Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure one of two sampled residents
(Resident 2) was free from physical abuse from Resident 3 who had just hit another resident (Resident 1)
by failing to provide a 1:1 (providing one to one continuous nursing or observation care to an individual
patient with behavioral problems for a period of time) supervision to Resident 3, in accordance with
Resident 3's care plan (CP, provides direction on the type of nursing care an individual needs that include
goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to
meet an objective] and an evaluation plan), titled The resident has a behavior problem .
This deficient practice resulted in Resident 3 hitting Resident 2 after an incident involving Resident 3 who
had hit Resident 1 the previous day.
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the
facility on [DATE] with multiple diagnoses including spinal stenosis (abnormal narrowing), site unspecified
and unspecified dementia (a general term to describe a group of symptoms related to loss of memory,
judgment, language, complex motor skills, and other intellectual function, caused by the permanent
damage or death of the brain's nerve cells, or neurons), unspecified severity, without behavioral
disturbance, psychotic (a mental disorder characterized by disconnection from reality) disturbance, mood
disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations).
During a review of Resident 1's History and Physical (H&P), dated 1/26/24, the H&P indicated, Resident 1
did not have the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS, an assessment and screening tool), dated
4/24/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) Score indicated severely
impaired cognition (ability to think and process information) status.
During a review of Resident 1's Progress Notes (PN), dated 5/16/24, at 7:15 a.m., the PN, indicated,
Resident 1 was tapped on the shoulder by Resident 3. The PN, indicated, Resident 3 denied tapping
Resident 1 on the shoulder but Resident 1 was So scared to what have happened.
During a review of Resident 1's Change in Condition (COC), dated 5/16/24, at 7:16 a.m., the COC,
indicated, Resident 1 stated, Resident 1 was hit in the arm by her roommate (Resident 3) next to
(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 7
Event ID:
055282
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
055282
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2024
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 0600
Resident 1's bed.
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 1's PN, dated 5/16/24, at 8:30 a.m., the PN, indicated, a rehab staff
(unidentified) reported to charge nurse that Resident 1 was hit on the arm by Resident 3.
Residents Affected - Some
During a review of Resident 1's Change in Condition (COC), dated 5/16/24, at 10:45 a.m., the COC,
indicated, Resident 1 complained to the charge nurse (unidentified) that roommate (Resident 3) also hit
Resident 1 in the head.
During a review of Resident 1's Care Plan, initiated on 5/16/24, the CP, indicated, assessment revealed
suspected abuse.
During a review of Resident 2's AR, the AR indicated, Resident 2 was originally admitted to the facility on
[DATE] and last readmitted on [DATE] with multiple diagnoses including muscle weakness (generalized)
and dementia in other diseases classified elsewhere, unspecified severity, with other behavioral
disturbance.
During a review of Resident 2's H&P, dated 6/29/23, the H&P indicated, Resident 2 had fluctuating capacity
to understand and make decisions.
During a review of Resident 2's MDS, dated 4/24/24, the MDS indicated, Resident 2's BIMS Score
indicated Resident 2 was moderately impaired cognitively.
During a review of Resident 2's PN, dated 5/17/24, at 6:45 a.m., the PN, indicated, Resident 2 claimed
Resident 2 was tapped on the left outer wrist by roommate, Resident 3. The PN, indicated, the incident
started when Resident 3 tried to get personal belongings from Resident 2's cabinet. Resident 2 shouted at
Resident 3 to stop getting in Resident 2's cabinet but Resident 3 went to Resident 2's bedside and tapped
Resident 2 on the upper left outer wrist and stated, Shut up! The PN indicated, charge nurse (unidentified)
placed a 1:1 CNA (Certified Nursing Assistant, unidentified) in the room.
During a review of Resident 2's COC, dated 5/17/24, at 6:45 a.m., the COC, indicated, Resident 2 got
tapped on the left upper wrist by roommate, Resident 3.
