Pomona Vista Care Center

F-F656

Findings:

During a review of Resident 16's Admission Record (AR), the AR indicated the facility admitted Resident 16

on 6/27/2024, with diagnosis including, PTSD, hypertension (HTN-high blood pressure), and peripheral vascular disease (PVD- a slow progressive narrowing of the vessels [blood flow] to the arms and legs).

During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2025,

the MDS indicated Resident 16 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 16 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance with mobility.

During an interview on 4/17/2024 at 11:57 AM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated CNA 3 didn't exactly know what PTSD stood for, but believed it was when someone went through a really bad experience. CNA 3 stated CNA 3 couldn't be specific or provide examples. CNA 3 stated CNA 3 couldn't recall ever caring for any residents who had PTSD. CNA 3 stated CNA 3 couldn't provide examples of PTSD triggers, but always ensured not to upset anyone. CNA 3 stated CNA 3 treated residents with respect and treated them like CNA 3 would like to be treated. CNA 3 stated CNA 3 had received in-services on general behavior issues, like dementia (a group of conditions, decline in mental ability, that interfere with daily activities), but for PTSD specifically, It hadn't been a big focus.

During an interview on 4/17/2024 at 11:58 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 was not aware of any residents with a formal PTSD diagnosis in the facility. LVN 1 stated PTSD affected how individuals responded to their environment, processed emotions, and interacted with others. LVN 1 stated without the understanding of the signs and triggers of PTSD, staff could have misinterpreted their behaviors, which could have led to frustration or ineffective support [to the residents with PTSD]. LVN 1 stated being mindful of PTSD helped the facility approach each resident with empathy and patience, ensured a safe and supportive environment. LVN 1 stated LVN 1 could not recall any in-services [provided by the facility] on PTSD. LVN 1 stated incorporating PTSD into the facility's lesson plan could help the facility stay up to date with the best practices and could have promoted an environment of understanding and compassion for the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0699 During an interview on 4/17/2025 at 12:35 PM, with the Director of Staff Development (DSD), the DSD stated

the DSD was unaware Resident 16 had a diagnosis of PTSD. The DSD stated it was crucial for staff to know Level of Harm - Minimal harm or if a resident had PTSD, because it affected how individuals responded to their environment, processed potential for actual harm emotions, and interacted with others. The DSD stated PTSD could impact a resident's emotional and psychological well-being, and awareness of the diagnosis enabled staff to tailor their approach to the Residents Affected - Few resident's specific needs. The DSD stated without an understanding of the signs and triggers of PTSD, staff might have misunderstood certain behaviors, which could have led to frustration or ineffective support to Resident 16. The DSD stated being mindful of PTSD ensured the facility approached each resident with empathy and patience, fostering a safe and supportive environment. The DSD stated staff had not been in-serviced on specific PTSD related topics. The DSD stated incorporating PTSD in the in-service lesson plan would help staff stay current with best practices and ultimately created an environment of understanding and compassion, benefiting everyone.

During an interview on 4/18/2025 at 11:31 AM, with Family Member (FM) 1, FM 1 stated Resident 16 was a former veteran with a documented history of PTSD. FM 1 stated Resident 16 endured severe trauma during his military service and often had episodes where he believed he was still in a combat zone or that the U.S. was under attack. FM 1 stated FM 1 was concerned the facility had never addressed these issues and stated

she was unsure if the facility was even aware of his PTSD or how to treat his symptoms. FM 1 stated FM 1 would love for the facility to recognize these concerns to better support Resident 16's well-being and provide

the care necessary to manage his symptoms effectively.

During an interview on 4/18/2025 at 2:02 PM, with the Director of Nursing, the DON stated PTSD awareness was critical in the facility as it directly impacted resident care. The DON stated many residents had experienced trauma, and PTSD could affect both emotional and physical health. The DON stated without awareness, staff may misinterpret behaviors. The DON there was no was no care plan developed with PTSD interventions for Resident 16. The DON emphasized the importance of regular PTSD-specific in-services to help staff recognize symptoms and respond appropriately. The DON stated training ensured all staff provided care with sensitivity and compassion. The DON added creating a supportive environment helped promote healing and minimize potential triggers.

During a review of the facility's policy and procedure (P&P) titled, Behavioral Health Services revision date 12/19/2022, the P&P indicated it is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning.

The P&P indicated Definitions that included:

Post-Traumatic Stress Disorder occurs is some individuals who have encountered a shocking, scary, or dangerous situation. Symptoms usually begin early, within three months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD.

The P&P indicated Policy Explanation and Compliance Guidelines included:

1. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, adjustment difficulty, and trauma or PTSD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0699 2. The facility will consider the acuity of the resident population. This includes residents with mental disorders, psychosocial disorders, or substance use disorders (SUDs), and those with a history of trauma Level of Harm - Minimal harm or and/or post-traumatic stress disorder (PTSD), as reflected in the facility assessment. potential for actual harm 3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the Residents Affected - Few resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.

4. Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports based upon residents' individual needs, include, but are not limited to:

a. Anxiety and anxiety disorders - There are many types of anxiety disorders, each with different symptoms.

The most common types of anxiety disorders include Generalized Anxiety Disorder, Social Anxiety Disorder, Panic Disorder, Phobias and Post-Traumatic Stress Disorder.

5. The resident, and as appropriate the resident's family, are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall:

a. Have interventions that are person-centered, evidence-based, culturally competent, trauma informed, and

in accordance with professional standards of practice.

b. Account for the resident's experiences and preferences.

6. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based

on the role of the staff member and resident needs identified through the facility assessment. Behavioral health training as determined by the facility assessment will include, but is not limited to, the competencies and skills necessary to provide the following:

a. Care specific to the individual needs of the residents that are diagnosed with a mental, psychosocial, or substance use disorder, a history of trauma and/or post-traumatic stress disorder, substance use disorder, or other behavioral health conditions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 42307 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure nurse staffing data in, two of Residents Affected - Few two nursing stations (North Station and South Station), was posted in a prominent place readily accessible to residents and visitors.

This deficient practice had the potential for residents and visitors to not be aware of the actual and accurate nursing hours to ensure facility had enough staff to provide care during each shift.

Findings:

During a concurrent observation, interview, and record review on 4/18/2025 at 3:35 PM with Licensed Vocational Nurse (LVN) 2, in the South Station, LVN 2 was asked where the facility's actual staffing schedule was posted. LVN 2 took a green colored binder titled, South Station Daily Assignment and Monthly Schedule (SDAMS), that was kept on the lower counter of the nursing station was reviewed. The lower counter was not visible from the hallway. The nursing staffing schedule for the day shift (7:00AM), dated 4/18/25, was the latest on file. LVN 2 stated, the SDAMS is where the staff checked their assignment.

During a concurrent observation, interview, and record review on 4/18/2025 at 3:52 PM with the Director of Staff Development (DSD), in the North Station, the facility's actual staffing schedule filed in a binder titled, North Station Daily Assignment (NSAMS), kept on the lower counter of the nursing station, was reviewed.

The lower counter was not visible from the hallway. The nursing staffing schedule for the day shift (7 AM), dated 4/18/2025, was the latest on file. The Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/18/2025, was posted on the wall by the door entrance. The DSD stated, that's the only place where it's [DHPPD] posted. The DSD stated it was important to post the staffing schedule for residents and visitors to know the staff working for the day caring for residents.

During a concurrent observation and interview on 4/18/2025 at 4:09 PM with the Director of Nursing (DON),

in the North Station, the DHPPD was posted on the wall by the door entrance. The DON stated, the nursing hours did not necessarily need to be viewable to visitors and should only be in the nursing station. The DON stated, it was important to make the nursing hours viewable to visitors and should be posted in the hallway where visitors would be able to see. The DON stated, there had been some family members asking if there was enough staff scheduled on the weekends.

During a review of the facility's policy and procedure (P&P) titled, Nurse Staffing Posting Information, date revised 3/10/2025, the P&P indicated, it was the policy of the facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. The P&P indicated, the nursing staffing sheet would be posted on a daily basis and would contain the following information:

a. Facility Name

b. The current date

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0732 c. Facility's current resident census

Level of Harm - Minimal harm or d. The total number and the actual hours worked by the following categories of licensed and unlicensed potential for actual harm nursing staff directly responsible for resident care per shift:

Residents Affected - Few i. Registered Nurse

ii. Licensed Practical Nurses/Licensed Vocational Nurses

iii. Certified Nurse Aides.

