Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on interview and record review, the facility failed to incorporate Assessments and Care Planning
Goals and Objectives in the Care Plans that lead to the residents' highest obtainable level of independence
for one of five residents (Resident 1).
Resident 1's care plan did not include Resident 1's behavior of crawling on the floor.
This failure result in no nursing interventions for Resident 1's behavior of crawling on the floor and placed
Resident 1 at risk for not reaching Resident 1's highest obtainable level of independence.
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1
on 2/7/2025 with diagnoses which included cerebral infarction (also called ischemic stroke, occurs as result
of disrupted blood flow to the brain) and cognitive communication deficit (impaired attention, memory,
perception, organization, language, and lack of coordination, symptoms and signs involving the
musculoskeletal system).
A review of Resident 1's fall risk care plan (CP), dated 2/7/2025, the CP indicated Resident 1 was at risk for
falls secondary to history of falls prior to admission, and due to confusion, gait (a person's way of walking)
and balance problems, and antihypertensive medication (medication used to treat high blood pressure with
common side effects of dizziness and fatigue) use. The fall risk care plan goal was for Resident 1 to be free
from injury through 5/7/2025. The fall risk care plan interventions indicated to provide bilateral floor mats for
all fall precautions, to keep the resident call light within easy reach and answer the call lights promptly and
within reasonable time, provide resident with a safe and clutter-free environment.
During a review of Resident 1's Fall Risk Evaluation, dated 2/9/2025, the Fall Risk Evaluation indicated
Resident 1 had confusion, had balance problem while standing and walking, had decreased coordination
(ability to use different parts of the body together smoothly and efficiently), and was at risk for falls.
During a review of Resident 1's History Physical (H&P) Examination, dated 2/10/2025, the H&P indicated
Resident 1 did not have the capacity to understand and make decision.
During a review of Resident 1's Minimum Data Set (MDS, a Resident assessment and care planning tool),
dated 5/9/2025, the MDS indicated Resident 1 had severely impaired cognitive (ability to think
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
055544
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055544
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harvard Creek Post Acute
519 W. Badillo St.
Covina, CA 91722
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and reason) skills for decision making and required extensive assistance of staff to move around in bed, to
move to or from bed, chair, wheelchair, or standing position, to dress, to eat, to use the toilet, and to
maintain personal hygiene (includes combing hair, brushing teeth, shaving, washing/drying face and
hands).
During a concurrent observation and interview 6/10/2025 at 11:35 am, Resident 2 was sitting in bed
watching television. Resident 2 stated my roommate Resident 1 crawls down to the floor every day, multiple
times a day, and crawls to my side of the room near my bedside table right here.
During an interview with Certified Nurse Assistant 1(CNA 1- a healthcare professional who provides
support and care for patients under the direction of licensed nurses) on 6/10/2025 at 12:30 pm, CNA 1
stated Resident 1 had periods of confusion, he crawled out of bed, and we transferred him back to his bed
or on his wheelchair. CNA 1 stated This occurs several times a day. CNA 1 stated there have been times
Resident 1 crawled out of the room to the hallway, and he assisted in picking himself up by grabbing onto
the hallway rails and we slide the wheelchair under him and sat down.
During an interview with Licensed Vocational Nurse 1 (LVN 1- an entry level health professional who
provides basic medical assistance and works under a registered nurse) on 6/10/2025 at 2:17 pm, LVN 1
stated LVN 1 was assigned to care for Resident 1 on 6/5/2025 and 6/6/2025. LVN 1 stated Resident 1 had a
wander guard (device worn by individuals at risk of wandering, often residents in assisted living or memory
care facilities, to trigger alerts when they move outside of a designated safe zone) on Resident 1's ankle.
During an interview with the Director of Nursing (DON) on 6/10/2025 at 3:30 pm, the DON stated the floor
mats were placed for fall precautions and the expectation was for staff to assist the resident back to bed
once they find the resident crawling on the floor mats. The DON stated Resident 1 crawls in his room, and
when staff see him, staff need to monitor and assist Resident 1 back to bed. The DON stated It is not safe
for Resident 1 to crawl to Resident 2's bedside because Resident 1 could hold onto objects and hurt
himself. The DON stated Resident 1's fall risk care plan should have been updated per the facility's policy
and procedure (P&P) to include crawling on the floor as one of Resident 1's behavior.
