Inland Valley Care And Rehabilitation Center

F-F693)

Findings:

During a review of Resident 4's Admission Record (AR), the AR indicated the facility admitted Resident 4 on 8/31/2024 diagnoses including traumatic subarachnoid hemorrhage (SAH, a type of bleeding in the brain), acute respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids).

During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024,

the MDS indicated Resident 4 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident was dependent (helper does all the effort) on staff for toileting, oral, and personal hygiene, dressing, and bathing.

During a review of Resident 4's physician orders, the physician orders indicated the following therapy orders for Resident 4:

Occupational Therapy Evaluate and Treat as Indicated, dated 11/14/2024

Physical Therapy Evaluate and Treat as Indicated, dated 11/14/2024

OT eval completed awaiting authorization. Once authorized OT clarification of order for skilled services QD (every day) 6 times a week for 4 weeks for tx (treatment) ., dated 11/15/2024

PT clarification order for Skilled Physical Therapy Services QD . X 4 wks (weeks) (awaiting auth from insurance .), dated 11/15/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 056431 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 02/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 During a concurrent interview and record review on 2/25/2025, at 11:27 a.m. with the Director of Rehabilitation (DOR), Resident 4's Physical Therapy (PT) Initial Evaluation (PT Eval), dated 11/15/2025 and Level of Harm - Minimal harm or Occupational Therapy (OT) Initial Evaluation (OT Eval), dated 11/15/2025 were reviewed. The OT Eval potential for actual harm indicated Resident 4's rehab potential was good. The OT eval indicated Resident 4 had a treatment plan to be conducted six times a week for four weeks with OT. The OT Eval indicated Resident 4 only receive one Residents Affected - Few session of OT and did not receive four weeks of treatment from. The PT Eval indicated had a treatment plan to be conducted six times a week for 4 weeks with PT. The PT Eval indicated Resident 4 only receive one session of PT and did not receive four weeks of treatment from PT. The DOR confirmed PT and PT both indicated Resident 4 would benefit from PT and OT. The DON stated Resident 4 did not receive the PT and OT treatment plan because the facility was waiting for Resident 4's insurance to authorize the PT and OT services. The DOR stated Resident 4's insurance did not approve Resident 4 to receive PT and OT.

During a concurrent interview and record review on 2/25/2025, at 12:40 p.m. with the DOR, Resident 4's care plan titled Resident requires skilled physical therapy ., dated 10/11/2024 was reviewed. The care plan indicated Resident 4 required PT due to decreased strength and endurance. The care plan indicated a goal was for Resident 4 to have an increase in strength to both legs. The care plan indicated Resident 4 would receive therapeutic activities. The DOR stated the care plan was appropriate for Resident 4. The DOR stated Resident 4 still needed PT.

During an interview on 2/25/2025 at 1:05 p.m. with the Director of Nursing (DON), The DON stated the decision to provide PT and/or OT to residents (in general) was not dependent on the residents' (in general) insurance authorization. The DON stated if the resident's PT eval and/or OT eval indicated the resident would benefit from PT and/or OT then the resident should receive PT and/or OT. The DON stated if the care plan indicated the resident (in general) needed PT and/or OT the resident should be provided PT and/or OT.

During a review of the facility's policy and procedure (P&P) titled, Functional Impairment - Clinical Protocol, revised September 2012, the P&P indicated, Upon admission to the facility, at any time a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical condition and functional status. The P&P indicated, .A physician, nurse or therapist may initiate screening for the potential to benefit from rehabilitative services such as physical and occupational therapy . Following the screening, the therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy (e.g., restorative nursing services that can be provided by caregivers or exercises with which family members can assist) .If a potential to benefit from rehabilitation therapies (either skilled or unskilled) is identified, the attending physician will order a relevant therapy evaluation (for example, by a physical or occupational therapist) In conjunction with the physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcomes efficiently using available resources .Based on a review of available information (including results of the evaluation),

the physician will determine if a resident meets the criteria for skilled therapy services .The physician will order therapy services based on the above considerations and the therapist's recommendations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 056431 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 02/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37198 potential for actual harm Based on observation, interview, and record review, the facility failed to follow the facility ' s Policy and Residents Affected - Some Procedure (P&P) titled, Answering the Call Light, and Maintenance Service, for 12 of 29 resident rooms (Rooms 112, 114a, 202, 208, 209, 211, 212, 216, 221, 222, 223 and 225) by failing to:

a. Ensure the call lights in the resident rooms were functioning.

b. Ensure the call light was accessible for one resident in room [ROOM NUMBER]a.

