Health inspection·April 25, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: CA00891825 Representing the Department: Health Facilities Evaluator Nurse: 46687 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were identified for the complaint number: CA00891825 (Refer to

F726, F760, and F842).

F726 SS=D Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 04/30/2024 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 1 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure all nursing staff had the appropriate skills and competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics an individual needed to perform work roles or occupational functions successfully) necessary to provide nursing care safely to one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, "Staffing, Sufficient and Competent Nursing," and "Administering Medication" by failing to: Ensure Licensed Vocational Nurse (LVN) 1 had demonstrated the skills and proper techniques necessary to care for Resident 1 with regards to medication management and/or medication administration. This deficient practice resulted in Resident 1 receiving an incorrect medication which caused Resident 1 to experience chest pain, burning sensation of Resident 1's body, and Resident 1 felt like Resident 1 was "dying." Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 3/14/2024 at 7:30 pm for further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 2 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE evaluation and was treated for acute opioid withdrawal (a set of symptoms from the sudden withdrawal or reduction of opioids where previous usage has been heavy and prolonged) induced (caused) by accidental Narcan administration. Cross Reference F760 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 8/16/2022, with diagnoses of asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), allergic rhinitis (nose irritation, sneezing, watery eyes, and nasal congestion caused by allergic reaction general to environmental factors), acquired absence of right leg above the knee and phantom limb syndrome with pain (the experience of painful sensations in a limb that did not exist). During a review of Resident 1's Physician Order (PO), dated 8/16/2022, the PO indicated, Resident 1 had an order for fluticasone furoate suspension, 27.5 micrograms (mcg- unit of measurement), spray one (1) spray in both nostrils, (nose) two times a day related to adverse (unwanted and harmful) effect of antiasthmatics (medications that reduced the swelling and tightening in the airways). During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 2/13/2024, the MDS indicated, Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated, Resident 1 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 3 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and/or contact guard assistance as resident completed the activity) with oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting/taking off footwear, and personal hygiene. During a review of Resident 1's PO, dated 2/14/2024, the PO indicated, Resident 1 had an order for Narcan nasal liquid (Naloxone Hydrochloride [HCl]), one (1) spray in nostril as needed for opioid overdose. During a review of Resident 1's Progress Notes (PN), dated 3/14/2024 at 7:38 pm, the PN indicated, at approximately 7:00 pm, LVN 1 administered nasal spray (unidentified) to Resident 1. The PN indicated, LVN 1 retrieved a box containing nasal spray (naloxone HCl nasal spray) labeled with Resident's 1 name. The PN indicated, immediately after administration of the nasal spray, Resident 1 began to shout and complain of chest pain, burning sensation of Resident 1's body, and felt like Resident 1 was "dying." The PN indicated, Resident 1 complained that Resident 1's body was on fire and Resident 1's nose was burning. The PN indicated, Resident 1's blood pressure (BP- the pressure of blood pushing against the walls of the arteries) was 142/94 millimeters of mercury (mmHg- unit of measurement) (Normal BP was 120/80). The PN indicated, the facility called paramedics (healthcare professional trained to give emergency medical care to people who were injured or ill, typically in a setting outside of a hospital). During an interview on 3/28/2024 at 12:02 pm with LVN 1, LVN 1 stated when giving medications, LVN 1 did not check the medication label on the nasal spray before administering the medication to Resident 1 (on 3/14/2024 at 7 pm). LVN 1 stated LVN 1 normally checked the resident's name, medication order, and matched the information FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 4 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE against the medication label to ensure LVN 1 had the right dose of medication, right time, right patient, right medication, and right route of administering the medication. LVN 1 stated on 3/14/2024 at approximately 7 pm, LVN 1 thought LVN 1 was giving Resident 1 Flonase nasal spray. LVN 1 stated LVN 1 had trouble finding the Flonase in the medication cart. LVN 1 stated LVN 1 found a box of nasal spray with Resident 1's name on it but did not look at the name/label of the medication or the bottle of the medication. LVN 1 stated after giving the nasal spray to Resident 1, LVN 1 left Resident 1's room to get Resident 1's prescribed narcotic (medication used to treat moderate to severe pain). LVN 1 stated Resident 1 then wheeled himself into the hallway screaming, "My body is on fire. I'm going to die. My chest, my chest!" LVN 1 stated Resident 1 vomited. LVN 1 stated at that time, LVN 1 did not know what