Pomona Vista Care Center
POMONA VISTA CARE CENTER in POMONA, CA — inspection on April 18, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 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.
055282
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 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
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.
055282
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.