The P&P indicated; the facility would post the Nurse Staffing Sheet at the beginning of each shift. The information posted should be up-to-date and current. The information should reflect staff absences on that shift due to call-outs and illness and after the start of each shift, actual hours would be updated to reflect such.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 50016 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of four sampled Residents Affected - Few residents (Resident 56) was free from a significant medication error by failing to clarify a physician's order for oral (PO) medication administration, despite Resident 56 being documented as NPO (nothing by mouth) and receiving medications via gastrostomy-tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).

This failure resulted in the administration of medication without confirming the appropriate route of administration and placed Resident 56 at risk for adverse medication side effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to a medication).

Findings:

During a review of Resident 56's Admission Record (AR), the AR indicated the facility admitted Resident 56

on 3/26/2023, with diagnoses including encephalopathy (a serious health problem that affects brain function or structure), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and dysphagia (difficulty swallowing).

During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated Resident 56 has severe cognitive (the ability to think and process information) impairment.

The MDS indicated Resident 56 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent with mobility.

During a review of Resident 56's Order Summary Report (OSR), dated active as of 4/17/2025, the OSR included a physician's order (PO), dated 3/26/2025, the PO indicated Resident 56 was NPO (nothing by mouth). The OSR included the following POs for Resident 56 indicating:

a. Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 milligrams (mg, unit of measurement) (Divalproex Sodium), give 4 capsules via G-tube two times a day for seizure (sudden burst of electrical activity in the brain, can cause changes in behavior, movements, feelings and levels of consciousness) disorder, start date: 3/27/2025.

b. Docusate Sodium Oral Tablet (Docusate Sodium) Give 200 mg via G-ube to times a day for bowel movement. The order indicated to hold for loose stools. 100 mg times 2 tabs, start date: 3/27/2025.

c. Levetiracetam Oral Solution 100 milligram/milliliter (ml-unit of measurement) Give 5 ml via G-tube two times a day for seizure disorder, start date: 3/31/2025.

d. Metoprolol Tartrate oral tablet (Metoprolol Tartrate) Give 12.5 mg via G-tube every 12 hours for hypertension (HTN-high blood pressure). The order indicated to hold if systolic blood pressure (SBP-measures the pressure your blood is pushing against your artery walls when the heart beats) and to hold if the SBP was less than 100 and the pulse rate (the number of times your heart beats in one minute) was less than 60 beats per minute, start date: 3/26/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0760 e. Quetiapine Fumarate oral tablet (Quetiapine Fumarate) Give 75 mg by mouth two times a day for psychosis manifested by combativeness/aggression towards staff for no apparent reason, start date: Level of Harm - Minimal harm or 3/27/2025. potential for actual harm f. Zoloft Oral Tablet 25 mg (Sertraline HCl [hydrochloride, the most commonly used salt and unit of Residents Affected - Few measurement) Give 1 tablet via G-tube one time a day for depression manifested by feeling hopeless and loss of interest in life, start date: 4/8/2025.

g. Brimonidine 0.2% eye drop instill 1 drop in the left eye two times a day for glaucoma (a group of eye diseases that damage the optic nerve, which connects the eye to the brain), start date: 3/27/2025.

During a medication administration observation on 4/17/2025 at 08:45 AM, Licensed Vocational Nurse (LVN) 2 prepared the following medications for Resident 56 to administer the medications via G-tube: Divalproex, Docusate Sodium, Levetiracetam, Metoprolol, Quetiapine, and Zoloft.

During a concurrent medication administration observation on 4/17/2025 at 9 AM, LVN 2 administered Quetiapine to Resident 56 via G-tube.

During an interview and concurrent record review on 4/17/2025 at 10:39 AM, Resident 56's OSR was reviewed with LVN 2. LVN 2 stated Resident 56's Quetiapine order indicated to give the medication, By mouth. LVN 2 stated LVN 2 administered Quetiapine via G-tube without clarifying the route (by mouth) indicated on the physician's order with the physician. LVN 2 stated it was important to verify any oral medication with the physician before administering the medication through G-tube, because the formulation may not be safe or effective when altered. LVN 2 stated not all medications were suitable for G-tube administration due to potential changes in absorption, effectiveness, or risk of tube obstruction.

During an interview on 4/18/2025 at 2:02 PM, with the Director of Nursing (DON), the DON stated it was critical for [licensed] nursing staff to verify all physician orders for oral medications before administering them via G-tube. The DON stated not all oral medications were safe to crush or alter, and doing so without clarification could lead to reduced effectiveness, altered absorption, or even harm to the patient, such as tube blockage or adverse reactions. The DON stated clear communication with the prescribing physician was essential to ensure safe medication administration.

During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration via Enteral Tube revision date 12/19/2022, the P&P indicated it was the policy of the facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines. The P&Ps procedure indicated, verify physician orders for medication and enteral tube flush amount.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 42307 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one of one locked medicine refrigerator (RM - a refrigerator that is dedicated to storing and keeping the temperature of medicines and biologicals) was maintained under proper temperature controls in accordance with the facility's policy and procedure (P&P) titled, Medication Storage.

This deficient practice could potentially lead to degrading and losing the potency (intensity of effect) of the medicines and biologicals which could potentially be harmful and compromise the health, safety, and well-being of the residents.

Findings:

During an observation on 4/18/2025 at 12:03 PM with the Registered Nurse Supervisor (RN), the facility's RM inside the medication storage room had a supply of medications that included insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pens and vaccines (medications used to prevent diseases usually given by injection or by mouth). The temperature inside the RM was forty-three point five (43.5) degrees Fahrenheit (*F - units/scale used to measure temperature).

During a concurrent interview and record review on 4/18/2025 at 12:03 PM with the RN, the facility's Refrigerator Temperature Log (RTL), dated February 2025, March 2025, and April 2025 were reviewed. The RTL indicated, a temperature range between thirty-six to forty- six (36-46 *F). The RTL indicated, the temperatures on the following dates during the night (11 to 7 PM) shift and during the day (7 to 3 PM) shift were out of range and no actions were taken:

2/1/25=47.8 and 47.0

2/2/25=47.8 and 48.0

2/3/25=46.6 and 47.0

2/4/25=46.8

2/5/25=47.8 and 47.0

2/6/25=47.5 and 47.0

2/7/25=46.9 and 47.0

2/8/25=46.9

2/9/25=46.8

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0761 2/10/25=46.9

Level of Harm - Minimal harm or 2/13/25=48.0 (Day Shift) potential for actual harm 2/19/25=47.0 (Day Shift) Residents Affected - Few 2/20/25=47.0 (Day Shift)

2/21/25=46.2

2/26/25=46.7 and 47.0

2/28/25=47.0 (Day Shift)

3/3/25=46.2

3/5/25=46.4

3/6/25=46.8 and 46.6

3/7/25=46.4 and 46.2

3/8/25=47.6

3/9/25=47.8

3/18/25=46.4 and 46.8

3/19/25=46.5

3/20/25=46.3

3/22/25=48.0 (Day Shift)

3/27/25=47.5

4/8/25=47.6 but reported

4/9/25=46.6

4/10/25=48.0 (Day Shift)

The RN stated, it was important for the refrigerator temperature to be within range, For the effectiveness of

the medication, if it's [temperature] too cold, it [the medication] could freeze, if it's too hot, it could damage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0761 During a review of the facility's P&P titled, Medication Storage, date revised 12/19/2022, the P&P indicated, it was the policy of the facility to ensure all medications housed on the facility's premises would be stored in Level of Harm - Minimal harm or the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to potential for actual harm ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The P&P indicated, all drugs and biologicals would be stored in locked compartments (i.e., medication carts, cabinets, Residents Affected - Few drawers, refrigerators, medication rooms) under proper temperature controls. The P&P indicated; temperatures were maintained within 36-46 degrees F for refrigerated products.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 36290

Residents Affected - Some Based on interview and record review, the facility failed to ensure completeness of medical records for two of two sampled residents (Residents 2 and 24).