was happening to Resident 1. LVN 1 stated the desk nurse called 911 (a phone number used to contact the emergency services). LVN 1 stated when the paramedics arrived, the paramedics asked for the medications administered to Resident 1. LVN 1 stated LVN 1 showed the paramedics the box of nasal spray LVN 1 thought was Flonase and administered to Resident 1. LVN 1 stated the paramedics told LVN 1 that LVN 1 gave Resident 1 the Narcan. LVN 1 stated LVN 1 accidentally gave Resident 1 the Narcan. LVN 1 stated it was important to check medication label and bottle to ensure the medication being given was the correct medication. LVN 1 stated not checking the medication bottle/label before giving the medication to Resident 1 caused Resident 1 harm and could have led to Resident 1's death. LVN 1 stated if LVN 1 checked the bottle/label of nasal spray before administering it to Resident 1, the medication error could have been avoided. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 5 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent interview and record review on 3/28/2024 at 2:03 pm with the Director of Staffing Development (DSD), LVN 1's Medication Competency Assessments, dated 3/27/2024, were reviewed. The DSD stated medication management included the five rights of medication administration (right patient, right medication, right dosage, right time, and right route), medication storage, and actual administration of medication to residents. The DSD stated newly hired nurses were educated on medication management. The DSD stated experienced nurses who mentored newly hired nurses were supposed to assess and sign off on the newly hired nurse's Medication Competency Assessments. The DSD stated once the newly hired nurse passed the medication competency assessment, the newly hired nurse could pass/administer medications to residents without the need of a mentor. The DSD stated LVN 1 administered medications to Resident 1 without a mentor on 3/14/2024 when LVN 1 administered naloxone (in error) instead of fluticasone to Resident 1. The DSD stated LVN 1 was not given the medication competency assessments until 3/27/2024. During a concurrent interview and record review on 3/28/2024 at 4:04 pm with the DSD, LVN 1's New Employee Checklist (NEC) dated 2/20/2024, and the facility's P&P titled, "Staffing, Sufficient and Competent Nursing," were reviewed. The DSD stated the NEC did not indicate the need for medication management competency. The DSD stated a medication competency assessment was how the DSD checked if a newly hired nurse had the skills and techniques necessary for medication management in accordance with the P&P "Staffing, Sufficient and Competent Nursing." The DSD stated it was possible that LVN 1 could have avoided making a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 6 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication error on 3/14/2024 with Resident 1 had LVN 1 demonstrated the skills and techniques necessary for medication management. The DSD stated the facility did not follow the facility's P&P on competent staffing and medication management. During an interview on 3/28/2024 at 4:44 pm with the Director of Nursing (DON), the DON stated a newly hired nurse competent in medication management meant the nurse was educated by the facility in medication management before passing medication without a mentor. The DON stated according to the facility's P&P titled, "Staffing, Sufficient and Competent Nursing," nurses must demonstrate the skills and techniques necessary for medication administration. The DON stated if staff skills had been assessed and staff was able to demonstrate correct techniques and passed the medication competency assessments, the staff was then competent in medication management. The DON stated LVN 1 was not assessed for medication competency until after LVN 1 made a medication error. The DON stated it was possible LVN 1's medication error on 3/14/2024 could have been avoided had LVN 1's medication management competency been assessed before LVN 1 administered medications without a mentor. During a review of the facility's P&P titled, "Administering Medications," revised in 4/2019, the P&P indicated new personnel authorized to administer medications were not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. The P&P indicated, the charge nurse must accompany new nursing personnel on their medications rounds for a minimum of three (3) days to ensure established procedures were followed and proper resident identification FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 7 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE methods were learned. During a review of the facility's P&P titled, "Staffing, Sufficient and Competent Nursing," revised in 8/2022, the P&P indicated, the facility provided staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The P&P indicated, all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. The P&P indicated, staff must demonstrate the skills and techniques necessary to care for resident needs including medication management. The P&P indicated, competency requirements and training for nursing staff were established and monitored by nursing leadership with input from the medical director to ensure that programming for staff training resulted in nursing competency, gaps in education were identified and addressed, tracking or other mechanisms were in place to evaluate effectiveness of training, and that training included critical thinking skills and managing care in a complex environment with multiple interruptions.

