02-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-10 | 2020-02-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-10 | 2020-02-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-10 | 2020-02-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-10 | 2020-02-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-10 | 2020-02-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-10 | 2020-02-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-01-10 | 2020-02-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-10 | 2020-02-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-10 | 2020-02-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-10 | 2020-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-10 | 2020-02-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-10 | 2020-02-12 | N |
| Keep all essential equipment working safely. | Health | 2020-01-10 | 2020-02-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-09 | 2020-01-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-09 | 2020-01-27 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2020-01-09 | 2020-01-27 | N |
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