West Covina Healthcare Center

In the surveyor’s words

From the most serious findings on record at West Covina Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 23, 2021

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the local Department of Public Health's (DPH) guidelines, facility's policy and Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 7 of 19 sampled residents (Residents 1, 2, 3, 4, 5, 6 and 7) by failing to: 1. Ensure Certified Nursing Assistants 1 and 2 (CNAs 1 & 2) don (put on) Personal Protective Equipment (PPE, gowns, gloves, N95 masks, and face shields worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). […]

• Actual harm, isolatedF760Mar 28, 2024

  Based 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. […]

• Actual harm, isolatedF656Jan 31, 2024

  Based 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. […]

• Actual harm, isolatedF686Oct 13, 2023

  Based 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… […]

• Actual harm, isolatedF688Jan 10, 2023

  Based on observation, interview, and record review, the facility failed to provide range of motion exercises (activities aimed at improving movement of a specific joint, a point where two bones make contact) for one of five sampled residents (Resident 1) as indicated in the physician ' s order and the facility's policy for Resident Mobility (ability to move) and Range of Motion (ROM, full movement potential of a joint). This deficient practice resulted for Resident 1 to experience pain and decline in ROM, that caused stiffness (inability to move easily and without pain) and contractures (deformity and joint stiffness) of Resident 1 ' s right hand and right arm. (Cross Reference F725). […]