Health inspection·August 12, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure infection control practices were implemented when one of one Certified Nurse Assistant (CNA 1) did not wash or sanitize hands after exiting Resident 1's shower room and before touching Resident 2.This deficient practice had the potential to result in cross contamination (transfer of germs and harmful substance) and spread of infection.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility readmitted the resident to the facility on 7/31/25 with diagnoses that included type 2 diabetes mellitus (elevated blood sugar level) and acute kidney failure (kidneys can't filter waste).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/28/25, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to understand and process thoughts) for daily decision making.During a review of Resident 1's History & Physical (H&P) dated 8/1/25, the H&P indicated Resident 1 did not have the capacity to make medical decisions.During a review of Resident 2's AR, the AR indicated the facility readmitted the resident on 5/15/25 with diagnoses that included type 2 diabetes mellitus and urinary tract infection (UTI).During a review of Resident 2's H&P dated 5/16/25, the H&P indicated Resident 2 did not have the capacity to make medical decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was not able to complete the interview.During a review of Resident 3's AR, the AR indicated the facility readmitted the resident on 5/8/25 with diagnoses that included encephalopathy (problem with the brain that changes how it works) and subdural hemorrhage (a pool of blood between the brain and its outermost covering).During a review of Resident 3's H&P dated 5/9/25, the H&P indicated Resident 1 did not have the capacity to make medical decisions.During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills.During a concurrent observation and interview on 8/8/25 at 3:40 p.m., CNA 1 was observed walking into Resident 1's shower room and turning the knobs that controlled the water. CNA 1 exited Resident 1's shower room. CNA 1 did not perform hand hygiene (cleaning hands to remove germs). CNA 1 proceeded by entering Resident 3's room and assisted Resident 2 out of Resident 3's room by touching Resident 3's arm. During an interview with CNA 1, CNA 1 stated handwashing or hand hygiene should be done after each contact with residents and upon exiting a room. CNA 1 stated hand hygiene was important to prevent contamination or spread of infection. CNA 1 stated CNA 1 did not perform hand hygiene and should have performed hand hygiene between Resident 1 and Resident 2's rooms.During an interview on 8/8/25 at 4:10 p.m., with the Infection Preventionist (IP), the IP stated hand hygiene was important between residents to prevent transmission and cross contamination, infection, prevent an outbreak, and mitigate the spread of any infection.During a subsequent interview on 8/8/25, at 4:15 p.m., the IP stated if staff were not following standard infection control precautions, staff would have the potential to spread infections. The IP stated all staff were required to perform hand hygiene between residents' contact and between resident rooms. The IP stated staff should be following 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 08/12/2025 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)