A review of the facility's P&P titled, Goals and Objectives, Care Plans, dated 2001, (Revised April 2009),
the P&P indicated, care plans shall incorporate goals and objectives that lead to the resident's highest
obtainable level of independence. Care plans goals and objectives are derived from information contained
in the resident's comprehensive assessment and are behaviorally stated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055544
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055544
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harvard Creek Post Acute
519 W. Badillo St.
Covina, CA 91722
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on interview and record review, the facility failed to implement its Policy and Procedure, titled Falls
and Fall Risk, Managing, for one of five sampled residents (Resident 1) when:
Residents Affected - Few
1. Resident 1 was not assessed for injury whenever staff (in general) found Resident 1 on floor crawling on
the floor mats (a padded cushion placed on the floor next to the bed to help reduce injuries from a fall) as
indicated in Resident 1's fall risk care plan.
2. Resident 1's care plan did not include Resident 1's behavior of crawling on the floor.
3. Licensed Vocational Nurse (LVN) 1 did not document Resident 1's wander guard trial in Resident 1's
medical record.
This failure placed Resident 1 at risk for harm and injury.
Cross reference F656, F842
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1
on 2/7/2025 with diagnoses which included cerebral infarction (also called ischemic stroke, occurs as result
of disrupted blood flow to the brain) and cognitive communication deficit (impaired attention, memory,
perception, organization, language, and lack of coordination, symptoms and signs involving the
musculoskeletal system).
A review of Resident 1's fall risk care plan (CP), dated 2/7/2025, the CP indicated Resident 1 was at risk for
falls secondary to history of falls prior to admission, and due to confusion, gait (a person's way of walking)
and balance problems, and antihypertensive medication (medication used to treat high blood pressure with
common side effects of dizziness and fatigue) use. The fall risk care plan goal was for Resident 1 to be free
from injury through 5/7/2025. The fall risk care plan interventions indicated to provide bilateral floor mats for
all fall precautions, to keep Resident 1's call light within easy reach and answer the call light promptly and
within reasonable time, provide resident with a safe and clutter-free environment.
During a review of Resident 1's Fall Risk Evaluation, dated 2/9/2025, The Fall Risk Evaluation indicated
Resident 1 had confusion, had balance problem while standing and walking, had decreased coordination
(ability to use different parts of the body together smoothly and efficiently), and was at risk for falls.
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care planning tool),
dated 5/9/2025, the MDS indicated Resident 1 had severely impaired cognitive (ability to think and reason)
skills for decision making and required extensive assistance of staff to move around in bed, to move to or
from bed, chair, wheelchair, or standing position, to dress, to eat, to use the toilet, and to maintain personal
hygiene (includes combing hair, brushing teeth, shaving, washing/drying face and hands).
During a concurrent observation and interview 6/10/2025 at 11:35 am, Resident 2 was sitting in bed,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055544
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055544
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harvard Creek Post Acute
519 W. Badillo St.
Covina, CA 91722
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
watching television. Resident 2 stated my roommate Resident 1 crawls down to the floor every day multiple
times a day, and crawls to my side of the room near my bedside table right here.
During an interview with Certified Nurse Assistant 1(CNA 1- a healthcare professional who provides
support and care for patients under the direction of licensed nurses) on 6/10/2025 at 12:30 pm, CNA 1
stated Resident 1 had periods of confusion, he crawled out of bed, and we transferred him back to his bed
or on his wheelchair. CNA 1 stated This occurs several times a day. CNA 1 stated there have been times
Resident 1 crawls out of the room to the hallway, and he assists in picking himself up by grabbing onto the
hallway rails and slide the wheelchair under him and sit down.
During an interview with LVN 1 on 6/10/2025 at 2:17 pm, LVN 1 stated LVN 1 was assigned to care for
Resident 1 on 6/5/2025 and 6/6/2025, Resident 1 had a wander guard (device worn by individuals at risk of
wandering, often residents in assisted living or memory care facilities, to trigger alerts when they move
outside of a designated safe zone) on Resident 1's ankle and LVN 1 did not document the Wander guard
trial in Resident 1's medical record. LVN 1 stated per facility's policy and procedure (P&P) It is my
responsibility to document in medical record and I did not follow the policy.
During an interview with the Director of Nursing (DON) on 6/10/2025 at 3:30 pm, the DON stated the floor
mats were placed for fall precautions and the expectation was for staff to assist Resident 1's back to bed
once staff find Resident 1 crawling on the floor mats. The DON stated Resident 1 crawls in his room, and
when staff see him, staff need to monitor and assist Resident 1's back to bed. The DON stated, It is not
safe for Resident 1 to crawl to Resident 2's bedside because Resident 1 could hold onto objects and hurt
himself. The DON stated Resident 1's fall risk care plan should have been updated per the facility's P&P to
include crawling behavior. The DON stated a change in condition like a wander guard should have been
endorsed from one staff to another, but it was not. The DON stated the assigned LVNs should have
endorsed and documented in Resident 1's medical record per the facility's policy, but it was not done.
