West Covina Medical Center D/P SNF

In the surveyor’s words

From the most serious findings on record at West Covina Medical Center D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF689May 2, 2022

  Based on interview and record review, the facility failed to ensure one (1) out of three (3) sampled residents (Resident 1) was supervised by the facility's staff member at all times, to prevent accidents during a family member's visit, in accordance with the facility's policy and procedure. Resident 1 was left unsupervised by staff in the activity room with a family member and fell on the floor from her (Resident 1) wheelchair, after leaning forward to take a photo, on 3/24/22. This deficient practice resulted in Resident 1 falling out of the resident's wheelchair and on to the floor during family visitation. […]

• No harm, potential for more than minimal, patternF657Dec 18, 2025

  Based 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. Findings: a. […]

• No harm, potential for more than minimal, patternF812Dec 18, 2025

  Based 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.Findings: During initial observation of the resident's refrigerator inside the supply room on 12/16/2025 at 12:11 PM, one box of pastries did not have a… […]

• No harm, potential for more than minimal, patternF558Oct 18, 2024

  Based 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. Findings: a. During a review of Resident 123's Face Sheet (FS), the FS indicated Resident 123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a long-term condition that occurs when the lungs could not exchange enough oxygen and carbon dioxide in the body) and dependence on… […]

• No harm, potential for more than minimal, patternF578Oct 18, 2024

  Based 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. Findings: a. […]