During a review of Resident 2's CP, date initiated 5/17/24, the CP, indicated, assessment revealed
suspected abuse.
During a review of Resident 3's AR, the AR indicated, Resident 3 was newly admitted to the facility on
[DATE] with multiple diagnoses including unspecified dementia, unspecified severity, without behavioral
disturbance, psychotic disturbance, mood disturbance, and anxiety and unspecified psychosis not due to a
substance or known physiological condition.
During a review of Resident 3's PN, dated 5/11/24, timed at 1:59 a.m., the PN, indicated, Resident 3 had
history of dementia (wandering around).
During a review of Resident 3's PN, dated 5/11/24, timed at 3:11 p.m., the PN, indicated, Resident 3 was
ambulatory and wandered, walked all over the facility, wandered off to other resident's room and took other
resident's belongings.
During a review of Resident 3's H&P, dated 5/13/24, the H&P indicated, Resident 3 did not have the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055282
If continuation sheet
Page 2 of 7
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
055282
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2024
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 0600
capacity to understand and make decisions.
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 3's MDS, dated 5/14/24, the MDS indicated, Resident 3's BIMS Score
indicated Resident 3 was severely impaired cognitively. The MDS indicated, Resident 3 exhibited other
behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching
self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily
wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and significantly intruded on the
privacy or activity of others and disrupted care or living environment. The MDS indicated, Resident 3 had a
behavior of wandering daily that significantly intruded on the privacy or activities of others.
Residents Affected - Some
During a review of Resident 3's CP, date initiated 5/15/24, the CP, indicated, Resident 3 had a behavior
problem. The CP, indicated one of the interventions initiated on 5/16/24 included a 1:1 supervision as
needed.
During a review of Resident 3's PN, dated 5/16/24, timed at 3:27 p.m., the PN, indicated, Resident 3 was
monitored at this time due to s/p (status post) incident of hitting roommate on the arm and head.
During a review of Resident 3's PN, dated 5/17/24, at 3:20 p.m., the PN, indicated, Resident 3 was
monitored for behavior of hitting Resident 3's roommate on the arm and other roommate on the left wrist
and getting belongings from other residents and still having episode of hitting other residents.
During an interview on 5/21/24 at 10:24 a.m. with Resident 1, Resident 1 stated, roommate, Resident 3 hit
Resident 1 on the head. Resident 1 stated, Resident 1 cried, and a staff (unidentified) got Resident 3 out of
the room. Resident 1 stated, Resident 1 had pain but now no more.
During a concurrent observation and interview on 5/21/24 at 11:12 a.m., with CNA 1, Resident 3 was in
bed. CNA 1 stated, CNA 1 was doing a 1:1 supervision since Resident 3 gets into things and had hit a
resident. Resident 3 denied hitting a resident, became uncooperative and got slightly restless (inability to
rest or relax) during the interview.
During a concurrent observation and interview on 5/21/24 at 11:24 a.m. with Resident 2, Resident 2 had a
small reddish colored bruise on the left wrist. Resident 2 stated, roommate, Resident 3 was slamming the
closet doors and going thru everybody's clothes then approached Resident 2 and hit Resident 2's left wrist.
Resident 2 stated, Resident 2 screamed and woke the other roommate up and the staff came. Resident 2
stated, Resident 2 had some pain and tenderness on the left wrist but did not notify staff.
During an interview on 5/21/24 at 1:04 p.m. with the Occupational Therapy Assistant (OTA), the OTA stated,
Resident 3 was confused and had days where Resident 3 had some irritation, agitation, and impulsive
tendencies.