This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided to Residents 2 and 24.

Findings:

a. During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility 10/7/2024 with diagnoses that included lack of coordination, major depressive disorder, and heart failure (condition in which the heart cannot pump enough blood to all parts of the body).

During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2025, the MDS indicated Resident 2's cognition was intact.

b. During a review of Resident 24's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility 5/31/2022 with diagnoses included hemiplegia/hemiparesis (paralysis [complete or partial loss of muscle function] on one side of the body) and unspecified dementia (a group of conditions, decline in mental ability, that interfere with daily activities).

During a review of Resident 24's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 2/25/25, the MDS indicated Resident 24 had mild congnitive impairment.

During an interview and concurrent record review on 4/18/2025 at 2:39 PM with Licensed Vocational Nurse 2 (LVN 2), Resident 2 and Resident 24's undated informed consents (IC, document indicating permission for something to happen or agreement to do something) for psychotropic (medications that change brain function) medications were reviewed. Residents 2 and 24's ICs did not have the signed dates. LVN 2 stated

the ICs for Resident 2 and for Resident 24 were incomplete (missing dates). LVN 2 stated it was important to complete the ICs because the ICs were a part of the resident's (in general) medical record.

During an interview and concurrent record review on 4/18/2025 at 3 PM with the Director of Nursing (DON), Resident 2 and Resident 24's undated ICs were reviewed. Residents 2 and 24's ICs did not have the signed dates. The DON stated, it was important to date the ICs for the facility to know when the doctor approved the administration of the psychotrophic medications. The DON stated the Registered Nurse Supervisors (in general) were responsible for reviewing [completeness] of the ICs and the Registered Nurse Supervisors should have noticed the undated ICs for Residents 2 and 24.

During a review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, revised date 12/19/2022, the P&P indicated documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42307 potential for actual harm Based on observation, interview, and record review, the facility failed to follow infection (the invasion and Residents Affected - Some growth of germs in the body) prevention and control practices designed to provide a safe, sanitary and comfortable environment for 13 of 13 sampled residents (Residents 14, 28, 5, 4, 48, 18, 54, 47, 34, 26, 10, and 30) and the residents (in general) by failing to ensure:

a. Personal toiletries and resident care items were labeled with resident names and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms accessible by the residents in both bedrooms) of Residents 14, 28, 5, 4, 48, 18, and of Residents 54, 47, 34, 26, and 10.

b. medical supplies, stored in the medication storage room, were not expired.

c. staff personal belongings were not stored in the medication storage room.

d. the enteral feeding ([also referred to as tube feeding], a way to deliver liquid nutrition directly into the stomach or small intestine through a tube when a person cannot eat or drink normally) water flush bag was changed within the required 24-hour timeframe for Residents 5 and 30.

e. a sanitary environment for Resident 17 when multiple staff failed to pick up and dispose of an absorbent brief observed on the floor near Resident 17's bed.

Findings:

a.During a review of Resident 14's Admission Record (AR), the AR indicated, Resident 14 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including dementia (a progressive state of decline in mental abilities), unspecified severity, with other behavioral disturbance and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).

During a review of Resident 14's History and Physical (H&P), dated [DATE REDACTED], the H&P indicated, Resident 14 did not have the capacity to understand and make decisions.

During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated [DATE REDACTED], the MDS indicated Resident 14's cognitive skills (ability to think and process information) for daily decision making were severely impaired.

During a review of Resident 28's AR, the AR indicated, Resident 28 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including sepsis (life-threatening complication of

an infection), unspecified organism and dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance.

During a review of Resident 28's H&P, dated [DATE REDACTED], the H&P indicated, Resident 28 did not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0880 During a review of Resident 5's AR, the AR indicated, Resident 5 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including chronic obstructive pulmonary disease Level of Harm - Minimal harm or (COPD - a long-standing lung disease causing difficulty in breathing), unspecified and personal history of potential for actual harm COVID-19 (coronavirus - a mild to severe respiratory illness that spreads from person to person).

Residents Affected - Some During a review of Resident 5's H&P, dated [DATE REDACTED], the H&P indicated, Resident 5 had fluctuating capacity to understand and make decisions.

During a review of Resident 5's MDS, dated [DATE REDACTED], the MDS indicated, Resident 5's cognition was intact.

During a review of Resident 4's AR, the AR indicated, Resident 4 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including immunodeficiency (a weakened or malfunctioning immune system, making individuals more susceptible to infections), unspecified and essential (primary) hypertension (HTN - high blood pressure).

During a review of Resident 4's H&P, dated [DATE REDACTED], the H&P indicated, Resident 4 did not have the capacity to understand and make decisions.

During a review of Resident 4's MDS, dated [DATE REDACTED], the MDS indicated, Resident 4's cognition was moderately impaired.

During a review of Resident 48's AR, the AR indicated, Resident 48 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including immunodeficiency, unspecified and essential (primary) hypertension.

During a review of Resident 48's H&P, dated [DATE REDACTED], the H&P indicated, Resident 48 had fluctuating capacity to understand and make decisions.

During a review of Resident 48's MDS, dated [DATE REDACTED], the MDS indicated, Resident 48's cognition was intact.

During a review of Resident 18's AR, the AR indicated, Resident 18 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including immunodeficiency, unspecified and sepsis, unspecified organism.

During a review of Resident 18's H&P, dated [DATE REDACTED], the H&P indicated, Resident 18 did not have the capacity to understand and make decisions.

During a review of Resident 18's MDS, dated [DATE REDACTED], the MDS indicated Resident 18's cognition was severely impaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0880 During a review of Resident 54's AR, the AR indicated, Resident 54 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including unspecified psychosis (a severe mental Level of Harm - Minimal harm or condition in which thought, and emotions are so affected that contact is lost with reality) not due to a potential for actual harm substance or known physiological condition and anxiety (a mental health condition characterized by persistent, excessive fear or worry that significantly interferes with daily life) disorder, unspecified. Residents Affected - Some

During a review of Resident 54's H&P, dated [DATE REDACTED], the H&P indicated, Resident 54 did not have the capacity to understand and make decisions.

During a review of Resident 54's MDS, dated [DATE REDACTED], the MDS indicated, Resident 54's cognition was severely impaired.

During a review of Resident 47's AR, the AR indicated, Resident 47 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance and immunodeficiency, unspecified.

During a review of Resident 47's H&P, dated [DATE REDACTED], the H&P indicated, Resident 47 did not have the capacity to understand and make decisions.

During a review of Resident 47's MDS, dated [DATE REDACTED], the MDS indicated Resident 47's cognition was severely impaired.

During a review of Resident 34's AR, the AR indicated, Resident 34 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including urinary tract infection (UTI - an infection in the bladder/urinary tract), site not specified and unspecified dementia, unspecified severity, without behavioral disturbance.

During a review of Resident 34's H&P, dated [DATE REDACTED], the H&P indicated, Resident 34 did not have the capacity to understand and make decisions.

During a review of Resident 34's MDS, dated [DATE REDACTED], the MDS indicated, Resident 34's cognition was severely impaired.

During a review of Resident 26's AR, the AR indicated, Resident 26 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including essential (primary) hypertension and urinary tract infection, site not specified.

During a review of Resident 26's H&P, dated [DATE REDACTED], the H&P indicated, Resident 26 did not have the capacity to understand and make decisions.

During a review of Resident 26's MDS, dated [DATE REDACTED], the MDS indicated, Resident 26's cognition was severely impaired.

During a review of Resident 10's AR, the AR indicated, Resident 10 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including immunodeficiency, unspecified and unspecified dementia, unspecified severity, without behavioral disturbance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0880 During a review of Resident 10's H&P, dated [DATE REDACTED], the H&P indicated, Resident 10 did not have the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 10's MDS, dated [DATE REDACTED], the MDS indicated, Resident 10's cognition was moderately impaired. Residents Affected - Some

During a concurrent observation and interview on [DATE REDACTED] at 10:03 AM with Certified Nursing Assistant (CNA) 4, inside the shared restroom of Residents 14, 28, 5, 4, 48, and 18, there was an unlabeled, opened 118 ml (milliliters - a measure of volume) of UltraSure (brand name) anti-perspirant deodorant stored on the windowsill. CNA 4 stated, Residents 14 and 5 were ambulatory (able to walk). CNA 4 stated, the anti-perspirant deodorant was for resident care and should not have been on the windowsill. CNA 4 stated, personal toiletries should be labeled with a resident's name, placed inside a Ziploc bag, and stored at the resident's bedside or the resident's closet for infection control [purposes].

