Health inspection·June 9, 2025

F 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) who had an order of X-ray (an imaging test to create detailed pictures of the organs) of the left hand was implemented in a timely manner, as ordered. Residents Affected - Few This failure had the potential for Resident 1 not to receive necessary care and services to immediately meet the resident's medical needs. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/9/2023 and readmitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interfere with daily functioning), history of falling, and age-related osteoporosis (a medical condition in which the bones become brittle and fragile) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/30/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing and toileting hygiene. The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) assistance from staff for dressing and personal and oral hygiene. During a review of Resident 1's COC/INTERACT ASSESSMENT FORM (COC), dated 6/6/2025, the COC indicated Resident 1 had swelling of the left hand. The COC indicated Resident 1's physician (MD- medical doctor) ordered a STAT (immediate/urgent) x-ray of Resident 1's left hand on 6/6/2025 at 4:44 pm. During a review of Resident 1's physician's orders (PO) dated 6/6/2025, the PO indicated Resident 1's physician ordered STAT X-ray of Resident 1's left hand. The x-ray was ordered on 6/6/2025 at 4:38 p.m. During an interview on 6/9/2025 at 10:27 a.m. with the Director of Nursing (DON), the DON stated the DON asked Registered Nurse 1 (RN 1) to follow up on the results of Resident 1's left hand x-ray on 6/8/25 because the Radiology Technician (RT) had not done Resident 1's ordered x-ray. The DON stated the radiology company claimed Resident 1 was combative and uncooperative on 6/6/2025 when the RT tried to get the x-ray. The DON stated the RT did not inform the facility staff that the RT was unable to get the x-ray of Resident 1's left hand on 6/6/2025. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055126 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766 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)