Inspection·November 13, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview , and record review, the facility failed to provide a safe environment that allow residents who wish to smoke, the opportunity to do so with optimal safety of themselves and others for two of eight sampled residents (Residents 4 and 5) according to the facility's policy and procedure (P&P) titled, Smoking by Residents, by failing to: Ensure Activities Assistant (AA) 1 provided adequate supervision (oversight, encouragement, or cueing) while Residents 4 and 5 were smoking on 11/13/2025 at 1 pm. As a result of this failure, AA 1 did not visualize Residents 4 and 5 smoking at the smoking patio. This failure placed Residents 4 and 5's safety at risk and had the potential for the residents to sustain cigarette burns (an injury to the skin's tissues caused by heat) and being harmful to themselves, each other, and being susceptible to abuse. Findings: a. During a Review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 2/25/2025 and was readmitted on [DATE] with diagnoses including peripheral vascular disease (PVD- poor blood flow to the legs and arms because the blood vessels are narrowed or blocked and lack of coordination (uncoordinated movement due to muscle control that causes an inability to coordinate movements). During a review of Resident 4's untitled Care Plan (CP) initiated on 4/4/2025, the CP indicated Resident 4 was at risk for hazards/injury (burn) related to smoking cigarettes. The CP goal indicated Resident 4 will not experience injuries associated with smoking daily. The CP interventions indicated Resident 4 would be provided by staff with precautionary measures and supervision during smoking schedule if possible. During a review of Resident 4's Smoking and Safety- V1 Assessment (SSA) dated 6/3/2025, timed at 11:01 pm, the SSA indicated Resident 4 had balance problems while sitting or standing (during smoking). The SSA indicated Resident 5 used tobacco products. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 8/29/2025, the MDS indicated Resident 4 had intact cognition (ability to think, reason, and function). The MDS indicated Resident 4 needed setup or clean-up assistance (helper sets up or cleans up while the resident completes the activity and helper assists only prior to or following the activity) with personal hygiene and upper body dressing. During a review of Resident 4's Order Summary Report (OSR) dated 11/13/2025, the OSR indicated Resident 4 did not have an order for smoking cigarettes. b. During a Review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 6/15/2012 and was readmitted on [DATE] with diagnoses including PVD, muscle wasting and atrophy (thinning of muscle mass) and nicotine (an addictive chemical found in tobacco plants and cigarettes) dependence ( a chronic addiction driven by a drug's effect on the brain which creates feelings of satisfaction). During a review of Resident 5's untitled CP initiated on 8/18/2024, the CP indicated Resident 5 was at risk for hazards/injury (burn, device explosion) related to smoking cigarettes and vaping (e-cigarette- an electronic device that heats up a liquid and turns it into a mist when inhaled). The CP goal indicated Resident 5 would not experience injuries associated with smoking/vaping daily. The CP interventions indicated Resident 5 (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 2 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 11/13/2025 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)