During a concurrent observation and interview on [DATE REDACTED] at 10:30 AM with the Restorative Nurse Assistant (RNA), inside the shared restroom of Residents 54, 47, 34, 26, and 10, an unlabeled, uncapped 222 ml bottle of TotalBath (brand name) skin and hair cleanser was stored on top of the sink. The RNA stated the skin and hair cleanser was a personal item and should not have been left on the sink. The RNA stated, personal items should be labeled with a resident's name and placed inside a, Baggie and kept at the bedside for infection control [purposes].

During an interview on [DATE REDACTED] at 4:55 PM with the Director of Nursing (DON), the DON stated, resident personal toiletries were not supposed to be stored inside the restroom. The DON stated, resident personal toiletries were supposed to be individually packed, labeled with the resident's name, and kept in the drawer or closet for infection control [purposes].

b.During a concurrent observation and interview on [DATE REDACTED] at 12:03 PM with the Registered Nurse Supervisor (RN) inside the medication storage room, a box of Cardinal Health (name brand) 200 ct (count) alcohol prep pads (made from a gauze swab impregnated with an alcohol disinfectant solution, used to prepare the skin prior to an injection and to decrease germs in minor cuts and scrapes) with a date Use By , d+[DATE REDACTED] were inside a bottom drawer. The RN stated, the expired alcohol prep pads could affect the effectivity and doubt if it's still effective in disinfecting (clean with a chemical, in order to kill germs).

During a concurrent observation and interview on [DATE REDACTED] at 12:36 PM with Licensed Vocational Nurse (LVN) 2, the Med Cart South had supplies of alcohol prep pads inside the first drawer. LVN 2 stated, the alcohol prep pads were used to cleanse the area. LVN 2 stated, staff got the supply of alcohol prep pads from Central Supply or from the medication storage room. LVN 2 stated, alcohol prep pads would not work if the alcohol prep pads were expired.

c. During a concurrent observation and interview on [DATE REDACTED] at 12:03 PM with the RN inside the medication storage room, there was a navy-colored floral printed lunch bag on top of a box of sterile pre-filled 3 ml normal saline flush injection syringes (mixture of water and salt, used to flush/clean out intravenous IV catheter) and a black colored lady's hand bag stored on the counter of the cabinet with supply of tube feeding formulas (a liquid form of food that's carried through your body through a flexible tube) and nutritional supplement drinks. The RN stated, the bags belonged to the staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0880 During an interview on [DATE REDACTED] at 4:55 PM with the DON, the DON stated, staff personal belongings should not be stored inside the medication storage room for infection control [purposes]. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, date revised [DATE REDACTED], the P&P indicated, the facility had established and maintained an infection prevention Residents Affected - Some and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent

the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The P&P indicated, sterile supplies were routinely checked for expiration dates and were replaced as necessary.

50016

d. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on [DATE REDACTED], and readmitted the resident on [DATE REDACTED], with diagnosis including, chronic obstructive pulmonary disease (COPD-a long standing lung disease causing difficulty in breathing), hemiplegia (when one side of a person's body is paralyzed or has no movement, usually because of brain damage, like from a stroke [when blood flow to part of the brain gets blocked or a blood vessel in the brain bursts]) and hemiparesis (is weakness on one side of

the body with reduced strength and movement) following cerebral infarction (loss of blood flow to a part of

the brain) and dysphagia (difficulty swallowing).

During a review of Resident 5's MDS dated [DATE REDACTED], the MDS indicated Resident 5's cognition (the ability to think and process information) was intact. The MDS indicated Resident 5 was dependent (helper does all of

the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance (helper does more than half the effort) with mobility.

During a review of Resident 5's Order Summary Report (OSR), dated active as of [DATE REDACTED], the OSR included

a physician's order (PO), start date [DATE REDACTED], the PO indicated enteral feed order, every 8 hours flush tube with 200 milliliters (ml-unit of volume) of water.

D1. During a review of Resident 30's AR, the AR indicated the facility admitted Resident 30 on [DATE REDACTED], and readmitted the resident on [DATE REDACTED], with diagnosis including, hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and adult failure to thrive (a decline in overall health and well-being in older adults, characterized by

a loss of appetite, weight loss, reduced physical activity, and a general decrease in the ability to perform daily tasks).

During a review of Resident 30's MDS dated [DATE REDACTED], the MDS indicated Resident 30 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 30 was dependent with activities of daily living and required substantial/maximal assistance with mobility.

During a review of Resident 30's OSR, dated active as of [DATE REDACTED], the OSR included a physician's order (PO), start date [DATE REDACTED], the PO indicated enteral feed order, every 6 hours flush enteral tube with 125 ml of water.

During an observation on [DATE REDACTED] at 10:33 AM, Resident 5 was observed lying in bed, there was an enteral feeding setup at Resident 5's bedside. The bag connected to Resident 5's enteral feeding system was labeled and dated [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0880 During an observation on [DATE REDACTED] at 1:55 PM, Resident 30 was observed lying in bed, there was an enteral feeding setup at Resident 30's bedside. The bag connected to Resident 5's enteral feeding system was Level of Harm - Minimal harm or labeled and dated [DATE REDACTED]. potential for actual harm

During an interview on [DATE REDACTED] at 1:38 PM, with the Infection Preventionist Nurse (IP), the IP nurse stated Residents Affected - Some tube feeding flush bags should be changed every 24 hours. The IP stated this should be done to prevent bacterial (living organism that can cause an infection) growth and reduce the risk of infection. The IP stated once the water bag was opened and hung, the sterile water could become contaminated, especially in warm environments.

During an interview on [DATE REDACTED] at 2:02 PM, with the DON, the DON stated it was essential to change tube feeding water flush bags every 24 hours to prevent bacterial growth and prevent infections. The DON stated exceeding this timeframe increased the risk for contamination, which could have potentially harmed residents (in general). The DON stressed that timely bag changes was a key part of maintaining safe and sanitary enteral feeding practices.

During a review of the facility's P&P titled, Infection Prevention and Control Program revision date [DATE REDACTED],

the P&P indicated the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

During a review of the facility's undated Competency Skills Checklist titled, Enteral Feeding Administration by Pump the checklist indicated the syringes and pole bags should be related with date and initials when changed and discarded after 24-hours.

45553

e. During a review of Resident 17's AR, the AR indicated, Resident 17 was admitted to the facility on [DATE REDACTED] with diagnoses that included, multiple sclerosis (MS- a long standing, progressive disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness - generalized (lack of muscle strength), Alzheimer's Disease, respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder.

During a review of Resident 17's History and Physical (H&P), dated [DATE REDACTED], the H&P indicated Resident 17 did not have the capacity to understand and make decisions.

During a review of Resident 17's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE REDACTED], the MDS indicated Resident 17's cognition was severely impaired. The MDS indicated Resident 17 required set up or clean-up assistance with eating, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0880 During a review of Resident 17's Change in Condition Evaluation - V5.1, (CIC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), dated [DATE REDACTED], Level of Harm - Minimal harm or the CIC indicated the primary physician was notified, Upon getting report resident has noted diarrhea x 3, potential for actual harm also upon checking resident while making rounds, resident has another episode, denies any pain, lower abdomen-nondistended, all vitals stable. The CIC indicated, Recommendation of Primary Clinician: MD Residents Affected - Some ordered D5NS [5% Dextrose and 0.9% Sodium Chloride] at 75cc [unit of volume]/hour IV [intravenous fluid therapy] for 48 hours and Flagyl (medication antibiotic used to treat various infections) 500 mg (milligrams, unit of measurement) TID [three times a day] for 7 days for diarrhea.

During an observation on [DATE REDACTED] at 07:35 AM, there was an absorbent brief located on the floor next to the left side of the room's doorway and across from Resident 17's foot of the bed.

