Health inspection·July 9, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to identify a skin rash (an area of irritated or swollen skin that can be red, itchy, painful, or bumpy) for one of one sampled resident (Resident 1) when Licensed Vocational Nurse (LVN) 1 discharged Resident 1 without doing a skin check (a visual examination of the skin surface) on 5/29/2025.This failure resulted in delayed treatment for Resident 1's skin rash and had the potential to result in physical decline to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 11/21/2023 and readmitted the resident 1/12/2024 with diagnoses including type 2 diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) and major depressive disorder (mental health condition where a person experiences a persistent low mood, loss of interest in activities and other symptoms that significantly impact daily life). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/29/2025, the MDS indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 1's Post Discharge Plan of Care, dated 5/29/2025, the care plan indicated Resident 1 was discharged home 5/29/2025. The Plan of Care indicated the skin condition assessment was left blank (a space left to be filled in on a document). During a review of Resident 1's Care Plan (CP) titled Pressure sore. (Resident 1) is at risk to develop pressure sores related to aging process.fragile skin., initiated 11/21/2023, revised 6/12/2025, the CP's goal indicated Resident 1's risk to having skin breakdown would be reduced with appropriate interventions. The CP's interventions indicated that staff would assess [Resident 1's] skin condition daily during care and [conduct] weekly body checks.During an interview on 7/7/2025 at 10:18 am with Family Member (FM) 1, FM 1 stated FM 1 took Resident 1 home from the facility on 5/29/2025. FM 1 stated FM 1 gave Resident 1 a shower on 5/29/2025 at FM 1's home and observed Resident 1's entire body was covered with bleeding scabs. FM 1 stated this made FM 1 angry because no one at the facility told FM 1 Resident 1 had a rash and FM 1 did not know how to treat the rash. During an interview on 7/8/2025 at 10:53 am with Registered Nurse (RN) 1, RN 1 stated it was part of the facility's discharge process for licensed nurses to conduct skin checks on residents (in general) prior to discharge. RN 1 stated skin check [assessments] should be documented on the discharge plan of care. RN 1 stated residents needed to have skin check [assessments] prior to discharge to determine if the resident needed treatment and to educate the family members if needed.During an interview on 7/8/2025 at 11:10 am with LVN 1, LVN 1 stated LVN 1 signed the discharge plan of Residents Affected - Few (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 07/09/2025 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)