These deficient practices had the potential to result in the delay of care for the residents affecting their safety and quality of life.

Findings:

During a concurrent observation and interview on 2/20/2025 at 11:31 am, with Resident 9, Resident 9 stated

the call light did not work the night before (2/19/2025). Resident 9 pressed the call light, and the light did not turn on outside of Resident 9 ' s room above the door.

During an observation on 2/20/2025 at 11:35 am, with the Director of Staff Development (DSD) and Maintenance Staff (MS), the facility call lights were checked in 29 resident rooms of the facility. MS checked

the call light in room [ROOM NUMBER] and the light did not turn on above the room ' s door in the hallway and there was no light turning on at the call light panel in the nurses ' station. MS checked the call lights in rooms [ROOM NUMBERS], and the lights did not turn on above the rooms ' doors in the hallway. MS checked the call lights in Rooms 202, 208, 209, 211, 212, 216, 221, 222, and 223 and there were no lights turning on at the call light panel in the nurses ' station.

During an observation on 2/20/2025 at 12:08 pm, MS was going to check the call light in room [ROOM NUMBER]a. The call light was observed hanging over an enteral feeding pump (a medical device that is used to deliver nutrients directly into the stomach or small intestine of a person who is unable to take food or liquids orally) on a pole next to the bed, not accessible to the resident lying in bed.

During an interview on 2/20/2025 at 12:11 pm, with the DSD, the DSD stated the call lights should always be placed on the resident ' s good side and within reach. The DSD stated the call lights were the residents ' form of communication if they needed help. The DSD stated it was everyone ' s responsibility to ensure the call lights were working.

During an interview on 2/20/2025 at 4:55 pm, with the Director of Nursing (DON), the DON stated the call lights were provided to the residents so their needs could be met, and their concerns immediately addressed.

The DON stated, the resident would not be able to get assistance timely if the call light was not accessible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 056431 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 02/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 During a review of the facility ' s P&P titled, Maintenance Service, revised December 2009, the P&P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment Level of Harm - Minimal harm or in a safe and operable manner at all times . The maintenance director is responsible for developing and potential for actual harm maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Residents Affected - Some

During a review of the facility ' s P&P titled, Answering the Call Light, revised in October 2010, the P&P indicated when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Report all defective call lights to the nurse supervisor promptly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 056431

F-F825)

Findings:

a. During a review of Resident 4's Admission Record (AR), the AR indicated the facility admitted Resident 4

on 8/31/2024 diagnoses including traumatic subarachnoid hemorrhage (SAH, a type of bleeding in the brain), acute respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids).

During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024,

the MDS indicated Resident 4 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident was dependent (helper does all the effort) on staff for toileting, oral, and personal hygiene, dressing, and bathing.

During a concurrent observation and interview on 2/20/2025 at 2:15 p.m. with Licensed Vocational Nurse (LVN) 1in Resident 4's room, Resident 4 was lying in bed with Resident 4's enteral feeding (a method of providing nutrition directly into the gastrointestinal [GI] tract through a tube) running via Resident 4's G-tube.

The HOB was raised slightly. LVN 1 stated the HOB needed to be raised to 30 - 40 degrees. LVN 1 stated LVN 1 did not know how high the HOB was raised but was sure it was not raised high enough. LVN 1 stated there were no marks on the bedframe to determine the degree of the HOB.

