Inland Valley Care: Therapy Denials, Call Light Failures - CA
Resident 4 was admitted on August 31, 2024, with diagnoses including traumatic subarachnoid hemorrhage, acute respiratory failure, and difficulty swallowing. The resident was severely impaired in cognitive skills and completely dependent on staff for toileting, oral and personal hygiene, dressing, and bathing.
On November 14, 2024, the facility's physician ordered occupational therapy and physical therapy evaluations and treatment as indicated. Both therapy evaluations, completed November 15, 2024, determined the resident had good rehabilitation potential and recommended treatment six times per week for four weeks.
The resident received only one session each of physical and occupational therapy.
During interviews on February 25, 2025, the Director of Rehabilitation confirmed both evaluations indicated the resident would benefit from therapy. The director stated the facility was waiting for the resident's insurance to authorize the services, and that insurance did not approve the treatment.
But the facility's Director of Nursing contradicted this explanation. The nursing director stated that decisions to provide therapy were not dependent on insurance authorization. If evaluations indicated a resident would benefit from therapy, the resident should receive it, the director said.
The resident's care plan, dated October 11, 2024, specifically stated the resident required skilled physical therapy due to decreased strength and endurance. The plan set a goal to increase strength in both legs and indicated the resident would receive therapeutic activities.
The Director of Rehabilitation acknowledged the care plan was appropriate and that the resident still needed physical therapy.
Meanwhile, widespread call light failures left residents unable to summon help. On February 20, 2025, inspectors tested call lights in 29 rooms and found malfunctions in 12 rooms.
Resident 9 told inspectors the call light hadn't worked the night before. When the resident pressed it, no light turned on outside the room above the door.
In room 112, the call light failed to activate both the hallway light and the alert panel at the nurses' station. The same double failure occurred in room 114a. Nine other rooms had call lights that failed to signal the nurses' station panel, though some hallway lights still functioned.
In one room, inspectors found a call light hanging over medical equipment next to the bed, completely inaccessible to the resident lying in bed.
The Director of Staff Development stated call lights should always be placed on the resident's functioning side and within reach. "The call lights were the residents' form of communication if they needed help," the director said, adding that ensuring working call lights was everyone's responsibility.
The Director of Nursing explained that call lights allowed residents' needs to be met and concerns immediately addressed. Without accessible call lights, residents couldn't get timely assistance.
The facility's own policies required working call systems. The maintenance policy stated the department was responsible for maintaining equipment in safe and operable condition at all times. The call light policy specifically required staff to keep call lights within easy reach and report defective lights promptly to supervisors.
The facility's therapy policy outlined a clear process: staff would screen residents for rehabilitation potential, therapists would evaluate and recommend treatment plans, and physicians would order services based on those recommendations. The policy made no mention of insurance authorization as a barrier to providing ordered therapy.
For Resident 4, this process worked exactly as intended through the evaluation phase. Both physical and occupational therapists determined good rehabilitation potential and recommended intensive treatment. The physician ordered the therapy. The care plan documented the need.
Yet the resident received virtually no treatment over the months that followed, remaining dependent on staff for basic functions while therapy that could have improved strength and mobility was withheld.
The call light failures compounded risks for all residents, but particularly those like Resident 4 who were completely dependent on staff assistance. With cognitive impairments from brain injury and total dependence for personal care, such residents relied entirely on functioning call systems to communicate their needs.
Instead, they found themselves in rooms where pressing the call button produced no response at nursing stations, or with call devices hanging beyond their reach over medical equipment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Inland Valley Care and Rehabilitation Center from 2025-02-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
INLAND VALLEY CARE AND REHABILITATION CENTER in POMONA, CA was cited for violations during a health inspection on February 25, 2025.
Resident 4 was admitted on August 31, 2024, with diagnoses including traumatic subarachnoid hemorrhage, acute respiratory failure, and difficulty swallowing.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.