A review of the facility's P&P titled, Fall and Fall Risk, Managing, dated 2001 (Revised March 2018), the
P&P indicated Based on previous evaluations and current data, the staff will identify interventions related to
the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize
complications from falling According to the MDS, a fall is defined as: Unintentionally coming to rest on the
ground, floor or other lower level, but not as a result of an over whelming external force (e.g., a resident
pushes another resident) Unless there is evidence suggesting otherwise, when a resident is found on the
floor, a fall is considered to have occurred.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055544
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055544
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harvard Creek Post Acute
519 W. Badillo St.
Covina, CA 91722
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on interview and record review, the facility failed to implement its Policy and Procedure titled,
Charting and Documentation, for one of five sampled residents (Resident 1) when:
Residents Affected - Few
Licensed Vocational Nurse 1 (LVN 1) did not document Resident 1's wander guard trial in Resident 1's
medical record.
This failure result in incomplete documentation for Resident 1 and placed Resident 1's inter disciplinary
team at risk for miscommunication regarding the Resident 1's condition and response to care.
Cross Reference: F689 and F656
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1
on 2/7/2025 with diagnoses which included cerebral infarction (also called ischemic stroke, occurs as result
of disrupted blood flow to the brain) and cognitive communication deficit (impaired attention, memory,
perception, organization, language, and lack of coordination, symptoms and signs involving the
musculoskeletal system).
A review of Resident 1's fall risk care plan (CP), dated 2/7/2025, the CP indicated Resident 1 was at risk for
falls secondary to history of falls prior to admission, and due to confusion, gait (a person's way of walking)
and balance problems, and antihypertensive medication (medication used to treat high blood pressure with
common side effects of dizziness and fatigue) use. The fall risk care plan goal was for Resident 1 to be free
from injury through 5/7/2025. The fall risk care plan interventions indicated to provide bilateral floor mats for
all fall precautions, to keep Resident 1's call light within easy reach and answer the call light promptly and
within reasonable time, provide resident with a safe and clutter-free environment.
During a review of Resident 1's Fall Risk Evaluation, dated 2/9/2025, The Fall Risk Evaluation indicated
Resident 1 had confusion, had balance problem while standing and walking, had decreased coordination
(ability to use different parts of the body together smoothly and efficiently), and was at risk for falls.
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care planning tool),
dated 5/9/2025, the MDS indicated Resident 1 had severely impaired cognitive (ability to think and reason)
skills for decision making and required extensive assistance of staff to move around in bed, to move to or
from bed, chair, wheelchair, or standing position, to dress, to eat, to use the toilet, and to maintain personal
hygiene (includes combing hair, brushing teeth, shaving, washing/drying face and hands).
During a concurrent observation and interview 6/10/2025 at 11:35 am, Resident 2 was sitting in bed,
watching television. Resident 2 stated my roommate Resident 1 crawls down to the floor every day multiple
times a day, and crawls to my side of the room near my bedside table right here.
During an interview with LVN 1 on 6/10/2025 at 2:17 pm, LVN 1 stated LVN 1 was assigned to care for
Resident 1 on 6/5/2025 and 6/6/2025. LVN 1 stated Resident 1 had a wander guard (device worn by
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055544
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055544
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harvard Creek Post Acute
519 W. Badillo St.
Covina, CA 91722
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
individuals at risk of wandering, often residents in assisted living or memory care facilities, to trigger alerts
when they move outside of a designated safe zone) on Resident 1's ankle, but LNV 1 did not document in
Resident 1's wander guard trial in Resident 1's medical record. LVN 1 stated per the facility's policy and
procedure (P&P) Tt is my responsibility to document in medical record and I did not follow the policy.
During an interview with the Director of Nursing (DON) on 6/10/2025 at 3:30 pm, the DON a change in
condition like a wander guard trial should have been endorsed from one staff to another but It was not. The
DON stated the assigned LVNs should have endorsed and documented information regarding Resident 1's
wander guard trial in Resident 1's medical record per the facility's policy.
A review of the facility's P&P titled, Goals and Objectives, Care Plans, dated 2001, (Revised July 2017),
indicated All medical record should facilitate communication between the interdisciplinary team regarding
the resident's condition and response to care Documentation in the medical record may be electronic,
manual or a combination The following information is to be documented in the resident's medical record:
Treatments or services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055544
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the June 10, 2025 survey of HARVARD CREEK POST ACUTE?
This was a inspection survey of HARVARD CREEK POST ACUTE on June 10, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HARVARD CREEK POST ACUTE on June 10, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.