During an observation on [DATE REDACTED] at 07:39 AM the Treatment Nurse (TN) entered Resident 17's room glanced at the absorbent brief located on the floor and proceeded to check if Resident 17 was awake for breakfast. The TN left the room and the absorbent brief remained on the floor.

During an observation on [DATE REDACTED] at 07:42 AM the Social Services Director (SSD) entered Resident 17's room glanced at the absorbent brief located on the floor and proceeded inside the room to check on the residents. At 07:44 AM the SSD looked at the absorbent brief for a second time and left the room. The SSD left the room, and the absorbent brief remained on the floor.

During an observation on [DATE REDACTED] at 07:47 AM, the Activities Director (AD) entered Resident 17's room, glanced at the absorbent brief located on the floor, and proceeded to check on the residents. The AD left the room, and the absorbent brief remained on the floor.

During an observation on [DATE REDACTED] at 07:51 AM, the TN returned to Resident 17's room and brought a drink for Resident 17. The TN glanced at the absorbent brief located on the floor, left the room, and the absorbent brief remained on the floor.

During an observation on [DATE REDACTED] at 7:54 AM, CNA 1 picked up the absorbent brief located on the floor in Resident 17's room and placed it in the trash.

During an interview on [DATE REDACTED] at 7:55 AM with CNA 1, CNA 1 stated CNA 1 threw the absorbent brief in the trash because CNA 1 saw it there in the corner by the doorway when CNA 1 entered Resident 17's room. CNA 1 stated the brief on the floor was unsanitary. CNA 1 stated no one told CNA 1 about the absorbent brief being on the floor. CNA 1 stated Resident 17 was alert and removed her absorbent brief and threw it on

the floor.

During an interview on [DATE REDACTED] at 8:01 AM with the IP, the IP stated staff knew if they saw an absorbent brief

on the floor, it should be picked up and thrown in the trash. The IP stated Resident 17 was always taking off her brief and throwing it on the floor. The IP stated the absorbent brief on the floor was an infection control issue because germs from the brief could spread.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0880 During a review of the facility's P&P titled, Infection Prevention and Control Program, revised [DATE REDACTED], the P&P indicated under Policy Explanation and Compliance Guidelines: Standard Precautions: All staff shall Level of Harm - Minimal harm or assume that all residents are potentially infected or colonized with an organism that could be transmitted potential for actual harm during the course of providing resident care services. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility Residents Affected - Some and are to report problems outside of their scope to the appropriate department.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50016

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure 15 of 22 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 10, 11, 17, 18, 20, 21, 22, 23, and 24) met the minimum 80 square foot (sq. ft.) requirement per resident in multiple resident bedrooms.

This failure had the potential to result in adequate useable living space for residents and limited working area for the facility staff to provide the care and services for the residents.

Findings:

During a review of the facility's Request for Room Size Waiver letter (RRSWL), dated 4/15/2025, the RRSWL indicated, the Administrator (ADM) submitted a written room size waiver request for Rooms 3, 4, 5, 6, 7, 8, 10, 11, 17, 18, 20, 21, 22, 23, and 24. The RRSWL indicated, the specified rooms did not meet the required 80 sq. ft. per resident in multiple-resident bedrooms. The RRSWL indicated, the facility diligently ensured that the special care needs of the residents were met, and residents' health and safety were not adversely affected.

During a review of the facility's Client Accommodation Analysis, dated 4/15/2025, the analysis indicated rooms 3, 4, 5, 6,7, 8, 10, 11, 17, 18, 20, 21, 22, 23, and 24 all measured 147 sq. ft. (14 ft. x 10.5 ft.). The analysis indicated rooms 3, 4, 5, 6,7, 10, 11, 17, 18, 20, 21, 22, 23, and 24 were three-bed rooms and room [ROOM NUMBER] was a two-bed room.

During an observation on 4/17/20205 at 1:13 PM with the Maintenance Supervisor (MS), the MS randomly selected three of 22 resident rooms. The rooms measured the following useable living space for the residents:

1. room [ROOM NUMBER] (three-bed) measured 14 ft x 10.5 ft.

2. room [ROOM NUMBER] (three-bed) measured 14 ft x 10.5 ft.

3. room [ROOM NUMBER] (three-bed) measured 14 ft x 10.5 ft.

During an interview on 4/18/2025 at 1:01 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated the rooms were set up well and had enough space to safely and effectively provide resident care.

During an interview on 4/18/2025 at 1:13 PM, with Resident 22, Resident 22 stated Resident 22 had enough space to move around freely and never experienced any issues with the space in his room (17). Resident 22 stated staff always had sufficient space to provide care whenever he needed it.

During an interview on 4/18/2025 at 1:19 PM, with Resident 2, Resident 2 stated her room (21) offered ample space for Resident 2 to move around comfortably. Resident 2 stated there were no problems with space when staff needed to assist Resident 2 with care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0912 During a review of the facility's policy and procedure (P&P), titled, Resident Rooms, dated 12/19/2022, the P&P indicated resident bedrooms must be designed and equipped for adequate nursing care, comfort and Level of Harm - Potential for privacy of residents. The P&P indicated, resident bedrooms must measure at least 80 sq. ft. per resident in minimal harm multiple resident bedrooms and at least 100 sq. ft. in single resident bedrooms. The P&P indicated, the facility shall request and/or maintain variances from the survey agency if the room variances: Residents Affected - Some a. Are in accordance with the special needs of the resident.

b. Will not adversely affect the residents' health and safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 37 055282

F-F699)

Findings:

A. During a review of Resident 42's Admission Record (AR), the AR indicated Resident 42 was admitted to

the facility 9/3/2024 with diagnoses that included unspecified dementia (a group of conditions, decline in mental ability, that interfere with daily activities), hyperlipidemia (having too many lipids [fats] in the blood), and psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality).

During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 3/31/2025,

the MDS indicated Resident 42's cognition (ability to understand and process information) was severely impaired. The MDS indicated Resident 42 was dependent with oral, toileting and personal hygiene and required maximal assistance with rolling left and right.

During an observation on 04/17/2025 at 9:51 AM, CNA 3 and CNA 6 entered Resident 42's room to provide care. CNA 6 removed the resident's gown and adult brief. CNA 6 wiped the perineal (an area lower in the body located between the thighs) area with a moistened towel and patted dry. CNA 6 turned Resident 42 to face the right side, Resident 42's left hand held on to the left siderails. CNA 3 stated, It's okay, I'm here. I'll hold your hand. Resident 42 slowly let go of the side rail and CNA 3 turned Resident 42 to the right side. CNA 3 stated Resident 42 was scared when being turned.

During an interview on 4/17/2025 at 2:57 PM, with CNA 6, CNA 6 stated CNA 6 did not turn or reposition Resident 42 because Resident 42 refused to be turned, It's like this every day. CNA 6 stated CNA 6 reported to the nurses occasionally and reported today to Licensed Vocational Nurse 1 (LVN 1) that Resident 42 refused to turn and reposition. CNA 6 stated LVN 1 stated, Okay.

During an interview on 4/17/2025 at 3:08 PM, the Treatment Nurse (TN) stated Resident 42 looked scared when being turned to the sides. The TN stated the TN observed the behavior when the TN helped change Resident 42's adult briefs two weeks ago.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0656 During an interview on 4/18/2025 at 8:28 AM with the Director of Nursing (DON), the DON stated the licensed nurses needed to develop a CP that addressed the refusal to turn and reposition and develop Level of Harm - Minimal harm or interventions to address the refusal to turn and reposition. potential for actual harm

During an interview on 4/18/25 at 9:10 AM, the DON stated the MDS coordinator needed to develop a CP Residents Affected - Some specific to address Resident 42's refusal to be turned and repositioned.

During a concurrent review of Resident 42's CPs and interview on 4/18/2025 at 9:25 AM with the DON, the DON stated there was no CP developed to addressed Resident 42's refusal to turn and reposition.

