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Deficiency Records for West Covina Healthcare Center
A list of the most recent deficiencies for West Covina Healthcare 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 West Covina Healthcare 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-03 | 2024-07-26 | Y |
| 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 | 2024-06-24 | 2024-07-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-07 | 2024-07-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-06 | 2024-05-30 | Y |
| 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 | 2024-05-06 | 2024-05-30 | Y |
| 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 | 2024-03-28 | 2024-04-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-28 | 2024-04-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-28 | 2024-04-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-31 | 2024-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-28 | 2023-12-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-13 | 2023-11-17 | 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 | 2023-10-13 | 2023-11-15 | 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 | 2023-10-13 | 2023-11-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-13 | 2023-11-15 | 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 | 2023-10-13 | 2023-11-06 | 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 | 2023-10-13 | 2023-11-06 | 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 | 2023-10-13 | 2023-11-06 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-13 | 2023-11-01 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-13 | 2023-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-12 | 2023-10-23 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-13 | 2023-10-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-12 | 2023-10-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-12 | 2023-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-12 | 2023-10-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-07 | 2023-08-25 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-30 | 2023-06-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-30 | 2023-06-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-26 | 2023-06-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-04 | 2023-04-24 | 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 | 2023-01-10 | 2023-01-26 | 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 | 2023-01-10 | 2023-01-20 | Y |
| 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 | 2022-12-21 | 2023-01-04 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-29 | 2022-12-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-21 | 2022-12-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-13 | 2022-12-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-13 | 2022-12-14 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-12-13 | 2022-12-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-13 | 2022-12-14 | Y |
| 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 | 2022-11-02 | 2022-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-28 | 2022-10-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-28 | 2022-10-28 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-01 | 2022-09-30 | 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 | 2022-09-01 | 2022-09-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-25 | 2022-09-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-25 | 2022-09-27 | Y |
| Post nurse staffing information every day. | Health | 2022-08-30 | 2022-09-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-08-02 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-13 | 2022-08-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-19 | 2022-06-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-19 | 2022-06-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-19 | 2022-06-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-18 | 2022-06-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-02 | 2022-06-16 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-01-13 | 2022-03-09 | Y |
| 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 | 2022-01-20 | 2022-02-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-20 | 2022-02-07 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-07 | 2022-02-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-23 | 2021-05-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-23 | 2021-05-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-04-23 | 2021-05-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-23 | 2021-05-21 | 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 | 2021-04-23 | 2021-05-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-05-21 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-04-23 | 2021-05-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-23 | 2021-05-21 | 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 | 2021-04-23 | 2021-05-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-04-23 | 2021-05-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-23 | 2021-05-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-23 | 2021-05-21 | 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 | 2021-04-23 | 2021-05-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-04-23 | 2021-05-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-23 | 2021-05-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-23 | 2021-05-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-23 | 2021-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-23 | 2021-05-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-23 | 2021-05-20 | 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 | 2019-09-26 | 2019-11-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-26 | 2019-11-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-26 | 2019-11-25 | 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 | 2019-09-26 | 2019-11-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-26 | 2019-11-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-26 | 2019-11-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-26 | 2019-11-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-26 | 2019-11-25 | 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 | 2019-09-26 | 2019-11-25 | N |
| Post nurse staffing information every day. | Health | 2019-09-26 | 2019-11-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-26 | 2019-11-25 | 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 | 2019-09-26 | 2019-11-25 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-09-26 | 2019-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-26 | 2019-11-25 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-26 | 2019-11-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-26 | 2019-10-28 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-09-26 | 2019-10-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-26 | 2019-10-28 | N |
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