F760 SS=G Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 04/30/2024 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: 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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 8 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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. Ensure LVN 1 checked Resident 1's Narcan nasal liquid medication label three times and verified that it was the right medication, right dosage, and right time before administering the medication to Resident 1 as indicated in the facility's policy and procedure (P&P) titled, "Administering Medications." As a result, on 3/17/2024 at 7:00 pm, immediately after Resident 1 received the incorrect medication, Resident 1 experienced chest pain, burning sensation of Resident 1's body, and Resident 1 felt like Resident 1 was "dying." Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 3/14/2024 at 7:30 pm for further evaluation and was treated for acute opioid withdrawal (a set of symptoms from the sudden withdrawal or reduction of opioids where previous usage has been heavy and prolonged) induced (caused) by accidental Narcan administration. Cross Reference F726 and F842 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 8/16/2022, with diagnoses of asthma (chronic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 9 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE lung disease caused by inflammation and muscle tightening around the airways), allergic rhinitis (nose irritation, sneezing, watery eyes, and nasal congestion caused by allergic reaction general to environmental factors), acquired absence of right leg above the knee and phantom limb syndrome with pain (the experience of painful sensations in a limb that did not exist). During a review of Resident 1's Physician Order (PO), dated 8/16/2022, the PO indicated, Resident 1 had an order for fluticasone furoate suspension, 27.5 micrograms (mcg- unit of measurement), spray one (1) spray in both nostrils, (nose) two times a day related to adverse (unwanted and harmful) effect of antiasthmatics (medications that reduced the swelling and tightening in the airways). During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 2/13/2024, the MDS indicated, Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated, Resident 1 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity) with oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting/taking off footwear, and personal hygiene. During a review of Resident 1's PO, dated 2/20/2024, the PO indicated, Resident 1 had an order for Percocet (a combination medication containing oxycodone [an opioid pain medication] and acetaminophen [medication used to treat mild to moderate pain and fever] oral (by mouth) tablet 5-325 milligrams (mg, unit of measurement), give one (1) tablet by mouth every six (6) hours as needed for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 10 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE moderate to severe pain. During a review of Resident 1's PO, dated 2/14/2024, the PO indicated, Resident 1 had an order for Narcan nasal liquid (Naloxone Hydrochloride [HCl]), one (1) spray in nostril as needed for opioid overdose. During a review of Resident 1's Progress Notes (PN), dated 3/14/2024 at 7:38 pm, the PN indicated, at approximately 7:00 pm, LVN 1 administered nasal spray (unidentified) to Resident 1. The PN indicated, LVN 1 retrieved a box containing nasal spray (naloxone HCl nasal spray) labeled with Resident's 1 name. The PN indicated, immediately after administration of the nasal spray, Resident 1 began to shout and complain of chest pain, burning sensation of Resident 1's body, and felt like Resident 1 was "dying." The PN indicated, Resident 1 complained that Resident 1's body was on fire and Resident 1's nose was burning. The PN indicated, Resident 1's blood pressure (BP- the pressure of blood pushing against the walls of the arteries) was 142/94 millimeters of mercury (mmHg- unit of measurement) (Normal BP was 120/80). The PN indicated, the facility called paramedics (healthcare professional trained to give emergency medical care to people who were injured or ill, typically in a setting outside of a hospital). During a review of Resident 1's PO, dated 3/14/2024, the PO indicated an order to transfer Resident 1 to GACH 1 via 911 (emergency medical services) on 3/14/2024 (no time and indication specified). During a review of Resident 1's GACH 1 Emergency Department Exam Narrative (ED Exam), dated 3/14/2024 at 7:47 pm, the ED Exam indicated, Resident 1 was brought in for accidental medication administration of Narcan, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 11 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE eight (8) mg. The ED Exam indicated, Resident 1 was normally on Percocet and occasionally on Morphine (opioid pain medication used to treat moderate to severe pain) for chronic pain. The ED Exam indicated, Resident 1 was very anxious and restless and was in acute withdrawal due to Narcan. The ED Exam indicated, Resident 1's blood pressure was 170/80 mmHg. The ED Exam indicated, Resident 1 was treated with buprenorphine (medication used to treat opioid use disorder), clonidine HCI (medication used to lower blood pressure and heart rate), and intravenous (into a vein) fluids. During an interview on 3/28/2024 