During a review of the facility's P&P titled Comprehensive Care Plans dated 12/19/2022, the P&P indicated

the comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to

the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, the resident and the resident representative .The P&P indicate the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative

50016

B. During a review of Resident 16's AR, the AR indicated the facility admitted Resident 16 on 6/27/2024, with diagnosis including, PTSD, hypertension (HTN-high blood pressure), and peripheral vascular disease (PVD-

a slow progressive narrowing of the vessels [blood flow] to the arms and legs).

During a review of Resident 16's MDS, dated [DATE REDACTED], the MDS indicated Resident 16 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 16 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance with mobility.

During an interview and a concurrent record review on 4/17/2025 at 12:35 PM, Resident 16's Care Plans were reviewed with the Director of Staff Development (DSD), the DSD stated Resident 16 did not have a CP for PTSD and the DSD was unaware Resident 16 had a PTSD diagnosis. The DSD stated the facility should have initiated an individualized, person-centered CP that addressed Resident 16's PTSD diagnosis. The DSD stated it was crucial for staff to know if a resident had PTSD, as it directly affected how staff approached care. The DSD stated PTSD could impact a resident's emotional and psychological well-being, and awareness of the diagnosis enabled staff to tailor their approach to the resident's specific needs. The DSD stated developing a PTSD CP ensured all members of the healthcare team were aligned with their approach and CPs outlined strategies for managing triggers, appropriate communication techniques, and ways to address behavioral concerns. The DSD stated CPs promoted consistent, compassionate, and mindful care delivery that supported the resident's mental health needs.

During an interview on 4/18/2025 at 2:02 PM, with the Director of Nursing, the DON stated early identification of PTSD allowed for personalized care and strategies to prevent triggers. The DON stated developing a PTSD CP was essential to keep all staff aligned and address each resident's unique needs. The DON stated

the facility should have initiated a PTSD CP for Resident 16 that included specific interventions, coping strategies, and trigger avoidance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0656 During a review of the facility's P&P titled, Comprehensive Care Plans, revision date 12/19/2022, the P&P indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan Level of Harm - Minimal harm or for each resident, consistent with resident rights, that includes measurable objectives and timeframes to potential for actual harm meet a resident's medical, nursing, and mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Residents Affected - Some

The P&P indicated the following definition:

Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.

The P&P indicated policy explanation and compliance guidelines:

a. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect if the trigger on the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or 40913 potential for actual harm Based on observation, interview, and record review, the facility failed to provide good hygiene to one of one Residents Affected - Few sampled resident (Resident 16).

This deficient practice had the potential to cause skin infections to Resident 16.

Findings:

During a review of Resident 16's Admission Record (AR), the AR indicated the facility admitted Resident 16

on 6/27/2024, with diagnoses that included dementia (a group of conditions, decline in mental ability, that interfere with daily activities), Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks).

During a review Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 16's cognition (ability to understand and process information) was severely impaired. The MDS indicated Resident 16 had no impairment with the range of motion (ROM, full movement potential of a joint) of both upper extremities (arms and legs). The MDS indicated Resident 16 was dependent on staff with toileting hygiene and required setup assistance with eating.

During a concurrent observation and interview on 4/17/2025 T 10:59 AM, with the Director of Nursing (DON), Resident 16 had long fingernails with black substance under the left fingernails. The DON stated Resident 16's fingernails needed to be cleaned because [black substance under the fingernails] could be a source of infection.

During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs), revised 12/19/2025, the P&P indicated the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. The P&P indicated care and services may consist of the following activities of daily living: bathing, dressing, grooming and oral care. The P&P indicated a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 40913 potential for actual harm Based on observation, interview, and record review, the facility failed to provide nursing care and services to Residents Affected - Some prevent pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for one of four sampled residents (Resident 42) when the facility failed to:

a. Develop a care plan to address Resident 42's non-compliance to turning and repositioning.

b. Ensure staff would follow the same system for turning and repositioning for Resident 42.

c. Ensure proper communication of Resident 42's changes in skin condition.

These deficient practices incresed the risk for Resident 42 to develop a deep tissue injury (DTI - Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue on the right malleolus.

Findings:

During a review of Resident 42's Admission Record (AR), the AR indicated Resident 42 was admitted to the facility 9/3/2024 with diagnoses that included unspecified dementia (a group of conditions, decline in mental ability, that interfere with daily activities), hyperlipidemia (having too many lipids [fats] in the blood), and psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality).

During a review of Resident 42's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/31/2025, the MDS indicated Resident 42 rarely/never understands verbal content and was rarely/never able to express ideas and wants. The MDS indicated Resident 42 was dependent with oral, toileting and personal hygiene and required maximal assistance with rolling left and right. The MDS indicated Resident 42 was at risk of developing pressure ulcers.

During a review of Resident 42's Pressure Ulcer Risk Evaluation, dated 3/24/2025, the evaluation indicated a score of 13. The evaluation indicated Resident 42 had slightly limited sensory perception, constantly moist and had problem with friction and shear.

During an observation on 04/17/2025 at 9:51 AM, CNA 3 and CNA 6 entered Resident 42's room to provide care. CNA 6 removed the resident gown and then the incotinence brief. CNA 6 wiped the perineal area with moistened towel and pat dry. When CNA 6 turned Resident 42 to face the Resident 42's right side, Resident 42's left hand held on to the left siderails. CNA 3 said, It's okay, I'm here. I'll hold your hand. Resident 42 slowly let go of the side rail and CNA 3 turned Resident 42 to the right side. CNA 3 stated Resident 42 was scared when being turned. When the CNAs were starting to turn Resident 42 to the left side, Resident 42 held the right siderails with both hands and after a minute of talking to Resident 42, CNA 3 was able to turn resident 42 to the the left side, there was a purple discoloration to the right lateral of Resident 42's foot. CNA 6 stated the discoloration was new and CNA 6 would notify the Treatment Nurse (TN). CNA 3 and CNA 6 assisted Resident 42 to lay on his back with no positioning pillow placed on either right or left side or under Resident 42's heels.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0686 During an interview on 4/17/2025 at 2:57 PM, CNA 6 stated CNA 6 did not turn and reposition Resident 42 because Resident 42 would refuse when being turned. CNA 6 stated, It's like this everyday. CNA 6 stated Level of Harm - Minimal harm or CNA 6 filled up the Skin Assessment Sheet and handed the sheet to the TN. CNA 6 stated CNA 6 did not potential for actual harm verbally report the change in skin condition to the TN.

Residents Affected - Some During an interview on 4/17/2025 at 3:08 PM, the TN stated Resident 42 looked scared when being turned to

the sides. The TN observed the behavior when TN helped change Resident 42's incontinence brief two weeks ago. The TN stated the TN did not report Resident 42's resistance to care to the Registered Nurse Supervisor. The TN stated Resident 42 did not have a pressure ulcer or injury. The TN stated the CNAs needed to turn and reposition the residents who were not ambulatory and had fragile skin. The TN stated there was no turning schedule as the CNAs turn and reposition the residents who needed assistance every 2 hours.

During a concurrent Resident 42's skin observation and interview on 4/17/2025 at 3:27 PM to 3:35 PM with TN and the Registered Nurse Supervisor (RNS). Resident 42 was lying on his back with the ankles crossed and the heels were not offload. The TN and RNS stated the right ankle had a discoloration on the right malleolus. The TN and RNS stated the area of discoloration was blue and purple in color. The TN and RNS stated there was no extra pillow or positioning pillows on Resident 42's bed, closet or anywhere inside Resident 42's room.

During an interview on 4/17/2025 at 3:37 PM, the RNS stated Resident 42 had a blue, purple discoloration

on the right malleolus. The RNS stated Resident 42 had a DTI because it would be unknown what was underneath the skin discoloration.

During an interview on 4/17/2025 at 3:41 PM, the RNS stated Resident 42 was not cooperative during admission and was not relaxed during turning. The RNS stated just like how the TN and RNS assured Resident 42 during turning, the staff just needed to talk more and reassure Resident 42 when turning and repositioning and give Resident 42 time to understand what is going on. Resident 42 has dementia, we need to give instructions clearly and inform Resident 42 what was going on and give time for Resident 42 to understand.

During an interview on 4/17/2025 at 3:57 PM, the RNS stated the assigned CNA needed to have everything such as pillows ready when performing incontinence care and place a pillow to position Resident 42 to the left, right or on Resident 42's back and to offload Resident 42's heels. The RNS stated Resident 42's resistance to turning and repositioning was not a reason to leave Resident 42 on his back and not offloading

the heels.

