POMONA, CA - Federal inspectors documented multiple care and safety lapses at Pomona Vista Care Center during an April 2025 inspection, including inadequate staff training for mental health conditions, medication administration errors, and infection control failures that placed vulnerable residents at risk.
Veteran With PTSD Lacked Specialized Care
The facility admitted a military veteran with documented post-traumatic stress disorder but failed to provide staff with adequate training to recognize or manage the condition's symptoms. The resident experienced episodes where he believed he was still in combat or that the U.S. was under attack, according to family members.
When interviewed, a certified nursing assistant stated she didn't know what PTSD stood for and couldn't provide examples of potential triggers. The aide acknowledged treating all residents with general respect but had never received specific training on trauma-related disorders. A licensed vocational nurse similarly reported being unaware of any residents with formal PTSD diagnoses in the facility and couldn't recall any training sessions on the condition.
The facility's Director of Staff Development confirmed that no care plan addressing PTSD interventions had been developed for the veteran. Multiple staff members acknowledged that understanding trauma responses was critical for providing appropriate care, yet the facility had not incorporated PTSD-specific education into its training curriculum.
Family members expressed concern that the facility appeared unaware of the resident's condition or how to address his symptoms effectively. "I would love for the facility to recognize these concerns to better support [the resident's] well-being and provide the care necessary to manage his symptoms effectively," the family member stated during the inspection.
Medical Context: Why Mental Health Training Matters
Post-traumatic stress disorder affects how individuals respond to their environment, process emotions, and interact with others. Without proper understanding, staff may misinterpret behaviors as defiance or confusion rather than trauma responses. Common triggers in nursing home settings can include loud noises, unexpected physical contact, or situations that evoke memories of traumatic events.
When caregivers lack training in trauma-informed care, residents may experience increased anxiety, agitation, or withdrawal. Staff members who understand PTSD can modify their approach by providing advance notice before entering rooms, maintaining consistent routines, and creating calm environments that minimize triggers.
The facility's own policy required behavioral health services for residents with trauma histories and mandated that staff receive education based on resident needs identified through facility assessments. The policy specifically stated that training should cover "care specific to the individual needs of residents diagnosed with mental, psychosocial, or substance use disorder, a history of trauma and/or post-traumatic stress disorder."
Medication Administration Without Proper Verification
Inspectors observed a licensed vocational nurse administering medication to a resident through a gastrostomy tube without first verifying that the physician's order, which specified "by mouth" administration, was appropriate for tube delivery. The resident had been documented as NPO (nothing by mouth) and received all nutrition and medications through the surgically placed feeding tube.
The nurse prepared and administered Quetiapine, an antipsychotic medication, via the feeding tube despite the physician's order indicating oral administration. When questioned, the nurse acknowledged failing to clarify the administration route with the prescribing physician before giving the medication.
Not all oral medications are safe for administration through feeding tubes. Some formulations lose effectiveness when crushed or altered, while others may cause tube blockages or create absorption problems that render the medication less effective or potentially harmful. Extended-release medications, for example, can deliver their full dose immediately if crushed, creating dangerous concentration levels in the bloodstream.
The nurse acknowledged that verifying physician orders before altering medication forms was essential because "not all medications were suitable for G-tube administration due to potential changes in absorption, effectiveness, or risk of tube obstruction." The facility's Director of Nursing confirmed that licensed staff must verify all oral medication orders before administering them through feeding tubes to prevent reduced effectiveness, altered absorption, or patient harm.
Temperature Control Failures Threatened Medication Integrity
The facility's medication refrigerator operated outside required temperature ranges for extended periods without corrective action, potentially compromising insulin and vaccines stored inside. Temperature logs from February through April 2025 showed the refrigerator exceeded the required 36-46 degree Fahrenheit range on more than 30 occasions.
Recorded temperatures reached as high as 48 degrees on multiple dates, with staff documenting the out-of-range readings but taking no action to address the problem or assess whether medications had been damaged. Insulin pens and vaccines require specific temperature ranges to maintain their potency and effectiveness.
When medications are stored at improper temperatures, their chemical composition can degrade. Insulin that becomes too warm may lose its ability to regulate blood sugar effectively, while vaccines exposed to heat may fail to provide immunity. For residents with diabetes who depend on insulin to prevent dangerous blood sugar fluctuations, degraded medication can lead to serious complications including hyperglycemia, diabetic ketoacidosis, or other metabolic emergencies.
The facility's policy required maintaining refrigerator temperatures between 36-46 degrees Fahrenheit and stated that "drugs and biologicals would be stored in locked compartments under proper temperature controls." Despite having this policy in place, staff repeatedly documented temperature violations without implementing corrective measures.
Additional Issues Identified
Staffing Information Not Posted: The facility failed to display current nursing staffing schedules in locations accessible to residents and visitors. Inspectors found staffing sheets stored in binders on lower counters not visible from hallways, rather than posted prominently as required. Family members had reportedly asked whether adequate staff were scheduled on weekends.
Infection Control Lapses: Multiple residents' personal toiletry items were found unlabeled and stored in shared bathrooms rather than in individual containers at bedsides. Expired medical supplies, including alcohol prep pads dated for use more than a year earlier, remained in storage areas. Staff personal belongings were stored on surfaces alongside medical supplies in the medication room.
Feeding Tube Equipment Not Changed: Water flush bags connected to residents' feeding tube systems were not changed within the required 24-hour timeframe. One bag remained in use for three days, creating bacterial growth risks that could lead to infections in residents receiving tube feeding.
Unsanitary Conditions: An absorbent brief remained on the floor of a resident's room for approximately 20 minutes as multiple staff members, including a treatment nurse, social services director, and activities director, entered the room but failed to remove it.
Medical Records Incomplete: Informed consent documents for psychotropic medications lacked dates for two residents, making it impossible to determine when physicians had authorized the treatments.
Room Size Below Standards: Fifteen resident rooms measured below the required 80 square feet per resident in multi-bed rooms. The facility submitted waiver requests for these rooms.
The inspection findings demonstrate gaps between the facility's written policies and actual practices. While protocols existed for trauma-informed care, medication safety, infection control, and temperature monitoring, implementation failures placed residents at risk for inadequate mental health support, medication errors, and potential infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pomona Vista Care Center from 2025-04-18 including all violations, facility responses, and corrective action plans.
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