at 9:05 am with Resident 1, Resident 1 stated LVN 1 was Resident 1's medication nurse in the afternoon (on 3/14/2024). Resident 1 stated LVN 1 handed Resident 1 a nasal spray medication that did not look familiar to Resident 1. Resident 1 stated Resident 1 explained to LVN 1 that "it was not Resident 1's medication," but LVN 1 insisted it was the correct nasal spray medication for Resident 1. Resident 1 stated Resident 1 explained to LVN 1 that Resident 1 normally took Flonase and not "Naloxona." Resident 1 stated LVN 1 told Resident 1 to take the medication because it was prescribed to Resident 1 and was due to be taken. Resident 1 stated LVN 1 made Resident 1 take the Narcan. Resident 1 stated immediately after LVN 1 sprayed the Narcan into Resident 1's nostril, Resident 1's body felt like it was burning. Resident 1 stated Resident 1 wanted to remove all of Resident 1's clothes because Resident 1's body felt like "it was on fire." Resident 1 stated Resident 1 felt "different" in Resident 1's head like Resident 1's head was "going to explode." Resident 1 stated Resident 1 urinated and vomited on Resident 1's self. Resident 1 stated Resident 1 started to scream and ask for help because Resident 1 felt like FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 12 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 was going to die. Resident 1 stated after Resident 1 returned to the facility from GACH 1, Resident 1 still experienced some chest pain and body tingling. Resident 1 stated Resident 1 had never been more scared in Resident 1's entire life than in that moment when Resident 1 received the wrong medication. During an interview on 3/28/2024 at 12:02 pm with LVN 1, LVN 1 stated when giving medications, LVN 1 did not check the medication label on the nasal spray before administering the medication to Resident 1 (on 3/14/2024 at 7 pm). LVN 1 stated LVN 1 normally checked the resident's name, medication order, and matched the information against the medication label to ensure LVN 1 had the right dose of medication, right time, right patient, right medication, and right route of administering the medication. LVN 1 stated on 3/14/2024 at approximately 7 pm, LVN 1 thought LVN 1 was giving Resident 1 Flonase nasal spray. LVN 1 stated LVN 1 had trouble finding the Flonase in the medication cart. LVN 1 stated LVN 1 found a box of nasal spray with Resident 1's name on it but did not look at the name/label of the medication or the bottle of the medication. LVN 1 stated after giving the nasal spray to Resident 1, LVN 1 left Resident 1's room to get Resident 1's prescribed narcotic (medication used to treat moderate to severe pain). LVN 1 stated Resident 1 then wheeled himself into the hallway screaming, "My body is on fire. I'm going to die. My chest, my chest!" LVN 1 stated Resident 1 vomited. LVN 1 stated at that time, LVN 1 did not know what was happening to Resident 1. LVN 1 stated the desk nurse called 911 (a phone number used to contact the emergency services). LVN 1 stated when the paramedics arrived, the paramedics asked for the medications administered to Resident 1. LVN 1 stated LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 13 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1 showed the paramedics the box of nasal spray LVN 1 thought was Flonase and administered to Resident 1. LVN 1 stated the paramedics told LVN 1 that LVN 1 gave Resident 1 the Narcan. LVN 1 stated LVN 1 accidentally gave Resident 1 the Narcan. LVN 1 stated it was important to check medication label and bottle to ensure the medication being given was the correct medication. LVN 1 stated not checking the medication bottle/label before giving the medication to Resident 1 caused Resident 1 harm and could have led to Resident 1's death. LVN 1 stated if LVN 1 checked the bottle/label of nasal spray before administering it to Resident 1, the medication error could have been avoided. During a telephone interview on 3/28/2024 at 1:36 pm with Pharmacist Consultant (PC) 1, PC 1 stated Narcan was administered only in the event of a suspected or confirmed opioid overdose situation. PC 1 stated Narcan would be administered if a resident was experiencing respiratory depression (decrease in breathing), lethargy (extreme exhaustion) or unresponsiveness. PC 1 stated Narcan diminished the effects of opioids. PC 1 stated Resident 1 had an adverse response to Narcan because it caused vomiting and hypertension (high blood pressure). PC 1 stated LVN 1 made a medication error because Resident 1 was not experiencing opioid overdose when LVN 1 administered the Narcan to Resident 1. PC 1 stated LVN 1 could have avoided the medication error if LVN 1 followed the five rights of medication administration (right medication, right dose, right time, right route, right patient). During an interview on 3/28/2024 at 4:44 pm with the Director of Nursing (DON), the DON stated the five rights of medication administration needed to be followed during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 14 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication pass to ensure mistakes or medication errors were not made. The DON stated if the licensed nurses did not follow the five medication rights, medication errors could be made. The DON stated giving a resident Narcan when not indicated could cause a resident to experience increased heart