During a concurrent interview and record review on 5/21/24 at 3:24 p.m., with the Registered Nurse (RN),
the facility's Census and Staff Assignment (SA), were reviewed. The SA indicated, on 5/16/24 during the
evening shift (3:00 p.m. to 11:00 p.m.) and night shift (11:00 p.m. to 7:00 a.m.), there was no 1:1 staff
supervision assigned to Resident 3. RN stated, 1:1 meant the CNA was specifically assigned to the
resident and to focus on the resident 1:1. RN stated, based on the SA schedule on 5/16/24, there was no
1:1 staff supervision assigned to Resident 3.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055282
If continuation sheet
Page 3 of 7
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
055282
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2024
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 0600
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 5/22/24 at 9:04 a.m. with CNA 3, CNA 3 stated, CNA 3 worked on the night shift of
5/16/24. CNA 3 stated, CNA 3 had four resident rooms assigned including the room where Resident 3 was.
CNA 3 stated, CNA 3 was assigned to Resident 3 but was not assigned as a 1:1 supervision to Resident 3.
CNA 3 stated, a 1:1 supervision was to watch the patient properly, maybe the patient has behavior
problems and to keep the residents safe.
Residents Affected - Some
During an interview on 5/22/24 at 9:21 a.m. with Resident 2, Resident 2 stated, there was no staff assigned
as 1:1 supervision to Resident 3 or staff assigned to the room only. Resident 2 stated, Resident 3 got a 1:1
after she hit me.
During an interview on 5/22/24 at 9:29 a.m. with the Licensed Vocational Nurse (LVN), the LVN stated,
there was no documented evidence that a 1:1 supervision was provided to Resident 3.
During an interview on 5/22/24 at 10:20 a.m. with the Director of Nursing (DON), the DON stated, Resident
3 had history of dementia and unspecified psychosis. The DON stated agitation was the most common
behavior for residents with dementia. The DON stated, agitation could potentially lead to a lot, might be
hitting other people. The DON stated, a 1:1 supervision was not provided to Resident 3 right away because
the DON did not expect Resident 3 to hit another resident.
During an interview on 5/22/24 at 11:05 a.m. with CNA 1, CNA 1 stated, there was no specific
documentation for 1:1 supervision and was just communicated with the CNA staff assigned to the room.
During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, date
revised 12/19/22, the P&P indicated, it was the policy of the facility to provide protections for the health,
welfare, and rights of each resident by developing and implementing written policies and procedures that
prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The P&P
indicated, the facility would make efforts to ensure all residents were protected from physical and
psychosocial harm, as well as additional abuse, during and after the investigation that included but not
limited to increased supervision of the alleged victim and residents.
During a review of the facility's P&P, titled Accidents and Supervision, date revised 12/19/22, the P&P
indicated, each resident will receive adequate supervision to prevent accidents that include implementing
interventions. The P&P indicated the facility would provide adequate supervision to prevent accidents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055282
If continuation sheet
Page 4 of 7
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
055282
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2024
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 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 two of two sampled residents
(Residents 1, Resident 2) were free from physical abuse from Resident 3 by failing to ensure Resident 3
who was newly admitted to the facility and diagnosed with dementia (a general term to describe a group of
symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual
function, caused by the permanent damage or death of the brain's nerve cells, or neurons) was provided
and received the appropriate treatment ( specific treatment?) and services to attain or maintain Resident 3 '
s highest practicable physical, mental, and psychosocial well-being.
Residents Affected - Few
This deficient practice resulted in Resident 1 and Resident 2 being physically abused by Resident 3.
Findings:
During a review of Resident 1 ' s admission Record (AR), the AR indicated, Resident 1 was admitted to the
facility on [DATE] with multiple diagnoses that included spinal stenosis (abnormal narrowing), site
unspecified and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic
(disconnection from reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent
worry and fear about everyday situations).
During a review of Resident 1 ' s History and Physical (H&P), dated 1/26/24,the H&P indicated, Resident 1
did not have the capacity to understand and make decisions.
During a review of Resident 1 ' s most recent Minimum Data Set (MDS, an assessment and screening tool),
dated 4/24/24, the MDS indicated, Resident 1 ' s BIMS (Brief Interview for Mental Status) Score indicated
Resident 1 had severely impaired cognition (ability to think and process information) status.
