Inspection·September 15, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 14) or the Resident's Representative a copy of the Resident 14's medical record upon request and within two working days from notice per the facility's Policy and Procedure (P&P) titled, Residents Access to Records. This failure resulted in violation of Resident 14's rights and in Resident 14's Representatives not receiving the medical records in a timely manner. Findings: During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted Resident 14 on 1/10/2025 with diagnoses that included lumbar region stenosis (narrowing of the spinal cannel which added pressure on the spinal cord and nerves) and hypertension (HTN, high blood pressure). During a review of Resident 14's Minimum Data Set (MDS, a resident assessment), dated 1/16/2025, the MDS indicated Resident 14's cognitive skills were intact. The MDS indicated Resident 14 required substantial assistance performing Activities of Daily Living (ADLs). The MDS indicated Resident 14 required substantial assistance turning from left to right in bed and transferring from the bed to chair or the chair to the bed. During a review of the Declaration of Custodian of Records (DCR), dated 6/13/2025, the DCR indicated record request date of 6/13/2025, addressed to medical records assistant in facility. During a review of Health Insurance Portability and Accountability Act (HIPPA, United States federal law enacted in 1996 that sets national standards for protecting sensitive patient health information, or Protected Health Information (PHI). It establishes rules for the secure and confidential handling, storage, and transmission of PHI to prevent unauthorized disclosure, and also addresses continuity of health insurance coverage and fraud reduction) Compliant Authorization for The Release of Patient Information dated 5/1/2025, the form indicated Resident 14 signed the authorization. During an interview on 9/11/2025 at 3:30 pm with Legal Assistant (LA), the LA stated, I have continued to request records from Point Click Care (PCC, a cloud based electronic health record platform designed for the skilled nursing facilities) format, but the facility continues to send uncomplete printed and scanned records. During a concurrent record review and interview on 9/15/2025 at 11:00 am with Director of Medical Records (DMR), the facility's policy and procedure (P&P) titled, Resident Access to Records, dated 12/14/2020 was reviewed. The P&P indicated Electronic Access-In an electronic form or format when such records are maintained electronically upon request Respond within twenty-four (24) hours for access, within forty-eight (48) hours for copies or provision in electronic format excluding weekends and holidays. The DMR stated the medical records department should have followed the P&P but they didn't. 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 3 Event ID: 056431 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 056431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inland Valley Care and Rehabilitation Center 250 W. Artesia Street 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)