rate, hypertension, anxiety, agitation, and acute opioid withdrawal. The DON stated LVN 1 did not follow the five rights of medication administration before administering the Narcan to Resident 1. The DON stated the medication error and Resident 1's adverse reaction could have been avoided had LVN 1 followed the five medication rights. During a review of the facility's P&P titled, "Administering Medications," revised in 4/2019, the P&P indicated, medications were administered in a safe and timely manner, and as prescribed. The P&P indicated, medications were administered in accordance with prescriber orders, including any required timeframe. The P&P indicated, individuals administering medications checked the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 04/22/2024 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 15 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 16 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain complete and accurately documented medical record for one of three sampled residents (Resident 1) by failing to: Ensure Licensed Vocational Nurse (LVN) 1 documented the administration of Narcan nasal liquid (Naloxone Hydrochloride [HCl]- nasal [nose] spray medication used to rapidly reverse the effects of opioid [class of drugs used to treat moderate to severe pain] overdose) instead of fluticasone furoate suspension (Flonase- nasal spray medication used to treat nasal congestion, sneezing, and runny nose caused by seasonal allergies [body's reaction to normally harmless substances) to Resident 1 on 3/14/2024 at 7 pm. This failure had the potential for Resident 1 to not receive appropriate care and treatment due to an incomplete/inaccurate medical record and could lead to more medication errors. Cross Reference F760 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 17 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 8/16/2022, with diagnoses of asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), allergic rhinitis (nose irritation, sneezing, watery eyes, and nasal congestion caused by allergic reaction general to environmental factors), acquired absence of right leg above the knee, and phantom limb syndrome with pain (the experience of painful sensations in a limb that did not exist). During a review of Resident 1's Physician Order (PO), dated 8/16/2022, the PO indicated, Resident 1 had an order for fluticasone furoate suspension, 27.5 micrograms (mcg- unit of measurement), spray one (1) spray in both nostrils (nose), two times a day related to adverse (unwanted and harmful) effect of antiasthmatics (medications that reduced the swelling and tightening in the airways). During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 2/13/2024, the MDS indicated, Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated, Resident 1 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity) with oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting/taking off footwear, and personal hygiene. During a review of Resident 1's PO, dated 2/14/2024, the PO indicated, Resident 1 had an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 18 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE order for Narcan nasal liquid (Naloxone HCl), one (1) spray in nostril as needed for opioid overdose. During a review of Resident 1's Progress Notes (PN), dated 3/14/2024 at 7:38 pm, the PN indicated, at approximately 7:00 pm, LVN 1 administered nasal spray (unidentified) to Resident 1. The PN indicated, LVN 1 retrieved a box containing nasal spray (Naloxone HCl nasal spray) labeled with Resident's 1 name. The PN indicated, immediately after administration of the nasal spray, Resident 1 began to shout and complain of chest pain, burning sensation of Resident 1's body, and felt like Resident 1 was "dying." The PN indicated, Resident 1 complained that Resident 1's body was on fire and Resident 1's nose was burning. The PN indicated, Resident 1's blood pressure (BP- the pressure of blood pushing against the walls of the arteries) was 142/94 millimeters of mercury (mmHg- unit of measurement) (Normal BP was 120/80). The PN indicated, the facility called paramedics (healthcare professional trained to give emergency medical care to people who were injured or ill, typically in a setting outside of a hospital). During a review of Resident 1's Medication Administration Record (MAR) for March 2024, the MAR indicated LVN 1 administered fluticasone to Resident 1 on 3/14/2024 at 5 pm. During a review of Resident 1's MAR for March 2024, the MAR indicated no documentation that LVN 1 administered the Narcan nasal liquid (Naloxone HCI) to Resident 1 on 3/14/2024 at 7 pm. During a review of Resident 1's PO, dated 3/14/2024, the PO indicated an order to transfer Resident 1 to GACH 1 via 911 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 19 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (emergency medical services) on 3/14/2024 (no time and indication specified). During a review of Resident 1's GACH 1 Emergency Department Exam Narrative (ED Exam), dated 3/14/2024 at 7:47 pm, the ED Exam indicated, Resident 1 was brought in for accidental medication administration of Narcan, eight (8) mg. The ED Exam indicated, Resident 1 was normally on Percocet (opioid pain medication used to treat moderate to severe pain) and occasionally on Morphine (opioid pain medication used to treat moderate to severe pain) for