During a review of Resident 1 ' s Progress Notes (PN), dated 5/16/24, at 7:15 a.m., the PN, indicated,
Resident 1 was tapped on the shoulder by Resident 3. The PN, indicated, Resident 3 denied tapping
Resident 1 on the shoulder but Resident 1 was Soscared to what have happened.
During a review of Resident 1 ' s Change in Condition (COC) form, dated 5/16/24, at 7:16 a.m., the COC,
indicated, Resident 1 stated, Resident 1 was by hit by Resident 3.
During a review of Resident 1 ' s PN, dated 5/16/24, timed at 8:30 a.m., the PN, indicated, Resident 1 was
hit on the arm by Resident 3.
During a review of Resident 1 ' s Care Plan (CP, provides direction on the type of nursing care an individual
needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or
activities designed to meet an objective] and an evaluation plan), date initiated 5/16/24, the CP, indicated,
assessment revealed suspected abuse.
During a review of Resident 2 ' s AR, the AR indicated, Resident 2 was originally admitted to the facility on
[DATE] and last readmitted on [DATE] with multiple diagnoses that included muscle weakness (generalized)
and dementia in other diseases classified elsewhere, unspecified severity, with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055282
If continuation sheet
Page 5 of 7
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
055282
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2024
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 0744
other behavioral disturbance.
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 2 ' s H&P, dated 6/29/23, the H&P indicated, Resident 2 had fluctuating
capacity to understand and make decisions.
Residents Affected - Few
During a review of Resident 2 ' s MDS, dated 4/24/24, the MDS indicated, Resident 2 ' s BIMS Score
indicated moderately impaired cognition status.
During a review of Resident 2 ' s PN, dated 5/17/24, at 6:45 a.m., the PN, indicated, Resident 2 claimed
Resident 2 was tapped on the left outer wrist by roommate, Resident 3. The PN, indicated, the incident
started when Resident 3 tried to get personal belongings from Resident 2 ' s cabinet. Resident 2 shouted at
Resident 3 to stop getting in Resident 2 ' s cabinet but Resident 3 went to Resident 2 ' s bedside and
tapped Resident 2 on the upper left outer wrist and stated, Shut up! The PN indicated, the charge nurse
(unidentified) placed a 1:1 (providing one to one continuous nursing or observation care to an individual
patient with behavioral problems for a period of time) CNA (Certified Nursing Assistant, unidentified) in the
room.
During a review of Resident 2 ' s COC, dated 5/17/24, at 6:45 a.m., the COC, indicated, Resident 2 got
tapped on the left upper wrist by roommate, Resident 3.
During a review of Resident 2 ' s CP, date initiated 5/17/24, the CP, indicated, assessment revealed
suspected abuse.
During a review of Resident 3 ' s AR, the AR indicated, Resident 3 was newly admitted to the facility on
[DATE] with multiple diagnoses including unspecified dementia, unspecified severity, without behavioral
disturbance, psychotic (a mental disorder characterized by disconnection from reality) disturbance, mood
disturbance, and anxiety and unspecified psychosis not due to a substance or known physiological
condition.
During a review of Resident 3 ' s H&P, dated 5/13/24, the H&P indicated, Resident 3 did not have the
capacity to understand and make decisions.
During a review of Resident 3 ' s MDS, dated 5/14/24, the MDS indicated, Resident 3 ' s BIMS Score
indicated severely impaired cognition status. The MDS indicated, Resident 3 exhibited other behavioral
symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing,
rummaging, public sexual acts, disrobing in public, throwing,or smearing food or bodily wastes, or
verbal/vocal symptoms like screaming, disruptive sounds) and significantly intrude on the privacy or activity
of others and disrupt care or living environment. The MDS indicated, Resident 3 had a behavior of
wandering daily that significantly intruded on the privacy or activities of others.