During an interview on 4/17/2025 at 4:36 PM, CNA 8 stated Resident 42 needed assistance with turning and repositioning because Resident 42 could not move independently. CNA 8 stated the facility followed a turning schedule and CNA 8 showed the schedule on the back of CNA 8's badge. The schedule indicated at 6AM to 8 AM residents would be on the back, at 8AM -10 AM, residents would be facing the door, at 10 AM to 12 PM resident would be facing the window, at 12PM to 2PM, residents would be on the back and at 2PM - 4 PM, residents would be facing the door. CNA 8 stated the turning schedule was provided by the Director of Staff Development when CNA 8 started working at the facility a year ago. CNA 8 stated Resident 42 would refuse turning by holding the siderails during repositioning. CNA 8 stated the licensed nurses were aware of Resident 42's refusal to turn.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0686 During an interview on 4/17/2025 at 3:44 PM, the TN, the TN was not informed verbally that Resident 42 had

a discolored area on the ankle. The TN stated the TN signed the Skin Assessment Sheet (SAS) but did not Level of Harm - Minimal harm or check and missed the skin report made by CNA 6. potential for actual harm

During an interview on 4/18/2025 at 8:28 AM, the Director of Nursing (DON) stated when residents (in Residents Affected - Some general) would refuse turning and repositioning, the CNA's need to continue to offer because initially the residents would refuse, when the CNA's go back and offer to reposition again. The DON stated the licensed nurses need to develop a care plan to address the refusal to turning and repositioning to develop interventions to address the refusal to turn and reposition.

During an interview on 4/18/2025 at 8:34 AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 42 would have moments of refusing to turn and reposition approximately 3 out of 7 days in a week. Resident 42 would refuse turning and repositioning by holding on to the siderails. LVN 1 stated there was no turning schedule to follow but it was facility practice to turn and reposition the residents who needed assistance with turning and repositioning every 2 hours. When residents (in general) were not turned and repositioned, it could lead to the development of a pressure injury because of the pressure from the mattress to the bony prominences.

During an interview on 4/18/25 at 9:10 AM, the DON stated interventions to the care plan when Resident 42 refused turning and repositioning, CNAs needed to attempt to turn and reposition Resident 42 three times. CNAs then needed to notify the charge nurse. The Charge Nurse once aware of the refusal needed to reach out to family members who might be able to talk to Resident 42. The DON stated the MDS Nurse needed to develop a care plan specific to the refusal to turn and reposition.

During a concurrent review of Resident 42's plan of care and interview on 4/18/2025 at 9:25 AM, the DON stated there was no care plan developed to address Resident 42's refusal to turn and reposition.

During a review of Resident 42's Change of Condition (COC) dated 4/18/2025, the COC indicated purplish discoloration (DTI) to the right lateral malleolus.

During a review of the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention Guidelines, dated 11/27/2023, the P&P indicated interventions will be documented in the care plan and communicated to all relevant staff. The P&P indicated individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment and any pressure injury assessment.

During a review of the facility's P&P titled, Pressure Injury Prevention and Management, dated 9/12/23, the P&P indicated interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications included resident non-compliance.

During a review of the facility's P&P titled, Comprehensive Care Plans, dated 12/19/2022, the P&P indicated

the comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to

the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, the resident and the resident representative .The P&P indicate the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or 40913 potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and services to prevent Residents Affected - Few weight loss for one of three sampled residents when Resident 43 did not meet the goal of 75-100 % meal intake.

This deficient practice had the potential to result in further weight loss and a physical decline to Resident 43.

Findings:

During a review of Resident 43's Admission Record (AR), the AR indicated the facility admitted Resident 43

on 10/10/2024, with diagnoses that included dementia (a group of conditions, decline in mental ability, that interfere with daily activities) and dysphagia (difficulty swallowing).

During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 43 had moderate impaired cognition and was dependent on staff with all activities of daily living (ADL, term used in healthcare that refers to self-care activities).

During a review of Resident 43's Interdisciplinary (IDT, a team of health care professions who work together to establish plans of care for residents) Care Conference note, dated 4/8/2025, the notes did not indicate Resident 43's meal intake was addressed.

During a review of Resident 43's meal intake percentage for April 2025, the meal intake from 4/9/2025 to 4/15/2025 indicated Resident 43's meal intake was below the 75-100 % goal except on 2 mealtimes on 4/11/2024 lunch and 4/13/2025 breakfast.

During an observation on 4/17/2025 at 12:38 PM, CNA 6 assisted Resident 43 during lunch. Resident 43 stated, No mas [no more].

During a concurrent interview and record review on 4/18/2025 at 2:28 PM, with the Director of Nursing (DON), the DON stated Resident 43 was being monitored during the weekly variance meeting. The DON stated the last dietary assessment was completed on 4/4/2025, the assessment indicated a plan to monitor Resident 43's intake.

During a concurrent review of Resident 43's meal intake percentage, dated April 2025, the meal intake and

interview on 4/18/2025 at 2:32 PM, the DON stated majority of the intake during meals did not meet the 75-100% intake goal. The DON stated there was an IDT on 4/8/2025 but the IDT did not address Resident 43 not meeting the desired meal intake goal.

During an interview on 4/18/2025 at 2:41 PM, the DON stated the DON needed to follow up on a weekly basis if Resident 43 met the goal of 75-100 % intake so there would be a reassessment for Resident 43 not meeting the goal of 75-100 % meal intake.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0692 During a review of the facility's Policy and Procedure (P&P) titled Weight Management Policy, revised 12/19/2022, the P&P indicated interventions will be identified, implemented, monitored, and modified (as Level of Harm - Minimal harm or appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current potential for actual harm professional standards to maintain acceptable parameters of nutritional status.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45553

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure 2 of 2 sampled residents (Resident 56 and Resident 41), who were fed by enteral feeding tubes (a tube inserted into the digestive system to deliver liquid nutrition when someone cannot eat or drink normally) received appropriate treatment by failure to:

a. change the water flush bag for Resident 56 to follow the manufacturer's recommended time of a 24-hour use time.

b. clarify a physician's order for oral (PO) medication administration for Resident 56, despite Resident 56 being documented as NPO (nothing by mouth) and receiving medications via gastrostomy-tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).

c. change the water flush bag for Resident 41 to follow the manufacturer's recommended time of a 24-hour use time.

These deficient practices had the potential for Resident 56 and Resident 41 to experience nausea and vomiting and failure increased the risk for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways).

Findings:

a. During a review of Resident 56's Admission Record (AR), the AR indicated, Resident 56 was admitted to

the facility on [DATE REDACTED] with diagnoses that included encephalopathy (brain disease that alters brain function or structure), protein-calorie malnutrition (a condition where there is a deficiency of both protein and calories in

the diet, leading to serious health consequences), other abnormalities of gait and mobility (includes various conditions affecting a person's ability to walk and move), muscle weakness-generalized (a lack of strength in multiple muscle groups across the body ), dysphagia (difficulty swallowing), encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dementia (progressive state of decline in mental abilities), anxiety disorder (a mental health condition characterized by persistent and excessive worry or fear that can interfere with daily life and cause significant distress), and unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality).

During a review of Resident 56's History and Physical (H&P), dated 3/26/2025, the H&P indicated Resident 56 did not have the capacity to understand and make decisions.

During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated Resident 56 was dependent on staff with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 an observation on 4/15/2025 at 04:32 PM in Resident 56's room, the water flush bag for Resident 56's tube feeding was observed with the date of 4/11/2025 written on the bag with black marker, and the Level of Harm - Minimal harm or tube feeding bag was dated 4/15/2025, timed 3:35 AM. potential for actual harm

During an interview with the Director of Nursing (DON) on 4/18/2025 at 2:02 PM, the DON stated the water Residents Affected - Some flush bag for the feeding should be changed within 24 hours. The DON stated potential complications [from not changing the bag timely] included clogged tubing, patient discomfort or nausea, vomiting, and abdominal cramping if contaminated water reached the stomach and reduced nutrient/fluid delivery due to the potential of a compromised water bag.

b. During a review of Resident 56's Order Summary Report (OSR), dated active as of 4/17/2025, the OSR included a physician's order (PO), dated 3/26/2025, the PO indicated Resident 56 was NPO (nothing by mouth). The OSR included the following POs for Resident 56 indicating:

Quetiapine Fumarate oral tablet (Quetiapine Fumarate) Give 75 mg (milligrams, unit of measurement) by mouth two times a day for psychosis manifested by combativeness/aggression towards staff for no apparent reason, start date: 3/27/2025.

