Inland Valley Care and Rehab: Advance Directive Failures - CA
Federal health inspectors cited the facility in August 2025 for failing to honor residents' rights to request, refuse, or discontinue treatment and to formulate advance directives. The violation was one of 27 deficiencies documented during a single complaint inspection on August 22, a number that places Inland Valley well above what most facilities accumulate in a standard survey.
The deficiency was classified as a pattern, meaning inspectors found the problem wasn't isolated to a single resident or a single moment. It was happening repeatedly, to more than one person, in more than one instance.
No resident was documented as suffering actual physical harm. But the inspectors' classification carries a specific meaning: there was potential for more than minimal harm. In the context of advance directives, that potential is not abstract.
An advance directive is the document through which a person tells medical providers and caregivers what they want done, and what they do not want done, if they can no longer speak for themselves. It is the instrument through which a resident with a terminal diagnosis can say they do not want to be resuscitated. It is how someone with dementia, while still lucid, can document that they do not want a feeding tube. It is, in many cases, the last meaningful act of self-determination a person can exercise.
When a nursing home fails to honor those documents, or fails to ensure residents can formulate them in the first place, it does not merely create a paperwork problem. It creates the conditions under which a person's final wishes can be overridden by institutional inertia, by a staff member who didn't check a file, by a system that didn't make the directive available at the moment it mattered.
The right at issue, codified under federal tag F0578, covers three distinct protections: the right to request treatment, the right to refuse or discontinue it, and the right to participate in or decline experimental research. The advance directive component is often the most consequential. Inspectors found Inland Valley deficient across that entire cluster of protections, in a pattern that extended beyond a single resident's experience.
Inland Valley Care and Rehabilitation Center is a skilled nursing facility serving residents who often arrive after hospitalizations, surgeries, or acute health events. Many are elderly. Many are managing serious chronic conditions. The population that lives in facilities like this one is precisely the population for whom advance directives carry the most immediate weight.
The facility reported correcting the deficiency by August 27, five days after inspectors documented it. Whether that correction addressed the pattern inspectors identified, or whether it resolved the paperwork for a handful of affected residents, the inspection report does not say.
What the report does say is that 27 separate deficiencies were cited on the same day. Twenty-seven. That figure matters because deficiencies are not cited casually. Each one represents a finding that inspectors documented, reviewed, and determined rose to the level of a formal citation. A facility that accumulates 27 in a single inspection is a facility where problems are not confined to one unit, one shift, or one lapse in judgment.
The advance directive violation sat among those 27 as a resident rights deficiency, a category that reflects not physical care failures but something more fundamental: whether the people living inside the building are being treated as people with the legal right to make decisions about their own bodies and their own deaths.
That right exists because Congress put it there, in response to decades of evidence that nursing home residents were routinely denied the ability to participate in their own care. The advance directive protections were not written as aspirational guidance. They were written because facilities, left without oversight, had demonstrated they would not honor those rights on their own.
Inland Valley now has a correction date on file. The inspectors will return. The 27 deficiencies will be reviewed for compliance.
But for any resident at Inland Valley whose advance directive was not honored in the weeks or months before August 22, the correction date is not a remedy. The decision that was made for them, instead of by them, has already been made.
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 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 10, 2026 · Our methodology
INLAND VALLEY CARE AND REHABILITATION CENTER in POMONA, CA was cited for violations during a health inspection on August 22, 2025.
The deficiency was classified as a pattern, meaning inspectors found the problem wasn't isolated to a single resident or a single moment.
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.