chronic pain. The ED Exam indicated, Resident 1 was very anxious and restless and was in acute withdrawal due to Narcan. The ED Exam indicated, Resident 1's blood pressure was 170/80 mmHg. The ED Exam indicated, Resident 1 was treated with buprenorphine (medication used to treat opioid use disorder), clonidine HCI (medication used to lower blood pressure and heart rate), and intravenous (into a vein) fluids. During an interview on 3/28/2024 at 9:05 am with Resident 1, Resident 1 stated LVN 1 was Resident 1's medication nurse in the afternoon (on 3/14/2024). Resident 1 stated LVN 1 handed Resident 1 a nasal spray medication that did not look familiar to Resident 1. Resident 1 stated Resident 1 explained to LVN 1 that "it was not Resident 1's medication," but LVN 1 insisted it was the correct nasal spray medication for Resident 1. Resident 1 stated Resident 1 explained to LVN 1 that Resident 1 normally took Flonase and not "Naloxona." Resident 1 stated LVN 1 told Resident 1 to take the medication because it was prescribed to Resident 1 and was due to be taken. Resident 1 stated LVN 1 made Resident 1 take the Narcan. Resident 1 stated immediately after LVN 1 sprayed the Narcan into Resident 1's nostril, Resident 1's body felt like it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 20 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE burning. Resident 1 stated Resident 1 wanted to remove all of Resident 1's clothes because Resident 1's body felt like "it was on fire." Resident 1 stated Resident 1 felt "different" in Resident 1's head like Resident 1's head was "going to explode." Resident 1 stated Resident 1 urinated and vomited on Resident 1's self. Resident 1 stated Resident 1 started to scream and ask for help because Resident 1 felt like Resident 1 was going to die. Resident 1 stated after Resident 1 returned to the facility from GACH 1, Resident 1 still experienced some chest pain and body tingling. Resident 1 stated Resident 1 had never been more scared in Resident 1's entire life than in that moment when Resident 1 received the wrong medication. During an interview on 3/28/2024 at 12:02 pm with LVN 1, LVN 1 stated on 3/14/2024 at approximately 7 pm, LVN 1 thought LVN 1 was giving Resident 1 Flonase nasal spray. LVN 1 stated LVN 1 had trouble finding the Flonase in the medication cart. LVN 1 stated LVN 1 found a box of nasal spray with Resident 1's name on it but did not look at the name/label of the medication or the bottle of medication. LVN 1 stated after giving the nasal spray to Resident 1, LVN 1 left Resident 1's room to get Resident 1's prescribed narcotic (medication used to treat moderate to severe pain). LVN 1 stated Resident 1 then wheeled himself into the hallway screaming, "My body is on fire. I'm going to die. My chest, my chest!" LVN 1 stated Resident 1 vomited. LVN 1 stated at that time, LVN 1 did not know what was happening to Resident 1. LVN 1 stated the desk nurse called 911 (a phone number used to contact the emergency services). LVN 1 stated when the paramedics arrived, the paramedics asked for the medications administered to Resident 1. LVN 1 stated LVN 1 showed the paramedics the box of nasal spray LVN 1 thought was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 21 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Flonase and administered to Resident 1. LVN 1 stated the paramedics told LVN 1 that LVN 1 gave Resident 1 the Narcan. LVN 1 stated LVN 1 accidentally gave Resident 1 the Narcan. LVN 1 stated if a medication was given, it had to be documented in the MAR, even if the medication was given by accident or in error, for safety and accuracy. LVN 1 stated LVN 1 documented that LVN 1 administered fluticasone and not naloxone because LVN 1 thought LVN 1 gave fluticasone. LVN 1 stated LVN 1 forgot to document that LVN 1 administered naloxone to Resident 1 on 3/14/2024 (at approximately 7:00 pm). During an interview on 3/28/2024 at 4:44 pm with the Director of Nursing (DON), the DON stated if a medication was administered to a resident, the medication administration needed to be documented in the MAR so anyone looking at the MAR could see what medications a resident had received. The DON stated documentation needed to be accurate, so the care team would know what medications were given and when for safety purposes. The DON stated not documenting medication administration accurately could lead to more medication errors that could cause adverse side effects and harm a resident. During a review of the facility's policy and procedure (P&P) titled, "Charting and Documentation," revised in 7/2017, the P&P indicated, all services provided to a resident should be documented in the resident's medical record. The P&P indicated, the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P indicated, medications administered were to be documented in the resident's medical record. The P&P indicated, documentation in the medical record would be objective, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 22 of 23 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055992 (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST COVINA HEALTHCARE CENTER 850 S Sunkist Ave West Covina, CA 91790 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE complete, and accurate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VIX111 Facility ID: CA950000049 If continuation sheet 23 of 23