During a review of Resident 3 ' s PN, dated 5/11/24, at 1:59 a.m., the PN, indicated, Resident 3 had a
history of dementia (wandering around).
During a review of Resident 3 ' s PN, dated 5/11/24, at 3:11 p.m., the PN, indicated, Resident 3 was
ambulatory and wandered, walked all over the facility, wandered off to other resident ' s room and took
other resident ' s belongings.
During a review of Resident 3 ' s CP, date initiated 5/15/24, the CP, indicated, Resident 3 had a behavior
problem.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055282
If continuation sheet
Page 6 of 7
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
055282
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/22/2024
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 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a review of Resident 3 ' s PN, dated 5/16/24, at 3:27 p.m., the PN, indicated, Resident 3 was
monitored at this time due to s/p (status post) incident of hitting roommate on the arm and head.
During a review of Resident 3 ' s PN, dated 5/17/24, at 3:20 p.m., the PN, indicated, Resident 3 was
monitored for behavior of hitting roommate on the arm and other roommate on the left wrist and getting
belongings from other residents and still having episode of hitting other residents.
During an interview on 5/21/24 at 10:24 a.m. with Resident 1, Resident 1 stated, roommate, Resident 3 hit
Resident 1 on the head. Resident 1 stated, Resident 1 cried, and a staff (unidentified) got Resident 3 out of
the room. Resident 1 stated, Resident 1 had pain but now no more.
During a concurrent observation and interview on 5/21/24 at 11:12 a.m., with CNA 1, Resident 3 was in
bed. CNA 1 stated, CNA 1 was doing a 1:1 supervision since Resident 3 gets into things and had hit a
resident. Resident 3 denied hitting a resident, became uncooperative and got slightly restless (inability to
rest or relax) during the interview.
During a concurrent observation and interview on 5/21/24 at 11:24 a.m. with Resident 2, Resident 2 had a
small reddish colored bruise on the left wrist. Resident 2 stated, roommate, Resident 3 was slamming the
closet doors and going thru everybody ' s clothes then approached Resident 2 and hit Resident 2 ' s left
wrist. Resident 2 stated, Resident 2 screamed and woke the other roommate up and the staff came.
Resident 2 stated, Resident 2 had some pain and tenderness on the left wrist but did not notify staff.
During an interview on 5/21/24 at 1:04 p.m. with the Occupational Therapy Assistant (OTA), the OTA stated,
Resident 3 was confused and had days where Resident 3 had some irritation, agitation, and impulsive
tendencies.
During an interview on 5/22/24 at 10:20 a.m. with the Director of Nursing (DON), the DON stated, Resident
3 had a history of dementia and unspecified psychosis. The DON stated agitation was the most common
behavior for residents with dementia. The DON stated, agitation could potentially lead to a lot, might be
hitting other people. The DON stated, the facility was required to have an IDT (Interdisciplinary Team, a
group of health care professionals with various areas of expertise who work together toward the goals of
their patients) to be able to provide better care, but the incidents (physical abuse) had already happened
prior to doing the IDT. The DON stated, residents admitted with dementia had the same needs as the rest
of the residents and there is no difference in assessment and care provided to residents who had dementia
and residents who did not have dementia.
During a review of the facility ' s policy and procedure (P&P) titled, Dementia Care, date revised 12/19/22,
the P&P indicated, it was the policy of the facility to provide the appropriate treatment and services to every
resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable
physical, mental, and psychosocial well-being. The P&P indicated, the facility will assess, develop, and
implement care plans through an IDT approach that includes the resident, their family, and/or resident
representative, to the extent possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055282
If continuation sheet
Page 7 of 7
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
FAQ · About this visit
Common questions about this visit
What happened during the May 22, 2024 survey of POMONA VISTA CARE CENTER?
This was a inspection survey of POMONA VISTA CARE CENTER on May 22, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at POMONA VISTA CARE CENTER on May 22, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.