Health inspection·January 2, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate neurological assessment (a check of how well the brain, nerves, and muscles work often performed after a suspected head injury) for two of eight sampled residents (Residents 1 and 2) after a resident-to-resident physical altercation (a fight or struggle where people used physical force, contact, or aggression against each other) that involved allegations of unwitnessed head injuries on 12/20/2025. These failures had the potential to compromise Residents 1's and Resident 2's health and safety.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), and metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the body). During a review of Resident 1's History and Physical (H&P), dated 7/12/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/10/2025, the MDS indicated Resident 1 had severe cognitive impairment (confusion or memory loss). The MDS indicated Resident 1 required setup assistance from staff with oral hygiene. The MDS indicated Resident 1 required supervision from staff with eating, toileting hygiene, personal hygiene, bed-to-chair transferring, and using the wheelchair. The MDS indicated Resident 1 required moderate assistance (helper did less than half the effort) from staff with showering. During a review of Resident 1's Change in Condition (COC), dated 12/20/2025, the COC indicated in the morning of 12/20/2025, Certified Nurse Assistant (CNA) 1 observed Resident 1 crying and covering left eye with hand. The COC indicated Resident 1 was holding a sandal with the other hand to demonstrate that Resident 2 hit Resident 1. The COC indicated Resident 1 sustained left eye redness. The COC further indicated that the neurological assessment was not done because it was not clinically applicable to the COC. During a review of Resident 1's Post-Event Review (PER), dated 12/20/2025, the PER indicated on 12/20/2025 at 12:15 PM, Resident 1 reported that Resident 2 hit Resident 1 on the face with a sandal. During an interview with Registered Nurse (RN) 1 on 1/2/2026 at 10:49 AM, RN 1 stated a neurological assessment must be performed on a resident with an unwitnessed head injury to check alertness, cognition, pupil response, responsiveness, and reflexes to make sure the resident was cognitive stable. RN 1 stated the licensed nurse assigned to care for the resident must check vital signs (measurements of temperature, heart rate, breathing rate, blood pressure), pain level, oxygen saturation (amount of oxygen in the blood), and blood sugar if resident was diabetic. RN 1 stated neurological assessments must be started right away if the suspected head injury was unwitnessed or if there was facial redness. RN 1 stated the neurological assessment should be done every 15 minutes for the first hour, every 30 minutes for the next hour, followed by hourly, every two hours, every four hours, and then every shift for total of 72 hours. RN 1 stated all findings should be documented on the neurological Residents Affected - Few Page 1 of 3 055992 055992 01/02/2026 West Covina Healthcare Center 850 S. Sunkist Ave. West Covina, CA 91790

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment form in the resident's medical record. RN 1 stated that the professional standard was not met when the staff failed to initiate a neurological assessment for the residents with an unwitnessed face injury, as this could have resulted in missing any potential changes or injuries. During a concurrent record review and interview with RN 1 on 1/2/2026 at 10:49 AM, Resident 1's Vital Summary (VS) dated 12/20/2025 to 12/23/2025 was reviewed. RN 1 stated the VS indicated no neurological assessment was done for Resident 1 after the resident-to-resident physical altercation on 12/20/2025. RN 1 stated the cause of Resident 1's left eye redness was unwitnessed and the licensed nurse should have initiated the neurological assessment on 12/20/2025. During a concurrent record review and interview with RN 1 on 1/2/2026 at 10:49 AM, Resident 1's medical record, including the Nursing Progress Notes (NPN), dated 12/20/2025 to 12/23/2025 was reviewed. RN 1 stated there were no neurological assessments documented on Resident 1's medical record after the unwitnessed resident-to-resident physical altercation on 12/20/2025. b. During a review of Resident 2's AR, the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia and encephalopathy. During a review of Resident 2's H&P, dated 12/11/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 2 required supervision from staff with eating. The MDS indicated Resident 2 required moderate assistance from staff with oral hygiene and personal hygiene. The MDS indicated Resident 2 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene, showering, bed-to-chair transferring, and walking. During a review of Resident 2's COC, dated 12/20/2025, the COC indicated in the morning of 12/20/2025, CNA 1 observed Resident 2 in emotional distress because of a physical disagreement with Resident 1. The COC further indicated that the neurological assessment was not done because it was not clinically applicable to the COC. During a review of Resident 2's PER, dated 12/20/2025, the PER indicated on 12/20/2025 at 12:15 PM, Resident 2 reported that Resident 1 hit Resident 2 with a sandal on face when Resident 2 was sitting at the foot of the bed. The PER indicated Resident 2 hit Resident 1 on left face. During a concurrent record review and interview with RN 1 on 1/2/2026 at 10:49 AM, Resident 2's VS dated 12/20/2025 to 12/23/2025 was reviewed. RN 1 stated the VS indicated no neurological assessment was done for Resident 2 after the resident-to-resident physical altercation on 12/20/2025. RN 1 stated Resident 2's allegation of Resident 1 hitting Resident 2's face with a sandal was unwitnessed and the licensed nurse should have initiated the neurological assessment on 12/20/2025. During a concurrent record review and interview with RN 1 on 1/2/2026 at 10:49 AM, Resident 2's medical record, including the Nursing Progress Notes (NPN), dated 12/20/2025 to 12/23/2025 was reviewed. RN 1 stated there were no neurological assessments documented on Resident 2's medical record after the unwitnessed resident-to-resident physical altercation on 12/20/2025. During an interview with the Director of Nursing (DON) on 1/2/2026 at 11:28 AM, the DON stated a neurological assessment should be initiated for any unwitnessed face and head injury. The DON stated the purpose of the neurological assessment was to determine if there were changes in residents' mental status and vital signs. The DON stated that neurological assessments helped nurses decide if residents, especially those on blood thinners, needed hospital transfer to prevent blood clot in brain. The DON stated it was important for the licensed nurse to initiate the neurological assessment immediately after an incident involving allegation of unwitnessed face or head injury, even without visible injuries on residents. The DON stated it was important to document incidents and neurological assessments in residents' medical records and documentation served as evidence to support the incident and to ensure no negative outcome. The DON stated the licensed 055992 Page 2 of 3 055992 01/02/2026 West Covina Healthcare Center 850 S. Sunkist Ave. West Covina, CA 91790

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses should have followed the neurological assessment frequency as indicated in the facility's Policy and Procedure (P&P) titled Fall Management Program. During a concurrent record review and interview with the DON on 1/2/2026 at 12:30 PM, the facility's P&P titled Neurological Assessment, dated 10/2010, was reviewed. The P&P indicated a neurological assessment should be done following a fall or other accident or injury involving head trauma or a suspected head injury. The P&P indicated staff should always include frequent vital signs when assessing neurological status. The P&P further indicated that staff should document the neurological assessment's date and time, the names and titles of those performing it, all assessment data, the resident's tolerance or refusal with reasons and interventions, and the signature and title of the person documenting in the resident's medical record. The DON stated Residents 1 and 2's unwitnessed physical altercation on 12/20/2025 indicated the neurological assessment should have been done. During a review of the facility's P&P titled Fall Management Program, dated 3/13/2021, the P&P indicated the neurological check frequency was every 15 minutes for an hour, then every 30 minutes for an hour, then hourly for four hours, and finally every four hours for 66 hours or until discontinued by the physician, or after 72 hours if the resident was stable without neurological symptoms. 055992 Page 3 of 3