Inland Valley Care And Rehabilitation Center
INLAND VALLEY CARE AND REHABILITATION CENTER in POMONA, CA — inspection on February 25, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 5's MDS, dated 1/2/2025, the MDS indicated Resident 1 had no impairments in cognitive skills.
The MDS indicated Resident 5 required partial/moderate (helper does less than half the effort) from staff for bathing.
The MDS indicated Resident 5 required setup or clean-up assistance from staff for eating and toileting, oral, and personal hygiene.
During an interview on 2/20/2025 at 12:25 p.m. with Resident 5, Resident 5 stated Resident 3 had a history of yelling at other residents. Resident 5 stated Resident 5 witnessed Resident 3 yelling at residents (in general), I'll kill you; I'll rip your f-ing head off. Resident 5 stated Resident 5 also witnessed Resident 3 say I'll kill you; I'll rip your f-ing head off, to Resident 2 by the smoking patio last week. Resident 5 stated Resident 3 slapped Resident 2 on the back of Resident 2's head.
A4.
During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 6/15/2012 and readmitted Resident 6 on 2/15/2024 with diagnoses including type 2 diabetes mellitus , 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), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood).
During a review of Resident 6's MDS, dated 2/4/2025, the MDS indicated Resident 6 had no impairments in cognitive skills .
The MDS indicated Resident 6 required partial/moderate (helper does less than half the effort) from staff for bathing, dressing, and toileting and personal hygiene.
During an interview on 2/20/2025 at 11:37 a.m. with Resident 6, Resident 6 stated Resident 6 witnessed Resident 3 yelling at Resident 2 and shoving Resident 2 in Resident 2's back. Resident 6 stated Resident 2 was wheeling Resident 2's wheelchair backwards from the smoking patio into the facility and Resident 3 was in the way. Resident 6 stated Resident 3 shouted at Resident 2, F### you, I'll kill you. Resident 6 stated Resident 3 went behind Resident 2 and shoved Resident 2 in Resident 2's back.
During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, revised December 2016, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.
This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse .
056431 02/25/2025
Inland Valley Care and Rehabilitation Center 250 W.
Artesia Street Pomona, CA 91768
During an interview on 2/25/2025 at 1:05 p.m. with the Director of Nursing (DON), the DON stated a resident's (in general) care plan was created to address all the needs of the resident.
The DON stated the care plan contained interventions needed to address the resident's needs while at the facility.
The DON stated if the care plan indicated the resident needed PT and/or OT then the resident should receive PT and/or OT.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
056431 02/25/2025
Inland Valley Care and Rehabilitation Center 250 W.
Artesia Street Pomona, CA 91768
During a review of Resident 8's MDS, dated 11/15/2024, 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:
- Clonazepam (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in
- Docusate Sodium (medication used to treat constipation) Oral Tablet 100 mg Give 2 tablet via
- Lisinopril (medication used to treat hypertension (HTN, high blood pressure) Tab 20 mg Give 1
- Metoprolol Tartrate (medication used to treat HTN) Tab 50 mg Give 1 tablet via G-Tube two times a
- Levetiracetam Oral Solution (medication used to treat seizures) 100 mg/ml Give 7.5 ml via G-tube
the brain]) Tab 2 milligram (mg, a unit of measurement) Give 1 tablet via G-Tube two times a day for seizure.
G-Tube two times a day for constipation.
tablet via G-Tube one time a day for HTN.
day
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.
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 with 15 mL warm purified water (or prescribed amount) between medications.
056431 02/25/2025
Inland Valley Care and Rehabilitation Center 250 W.
Artesia Street Pomona, CA 91768
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.
056431 02/25/2025
Inland Valley Care and Rehabilitation Center 250 W.
Artesia Street Pomona, CA 91768
During a concurrent interview and record review on 2/25/2025, at 12:40 p.m. with the DOR, Resident
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.
056431 02/25/2025
Inland Valley Care and Rehabilitation Center 250 W.
Artesia Street Pomona, CA 91768
P&P indicated when the resident is in bed or confined to a chair be sure the call light is within easy
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.
056431
Form Approved OMB
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
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.
056431
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.