Health inspection·January 31, 2025

F 0610 Respond appropriately to all alleged violations. 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 conduct a thorough investigation of an allegation of abuse that occurred between Residents 1 and 2 on 1/18/2025 per the facility's Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation, by failing to obtain a statement/information from Resident 3 who identified herself as a witness. Residents Affected - Few This failure had the potential to omit possible evidence in the allegation of abuse between Residents 1 and 2. Findings: During a review of Resident 1's admission Record, (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects the brain) and type 2 diabetes (disorder characterized by difficulty in blood sugar control). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, reason, plan) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying as resident completes activity) for bathing and toileting. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy and dementia (a progressive state of decline of mental abilities.) During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition and required substantial or maximum assistance (helper does more than half the effort) for toileting and bathing. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and immunodeficiency (decreased ability of the body to fight infections and other diseases.) During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had intact cognition and was dependent (helper does all of the effort) for toileting and bathing. During an interview on 1/30/2025 at 10:00 AM with Resident 3 in Resident 3's room, Resident 3 stated Resident 3 was a roommate of Resident 1 and Resident 3 witnessed Resident 2 enter Resident 1's room and approached Resident 1. Resident 3 stated, there were no staff present during the interaction (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 5 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 01/31/2025 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)