POMONA, CA - Federal inspectors documented multiple care violations at Pomona Vista Care Center during an April 2025 inspection, including failures to prevent pressure injuries, inadequate feeding tube management, and missing care plans for residents with post-traumatic stress disorder.
Critical Care Planning Failures Put Vulnerable Residents at Risk
The most serious violations centered on the facility's failure to develop comprehensive care plans for residents with complex medical and psychological conditions. Inspectors found that a resident with severe dementia who consistently refused repositioning did not have a care plan addressing this behavior, despite being at high risk for pressure injuries.
The resident, identified as Resident 42, was documented as having severely impaired cognition and requiring maximal assistance with basic movements. During inspection observations, nursing assistants noted the resident appeared "scared" when being turned and would grip the bed rails to resist repositioning. One certified nursing assistant told inspectors, "It's like this every day" when describing the resident's refusal to be repositioned.
This lack of individualized planning directly contributed to the development of a deep tissue injury on the resident's right ankle. The purple discoloration was discovered during the inspection, with facility staff acknowledging it was a new finding that required immediate attention.
Pressure Injury Prevention Protocols Compromised
The facility's approach to pressure injury prevention revealed multiple systemic failures that put immobile residents at significant medical risk. Pressure injuries develop when sustained pressure restricts blood flow to tissue, typically occurring over bony prominences like heels, hips, and ankles. For residents with limited mobility, regular repositioning every two hours is the primary prevention method.
The medical implications of these failures are substantial. Pressure injuries can progress rapidly from superficial skin damage to deep wounds involving muscle and bone. In elderly residents with compromised immune systems and underlying health conditions, these injuries can lead to serious infections, prolonged healing times, and increased mortality risk.
The inspection revealed inconsistent staff practices regarding repositioning schedules. While some nursing assistants referenced a formal turning schedule requiring position changes every two hours, others indicated no such schedule existed. This confusion meant residents like Resident 42 could remain in the same position for extended periods, dramatically increasing pressure injury risk.
When the deep tissue injury was discovered on Resident 42's ankle, communication breakdowns further compromised care. The certified nursing assistant who found the injury completed a skin assessment form but failed to verbally notify the treatment nurse. The treatment nurse later admitted to missing the documented finding, delaying appropriate intervention.
Feeding Tube Management Violations Raise Infection Concerns
The facility demonstrated serious deficiencies in managing residents who receive nutrition through feeding tubes, affecting two residents who depend entirely on enteral nutrition for survival. Proper feeding tube management requires strict adherence to sterile techniques and equipment replacement schedules to prevent life-threatening complications.
Inspectors documented water flush bags that had been in use for multiple days beyond the manufacturer's recommended 24-hour limit. One resident's water bag was dated five days earlier, while another had been in use for four days. Contaminated feeding equipment can introduce harmful bacteria directly into the digestive system, potentially causing nausea, vomiting, and aspiration pneumonia.
The medical risks associated with these violations are particularly serious for residents with compromised immune systems. Contaminated feeding equipment can lead to gastroenteritis, systemic infections, and aspiration events where stomach contents enter the lungs. For residents who cannot communicate discomfort or symptoms effectively, these complications may progress undetected until they become life-threatening.
Additional feeding tube violations included confusion about medication administration routes. Inspectors found a resident ordered to receive nothing by mouth was simultaneously prescribed oral medications, creating dangerous ambiguity about proper administration methods. Such contradictions can result in medications being given incorrectly, either failing to provide therapeutic benefit or causing harm through inappropriate delivery routes.
Respiratory Care Deficiencies Compromise Essential Treatment
The facility failed to ensure residents received prescribed respiratory treatments according to their care plans, potentially compromising their ability to maintain adequate oxygen levels. One resident with chronic obstructive pulmonary disease required continuous oxygen therapy but was repeatedly observed without the nasal cannula properly positioned.
Continuous oxygen therapy is prescribed when residents cannot maintain safe blood oxygen levels independently. Interruptions in oxygen delivery can cause immediate symptoms including shortness of breath, confusion, and fatigue. Over time, inadequate oxygenation can lead to organ damage, particularly affecting the heart and brain.
The inspection also revealed outdated nebulizer equipment that had not been changed according to infection control protocols. Nebulizer masks and tubing dated from three weeks earlier were still in use, despite facility policies requiring weekly replacement. Old equipment may not deliver medications effectively and can harbor bacteria that cause respiratory infections.
Trauma-Informed Care Gaps Leave Vulnerable Residents Unprotected
Perhaps most concerning was the facility's failure to implement trauma-informed care for a resident with documented post-traumatic stress disorder. The facility admitted they were unaware of the resident's PTSD diagnosis and had not developed appropriate care strategies to prevent triggering traumatic responses.
PTSD in nursing home residents requires specialized approaches to daily care activities. Routine procedures like bathing, medical examinations, or unexpected loud noises can trigger severe psychological distress in trauma survivors. Without proper awareness and planning, staff may unknowingly re-traumatize residents, causing significant psychological harm and interfering with other aspects of care.
The facility's own policies emphasized the importance of trauma-informed care, stating that trigger-specific interventions should identify ways to decrease residents' exposure to traumatic stimuli. However, these policies were not implemented for the affected resident, leaving them vulnerable to psychological distress during routine care activities.
Additional Issues Identified
The inspection uncovered several other care deficiencies that affected resident health and safety:
- Hygiene maintenance failures: One resident with severe dementia had visibly dirty fingernails with black substance underneath, which the Director of Nursing acknowledged could cause infections - Nutritional monitoring gaps: A resident with dysphagia consistently failed to meet the facility's 75-100% meal intake goal, but this issue was not addressed during interdisciplinary care conferences - Communication breakdowns: Staff failed to properly report significant changes in resident conditions, delaying necessary medical interventions
The violations collectively demonstrate systemic issues with care planning, staff communication, and adherence to established medical protocols. Federal regulations require nursing homes to provide individualized care that meets each resident's specific medical, psychological, and social needs while maintaining dignity and quality of life.
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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