Health inspection·June 7, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/6/24 at 3:53 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 8 was a wandering resident who walked around the facility and needed redirection. CNA 1 stated CNA 1 had seen Resident 8 go inside other residents' rooms. CNA 1 stated Resident 8 would stand in other residents' rooms but did not take anything from other residents. CNA 1 stated there was no 1:1 sitter (one staff stayed and directly supervised one resident) for Resident 8. Residents Affected - Few During an interview on 6/6/24 at 4:12 p.m. with LVN 2, LVN 2 stated Resident 8 was usually a wanderer and walked around the facility a lot. LVN 2 stated LVN 2 had seen Resident 8 go into other residents' rooms. LVN 2 stated Resident 8 usually walked in and out of other residents' rooms and other residents' bathrooms. LVN 2 stated Resident 8 was confused and at times would take things from his roommates, but Resident 8 would give it right back. LVN 2 stated Resident 8 would touch other residents' blankets and beds but had not heard any residents complain that Resident 8 touched them inappropriately. During an interview on 6/7/24 at 9:36 a.m. with Resident 12, Resident 12 stated Resident 8 wandered around the facility and into Resident 12's room and would use Resident 12's bathroom. During an interview on 6/7/24 at 3:13 p.m. with the Business Office Manager (BOM), the BOM stated the BOM had seen Resident 8 wandering around the facility a lot. The BOM stated the BOM had observed Resident 8 standing in front of other residents' room doors. During an interview on 6/7/24 at 3:14 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 8 had a history of wandering in the hallway and into different residents' rooms. The DSD stated the staff were aware Resident 8 wandered into other residents' room and knew to redirect Resident 8 when Resident 8 would go inside other residents' rooms. The DSD stated the facility did not provide a 1:1 sitter for Resident 8 but facility nurses were instructed to monitor and supervise Resident 8. The DSD stated Resident 8 had dementia. The DSD stated it was important to closely monitor dementia residents for safety and protection of residents. The DSD stated there was no specific monitoring or supervision schedule for Resident 8. During an interview on 6/7/24 at 3:40 p.m. with Resident 5, Resident 5 stated Resident 8 wandered all the time into his room and other residents' rooms. During an interview on 6/7/24 at 4:23 p.m. with the Social Services Director (SSD), the SSD stated Resident 8 was confused and wandered around the facility. The SSD stated the staff must monitor and redirect Resident 8 when he wandered inside other residents' rooms. The SSD stated at times, the SSD would hear other residents telling Resident 8 to get out of their rooms and Resident 8 would usually leave. During an interview on 6/7/24 at 4:35 p.m. with LVN 1, LVN 1 stated Resident 8 was very confused and always wandered around the facility. LVN 1 stated residents would yell at Resident 8 and would ask Resident 8 to get out of their rooms. LVN 1 stated all facility staff including housekeeping and kitchen staff were aware of Resident 8's wandering behavior and would monitor Resident 8. LVN 1 stated some families had complained about Resident 8 going into their family member's rooms. LVN 1 stated the facility had not considered 1:1 supervision for Resident 8's wandering or dementia related behaviors. LVN 1 stated it was important to provide monitoring and supervision for residents with wandering and dementia related behaviors to prevent harm and ensure safety of residents. During a review of the facility's policy and procedure (P&P) titled Accidents and Supervision, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055282 If continuation sheet Page 2 of 3 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 06/07/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm dated 12/19/2022, the P&P indicated each resident received adequate supervision to prevent accidents. This included implementing interventions to reduce hazard(s) and risk(s). The P&P indicated adequacy of supervision: defined by type and frequency and based on the individual resident's assessed needs and identified hazards in the resident environment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055282 If continuation sheet Page 3 of 3