Inland Valley Care and Rehab: Catheter Care Failures - CA
The catheter care citation, recorded under a federal quality-of-care standard, covered a range of related failures: proper care for residents who are continent, proper care for residents who are incontinent, appropriate catheter management, and steps to prevent urinary tract infections. Inspectors classified it as an isolated deficiency, meaning they did not find the problem spread throughout the facility. They also noted no actual harm had occurred. But they were clear that the potential for more than minimal harm was there.
That distinction matters. Urinary tract infections are among the most common and dangerous complications for nursing home residents. In older adults, particularly those with catheters, an untreated or poorly managed infection can escalate quickly, moving from the bladder to the kidneys and, in the worst cases, into the bloodstream. For residents who are already frail, that progression can be fatal.
Catheters require consistent, careful handling. The risk is not theoretical.
The inspection was triggered by a complaint, not a routine survey cycle. That means someone, whether a resident, a family member, or a staff member, contacted regulators with a concern serious enough to prompt a visit. The August 22 inspection that followed documented 27 deficiencies in total. The catheter care failure was one piece of a much larger picture.
Inland Valley Care and Rehabilitation Center told regulators it had corrected the catheter care deficiency by August 27, five days after the inspection concluded. Whether that correction involved retraining staff, updating procedures, reviewing which residents had catheters in place, or some combination of those steps, the inspection record does not say. The facility's word is what the record reflects.
Twenty-seven deficiencies from a single inspection is a significant number. Federal inspectors use a scope and severity grid to classify each finding, rating how widespread a problem is and how serious the harm is or could be. A facility can accumulate deficiencies across many categories, from infection control to staffing to resident rights to medication management, and each one represents something inspectors observed or confirmed was not being done correctly.
The catheter care finding sat at the lower end of the severity scale, classified as a "D" level deficiency, isolated and without documented harm. But the other 26 deficiencies cited during the same inspection have not been detailed here, and the full picture of what inspectors found at Inland Valley in August 2025 extends well beyond this single citation.
What the catheter care finding does reflect, even at the lower severity level, is a gap in one of the most basic and consequential areas of nursing home care. Residents who require catheters are, by definition, among the most vulnerable in a facility. They depend entirely on staff to manage a device that, if handled improperly, becomes a direct route for infection into the body. Residents who are incontinent without catheters depend on staff for timely, dignified care that also protects their skin and reduces infection risk.
The inspection report does not name the residents involved. It does not describe what inspectors observed, what staff said, or what records showed. The narrative is thin. What it confirms is that something in the facility's approach to this category of care was found lacking, that a complaint brought inspectors through the door, and that 27 problems were waiting when they arrived.
The facility's reported correction date of August 27 sits in the record now as a closed item. For the residents who had catheters in place during the days and weeks before that inspection, the correction came after the fact.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 15, 2026 · Our methodology
INLAND VALLEY CARE AND REHABILITATION CENTER in POMONA, CA was cited for violations during a health inspection on August 22, 2025.
Inspectors classified it as an isolated deficiency, meaning they did not find the problem spread throughout the facility.
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.