During a medication administration observation with Licensed Vocational Nurse 2 (LVN 2) on 4/17/2025 at 08:45 AM in Resident 56's room, LVN 2 administered Quetiapine Fumarate (medication used to treat several kinds of mental health conditions including schizophrenia [a serious mental health condition that affects how people think, feel, and behave] and bipolar disorder [serious mental illness that causes unusual shifts in mood] oral tablet via G-tube to Resident 56.

During an interview with the Director of Nursing (DON) on 4/18/2025 at 2:02 PM, the DON stated the nurse must clarify with the physician if Resident 56 was NPO or need to receive medications via G-Tube. The DON stated the route must be verified and clarified with the physician. The DON stated administering medications

the wrong way can cause harm to the residents. The DON stated even if given via G-tube, if the order indicated PO (by mouth), the order needed clarification from the physician.

40913

c. During a review of Resident 41's AR, the AR indicated Resident 41 was admitted to the facility on [DATE REDACTED], with diagnoses that included hemiplegia (paralysis [complete or partial loss of muscle function] on one side of the body) and hemiparesis following cerebral infarction (one sided weakness and paralysis after a stroke), respiratory failure with hypoxia (occurs when you don't have enough oxygen in the blood).

During a review of Resident 41's MDS, dated [DATE REDACTED], the MDS indicated Resident 41's cognition was severely impaired.

During an observation on 4/15/2025 at 10:37 AM, Resident 41 was asleep in bed, a 1-liter (unit of volume) bag of diabetisource (a formula used for tube feeding, TF) had a written date of 4/15/2025, timed at 3:49 AM, there was 800 ml (milliliters, unit of volume) left in the bag. The TF set up had a bag of water for water flush that had a written date of 4/10/2025, there was 500 ml left inside the water bag. Both bags were attached to

the TF pump.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 an interview with the DON on 4/18/2025 at 2:02 PM, the DON stated the water flush bag for the feeding should be changed within 24 hours. The DON stated potential complications [from not changing the Level of Harm - Minimal harm or bag timely] included clogged tubing, patient discomfort or nausea, vomiting, and abdominal cramping if potential for actual harm contaminated water reached the stomach and reduced nutrient/fluid delivery due to the potential of a compromised water bag. Residents Affected - Some

During a review of the facility's policy and procedure (P&P) titled, Flushing a Feed Tube, revised 12/19/2022,

the P&P indicated, Policy: It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice.

During a review of the facility's P&P titled, Care and Treatment of Feeding Tubes, revised 12/19/2022, the P&P indicated, Policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: Direction for staff on how to provide the following care will be provided: use of infection control precautions and related techniques to minimize the risk of contamination.

During a review of the undated Cardinal Health's, Kangaroo OMNI Enteral Feed Pump Setup and Troubleshooting Guide, dated 2023, the guide indicated, Reusing feeding sets can impact feeding accuracy. Feeding sets are designed for single-patient use with a recommended 24 hour use time. Using the feeding set beyond the recommended 24 hours can impact the delivery accuracy of the pump by subjecting the silicone tubing to excessive or repeated strain.

During a review of the facility's P&P titled, Medication Administration via Enteral Tube, revised 12/19/2022,

the P&P indicated, Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines. Policy Explanation and Compliance Guidelines: Verify physician orders for medication and enteral tube flush amount.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40913 potential for actual harm Based on observation, interview, and record review, the facility failed to provide respiratory care and services Residents Affected - Some for two of two sampled residents (Resident 20 and Resident 41) when,

a. Resident 20's oxygen [colorless, odorless gas] was not on continuously as indicated in Resident 20's care plan (CP).

b. Resident 41's nebulizer mask and tubing was not changed in accordance with the facility's Policy and Procedure (P&P) titled, Oxygen Administration.

These deficient practices had the potential to result in physical declines to Residents 20 and 41.

Findings:

a. During a review of Resident 20's Admission Record (AR), the AR indicated the facility admitted Resident 20 on 2/28/2025, with diagnoses that included acute (sudden) respiratory failure (when lungs cannot release enough oxygen into the blood, which prevents the organs from properly functioning. It also occurs if the lungs cannot remove carbon dioxide from the blood), chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow).

During a review of Resident 20's CP titled, The resident has COPD, at risk for SOB [shortness of breath] initiated on 3/3/2025, the CP indicated to provide oxygen at 4 L (liters, unit of volume) per minute via nasal cannula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears) continuously every shift for acute respiratory failure.

During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 3/4/2025, the MDS indicated Resident 20 had moderate deficit in cognition (ability to understand and process information), Resident 20 was dependent on staff with toileting hygiene and required maximal assistance (helper does more than half the effort) with personal hygiene and rolling left and right bed mobility.

During the following observations on 4/17/2025 at 8:21 AM, 9:44 AM, and at 10:39 AM, Resident 20's oxygen was off, the NC was not on Resident 20's nostrils and was on Resident 20's chin.

During an interview on 4/17/2025 at 10:53 AM, the Director of Nursing (DON) stated the nurses, and the CNA assigned to Resident 20 needed to make rounds and check [to ensure oxygen delivery] Resident 20.

During a review of the facility's P&P titled, Oxygen Administration revised 5/20/2024, the P&P indicated oxygen is administered under orders of a physician. The P&P indicated the resident's care plan shall identify

the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to:

1. The type of oxygen delivery system.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0695 2. When to administer, such as continuous or intermittent and/or when to discontinue.

Level of Harm - Minimal harm or b. During a review of Resident 41's AR, the AR indicated Resident 41 was admitted to the facility on [DATE REDACTED], potential for actual harm with diagnoses that included hemiplegia (paralysis [complete or partial loss of muscle function] on one side of the body), hemiparesis following cerebral infarction Residents Affected - Some (one sided weakness and paralysis after a stroke), and respiratory failure with hypoxia (occurs when a person doesn't have enough oxygen in the blood).

During a review of Resident 41's MDS, dated [DATE REDACTED], the MDS indicated Resident 41's cognition was severely impaired.

During an observation on 4/15/2025 at 10:35 AM, Resident 41 was asleep in bed, the nebulizer mask tubing had a label indicating a date 3/23/2025. The tubing was hooked up to the nebulizer machine, with the nebulizer mask inside a clear, plastic bag dated 3/23/2025.

During an interview on 4/16/2025 at 1:20 PM, Licensed Vocational Nurse 3 (LVN 3) stated the nurses administered the breathing treatments, the nebulizer mask and tubing dated 3/23/2025 were old and the masks and tubing needed to be changed weekly for infection control [purposes].

During an interview on 4/18/2025 at 11:10 AM, the Registered Nurse Supervisor (RN), the RN stated if the nebulizer mask was not changed per the facility's policy, there was a potential to not deliver the correct amount of nebulizer medication because the facility was using an old nebulizer mask and tubing.

During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration dated 5/20/2024,

the P&P indicated to change the nebulizer tubing and delivery devices weekly and PRN [as needed], per manufacturer's recommendation or per facility policy and if they became soiled or contaminated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 37 055282 Department of Health & Human Services Printed: 08/28/2025 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 055282 B. Wing 04/18/2025

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

Pomona Vista Care Center 651 N Main St 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 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or 50016 potential for actual harm Based on interview and record review, the facility failed to provide trauma-informed care for one of one Residents Affected - Few sampled resident (Resident 16) by not ensuring that the resident received adequate care and services to address their Post-Traumatic Stress Disorder (PTSD-a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event).

This deficient practice resulted in inadequate attention to Resident 16's specific trauma-related needs and

the potential to affect the resident's physical and psychosocial well-being.

Cross Reference