During an interview on 2/24/2025 at 3:15 p.m. with the Director of Nursing (DON), the DON stated the HOB must be raised to 35-45 degrees whenever residents (in general) where receiving enteral feeding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 056431 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 02/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, revised November 2018, the P&P indicated, Elevate the head of the bed (HOB) at least 30 during tube Level of Harm - Minimal harm or feeding and at least 1 hour after feeding. potential for actual harm b. During a review of Resident 8's AR, the AR indicated the facility admitted Resident 8 on 7/12/2019 and Residents Affected - Few readmitted Resident 8 on 6/17/2024 with diagnoses including hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), acute and chronic respiratory failure, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).

During a review of Resident 8's MDS, dated [DATE REDACTED], the MDS indicated Resident 8 was severely impaired in cognitive skills. The MDS indicated Resident was dependent (helper does all the effort) on staff for toileting, oral, and personal hygiene, dressing, and bathing.

During a review of Resident 8's Order Summary Report, dated 2/25/2025, the Order Summary Report indicated Resident 8 had active orders from the physician for medications, including:

1. Clonazepam (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain]) Tab 2 milligram (mg, a unit of measurement) Give 1 tablet via G-Tube two times a day for seizure.

2. Docusate Sodium (medication used to treat constipation) Oral Tablet 100 mg Give 2 tablet via G-Tube two times a day for constipation.

3. Lisinopril (medication used to treat hypertension (HTN, high blood pressure) Tab 20 mg Give 1 tablet via G-Tube one time a day for HTN.

4. Metoprolol Tartrate (medication used to treat HTN) Tab 50 mg Give 1 tablet via G-Tube two times a day

5. Levetiracetam Oral Solution (medication used to treat seizures) 100 mg/ml Give 7.5 ml via G-tube two times a day for seizures

During a medication administration observation on 2/25/2025 at 8:48 a.m. with LVN 2, LVN 2 administered five medications to Resident 8 via Resident 8's G-tube. The five medications were Clonazepam, Docusate Sodium, Lisinopril, Metoprolol Tartrate, and Levetiracetam. LVN 2 administered the first medication and then flushed the G-tube with water before administering the second medication. LVN 2 failed to flush the G-tube with water between LVN 2 administering the second, third, the fourth medication. LVN 2 administered the fourth medication and flushed the G-tube with water before giving the fifth medication.

During an interview on 2/25/2025 with the DON, the DON stated medications given via G-tube need to be flushed with water between medications to help with medication absorption and to keep the G-tube from clogging.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 056431 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 02/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 During a review of the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, revised November 2018, the P&P indicated, If administering more than one medication, flush Level of Harm - Minimal harm or with 15 mL warm purified water (or prescribed amount) between medications. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 056431 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 02/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 44027 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse Residents Affected - Some properly when eight of eight facility dumpsters' lids were open, leaving the top of the dumpsters uncovered.

This failure had the potential to negatively impact the health of residents by attracting rodents and pests to

the facility, which could carry infectious diseases.

Findings:

During a concurrent observation and interview on 2/20/2025 at 2:40 p.m. with the Director of Food Services and Environmental (DOF), eight dumpsters were observed behind the facility. All the dumpsters had their lids opened. Three of the dumpsters had trash inside. The DOF stated the dumpster lids should be closed because rodents could get inside the dumpsters if left opened.

During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised October 2017, the P&P indicated, Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding littler.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 056431 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 02/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Provide or get specialized rehabilitative services as required for a resident.

Level of Harm - Minimal harm or 44027 potential for actual harm Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 4) Residents Affected - Few received Physical Therapy (PT, specialized rehabilitative service that helps you improve how your body performs physical movements) and Occupational Therapy (OT, specialized rehabilitative service that helps you improve your ability to perform daily tasks) as indicated in the Resident 4's plan of care.

This failure resulted in Resident 4 did not receive PT and OT services as indicated in Resident 4's care plan and had the potential for Resident 4 to not attain, maintain or restore Resident 4's highest practicable level of physical, mental, functional and psycho-social well-being.

(Cross Reference