Inspection·October 23, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete pictures of the inside of the body) due to pain and status post assault with blunt trauma. The DR indicated Resident 8 had a fracture at the back of the right elbow. b. During a review of Resident 9's AR, the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interfere with daily functioning), encephalopathy (brain disease that alters brain function or structure), and anxiety disorder. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was severely impaired in cognitive skills. The MDS indicated Resident 9 required partial/moderate assistance from staff for toileting and personal hygiene, lower body dressing, and bathing. During a review of Resident 9's Care Plan Report (CPR), undated, the CPR indicated the facility initiated a care plan on [DATE] with the focus being, The resident is/has potential to be physically aggressive r/t (related to) throwing items on the floor, and The resident is/has potential to be verbally aggressive r/t screaming/yelling at staff. The care plan indicated an intervention was to closely observe Resident 9. During a review of Resident 9's CIC, dated [DATE], the CIC indicated, on [DATE] Resident (Resident 9) with her roommate (Resident 8) argue in their room.CNA (4) and charge nurse (LVN 1) came to check immediately, resident (Resident 9) pushes her roommate (Resident 8) out of the room on the ground. During an interview on [DATE], at 10:30 AM with Resident 9, Resident 9 stated Resident 8 would always open Resident 8's privacy curtain. Resident 9 stated Resident 8 was taking Resident 9's clothes out of the closet. Resident 9 stated Resident 8 was trying to take Resident 9's blanket from Resident 9 so Resident 9 pushed Resident 8. Resident 9 stated Resident 8 fell. During an interview on [DATE], at 3:30 PM with CNA 4, CNA 4 stated that at around 8:30 PM on [DATE], CNA 4 heard what sounded like arguing coming from the direction of Resident 8 and Resident 9's room. CNA 4 stated CNA 4 was heading toward the room when CNA 4 saw Resident 8 falling backward out of Resident 8's room. CNA 4 stated Resident 8 fell backward and hit Resident 8's head on the floor. CNA 4 stated CNA 4 saw blood on the back of Resident 8's head. CNA 4 stated Resident 9 informed CNA 4 that Resident 9 had pushed Resident 8 because Resident 8 was trying to push Resident 9. During an interview on [DATE], at 10:20 AM with CNA 5, CNA 5 stated Resident 9 had a behavior of losing her temper. CNA 5 stated Resident 9 would get mad at residents (in general) when they walked past Resident 9 in the hallway. CNA 5 stated Resident 9 would also yell angrily at residents (in general) who were sitting in chairs when Resident 9 walked past the residents (in general). CNA 5 stated Resident 9 would argue with other residents (in general). During a review of the facility's policy and Procedure (P&P) titled, Resident-to-Resident Altercations, revised [DATE], the P&P indicated: 1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff.2. Behaviors that may provoke a reaction by residents or others include:a. verbally aggressive behavior. such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating:b. physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; .d. taking, touching, or rummaging through others property, ande. Wandering into others rooms/space. Event ID: Facility ID: 056431 If continuation sheet Page 2 of 4 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 10/23/2025 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)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Based on interview and record review, the facility failed to arrange for a safe and orderly discharge for one of two sampled residents (Resident 7) when the facility failed to communicate Resident 7's medical conditions and needs to Intermediate Care Facility (ICF, provides long-term care for individuals who need more assistance than residential care but less than a skilled nursing facility) 1 prior to Resident 7's transfer to ICF 1. This failure had the potential for Resident 7 to experience an unsafe discharge due to receiving inappropriate and or inadequate care.Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 8/8/2025 with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), malignant melanoma of skin (skin cancer), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 8/14/2025, the MDS indicated Resident 7 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 7 was dependent (helper does all the effort) on staff for bathing and required substantial/maximal assistance (helper does more than half the effort) from staff for dressing, toileting, and personal hygiene. During a telephone interview on 10/22/2025 at 1:12 PM with the Administrator (ADM) from ICF 1, ADM stated the ADM was expecting Resident 1 to come to ICF 1 and was in contact with Resident 7's sister several weeks prior to Resident 7's discharge from the facility. The ADM stated when Resident 7 arrived to ICF 1 on 10/6/2025, ICF 1 staff assessed Resident 7 and realized ICF 1 could not accept Resident 7 to ICF 1 because Resident 7 had bed sores and a tumor on the neck that looked infected. The ADM stated Resident 7 was sent to a General Acute Care Hospital (GACH) 1 for the infected tumor on the neck. The ADM stated it was not appropriate for Resident 7 to be at ICF 1 because ICF 1 was an ICF/DD-H (Intermediate Care Facility for the Developmentally Disabled-Habilitative). The ADM stated Resident 7 needed to be at an ICF/DD-N (Intermediate Care Facility for the Developmentally Disabled-Nursing) facility due to Resident 7's medical needs. The ADM stated the ADM had not received any transfer paperwork from the facility prior to Resident 1 being discharged to ICF 1 and that the ADM did not realize ICF 1 was not an appropriate facility for Resident 7. The ADM stated the facility did not communicate Resident 7's needs to ICF 1 prior to discharging Resident 1 to ICF 1 on 10/6/2025. During an interview on 10/23/2025 at 9:15 AM with the Case Manager (CM), the CM stated the CM was responsible for arranging the discharge of Resident 7. The CM stated a fax confirmation would be the evidence the CM communicated Resident 7's medical condition and needs to ICF 1. The CM stated the CM did not have a fax confirmation that the facility communicated Resident 7's needs prior to Resident 7's discharge to ICF 1. The CM confirmed the CM did not call ICF 1 to communicate Resident 7's medical needs prior to Resident 7's discharge to ICF 1. During a review of the facility's Policy and Procedure (P&P) titled, Transfer and Discharge, Resident -Initiated, dated October 2025, the P&P indicated: 1. If the resident is being transferred. and return is expected, the following information is conveyed to the receiving provider:a. Contact information of the practitioner who was responsible for the care of the resident;b. Resident representative information, including contact information;c. Advance directive information;d. All special instructions and/or precautions for ongoing care, as appropriate such as:(1) treatments and devices (oxygen, implants, IVs, tubes/catheters);(2) transmission-based precautions such as contact, droplet. or airborne; and(3) special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions:e. The resident's comprehensive care plan goals:f. All other information necessary to meet the resident's needs, which includes. but may not be limited to:(1) resident status, including baseline and current mental, behavioral, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 3 of 4 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 10/23/2025 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)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and functional status;(2) reason for transfer, recent vital signs;(3) diagnoses and allergies;(4) medications (including when last received); and(5) most recent relevant labs, other diagnostic tests, and recent immunizations; andg. additional information. if any, outlined in the transfer agreement with the acute care provider (per S483.70U)).2. The above information is conveyed as close as possible to the actual time of transfer.3. Information may be conveyed using a universal transfer fom1 or an electronic health record summary, as long as the method contains the required elements, the resident's privacy is protected and the receiving facility has the capacity to receive and use the information.4. For residents being discharged (return not expected). all of the information listed above is conveyed to the receiving provider, along with a copy of the required information found at S483 .21 (c)(2) Discharge Summary (F661), as applicable.5. Communication of this required information will occur as close as possible to the time of discharge. Event ID: Facility ID: 056431 If continuation sheet Page 4 of 4