Cycle 1
Health 2025-12-18 · Fire 2025-12-18
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
West Covina, CA
West Covina Medical Center D/P SNF
3-star overall rating with 4-star inspections with $7,026 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
725 S. Orange Avenue, West Covina, CA
(626) 338-8481
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
33
Certified beds
Average residents
22
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Rollins-Nelson Healthcare Management
Operator or chain grouping
Approved since
1995-10-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.22
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
2.93
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.65
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
7.80
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
4.15
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
6.67
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.91
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
3.39
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.43 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 16.67% |
8.2%
8.5 pts better
|
Numerator 13 · Denominator 78 |
| Staff flu vaccination coverage | 40.91% |
42%
1.1 pts worse
|
Numerator 45 · Denominator 110 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
98.5%
0.1 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
13.7%
2.6 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
14.2%
3.4 pts worse
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 14.8% |
1.0%
13.8 pts worse
|
1.0%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.2%
1.7 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.9% |
10.9%
8 pts better
|
19.8%
16.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.7%
3 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
94.0%
1.2 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 95.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-18 · Fire 2024-10-18
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-11-22 · Fire 2023-11-22
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-18
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-08
F · Potential for more than minimal harm
2024-10-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-07
F · Potential for more than minimal harm
2023-11-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-16
F · Potential for more than minimal harm
2023-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-16
F · Potential for more than minimal harm
2023-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-12-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-19
E · Potential for more than minimal harm
2024-10-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-18
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-07
E · Potential for more than minimal harm
2023-11-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-22
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-22
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-16
E · Potential for more than minimal harm
2023-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-12-16
Penalties and ownership
What sits behind the stars
$2,117
2023-06-26
Fine
Fine · fine $2,117
Fine
$1,764
2023-06-20
Fine
Fine · fine $1,764
Fine
$3,145
2023-05-30
Fine
Fine · fine $3,145
Fine
Ownership
Besharat, Farid
Operational/Managerial Control · Individual
Brooks, Mark
Operational/Managerial Control · Individual
Francisco, Ann
Operational/Managerial Control · Individual
Nelson, William
5% Or Greater Direct Ownership Interest · Individual
Nelson, William
Corporate Director · Individual
Nelson, William
Corporate Officer · Individual
Nelson, William
5% Or Greater Mortgage Interest · Individual
Rollins, Vicki
5% Or Greater Direct Ownership Interest · Individual
Rollins, Vicki
Operational/Managerial Control · Individual
Rollins, Vicki
Corporate Director · Individual
Rollins, Vicki
Corporate Officer · Individual
Rollins, Vicki
5% Or Greater Security Interest · Individual
Rollins, Vicki
5% Or Greater Mortgage Interest · Individual
West Covina Medical Center Inc
5% Or Greater Direct Ownership Interest · Organization
West Covina Medical Center Inc
Operational/Managerial Control · Organization
West Covina Property Holding, LLC
5% Or Greater Mortgage Interest · Organization
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