Inspection·December 18, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete titled, Activities of Daily Living (ADL), Supporting revised March 2018, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facility's P&P titled, Perineal Care, revised February 2018, the P&P indicated, The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin conditions. 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 12/18/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staffing, resulting in toileting and/or incontinent care not being provided for two of three sampled residents (Residents 2 and 3) in a timely manner. This failure had the potential to result in Residents 2 and 3 experiencing skin breakdown and/or placing the residents at risk for urinary tract infection (UTI, an infection in any part of the urinary system). Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disorder that can cause people to suddenly become unconscious and have violent, uncontrolled movements of the body), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and a history of falling. During a review of Resident 2's History and Physical (H&P) dated 1/6/2025, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 10/5/2025, the MDS indicated Resident 2's cognitive (the ability to think and process information) skills for daily decision making was severely impaired. The MDS indicated Resident 2 needed supervision to extensive assistance from staff for the activities of daily living (ADL- self-care tasks including bathing, dressing, toileting, transferring [mobility], continence and eating). During an interview on 12/17/2025 at 1:15 PM with Resident 2, Resident 2 stated Resident 2 was left wet during nighttime hours due to staffing shortage in the facility. b. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus and hypertension (a long-term medical condition in which the blood pressure was persistently elevated). During a review of Resident 3's H&P dated 12/12/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions making was intact. The MDS indicated Resident 3 was dependent care (helper does all of the effort, the resident does no effort to complete the activity) from staff for toileting hygiene. During an interview on 12/17/2025 at 1:45 PM with Resident 3, Resident 3 stated Resident 3 was left soiled for an extended period during nighttime hours due to staffing shortage. Resident 3 could not recall how long Resident 3 had to wait to be changed. Resident 3 expressed concern for prolonged incontinence and skin breakdown. During an interview on 12/17/2025 at 2:30 PM with CNA 2, CNA 2 stated CNA 2 received residents wet and unkempt during morning handoff (transfer of responsibility) and attributed this to nighttime CNAs being unable to complete tasks due to excessive assignments. During a concurrent interview and record review on 12/17/2025 at 3:00 PM with the Staffing Assistant (SA), the facility's Station 4,5, and 6 C.N.A. Assignment Sheets (AS), dated 12/12/2025 to 12/16/2025 were reviewed. The AS dated 12/12/2025 to 12/16/2025 indicated night shift CNAs were assigned to care for more than 16 residents during the 11PM - 7 AM shift. The SA stated CNAs were assigned to care for 14-16 residents (in general) during the 11 PM - 7 AM shift. The SA stated due to excessive workload, CNAs were unable to complete all assigned care tasks. The SA stated CNA assignments exceeded the facility staffing assessment. During a review of the facility's undated Facility Assessment (FA) titled, HSAG-File--Facility Assessment Tool, undated, the FA indicated the facility's staffing plan included CNAs would be assigned to care for 14-16 residents during the 11 PM - 7 AM shift. During a review of the facility's Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, revised August 2022, the P&P indicated, the facility provides sufficient numbers of nursing staff . to provide nursing and related care and services for all residents in accordance with resident care plans and (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 12/18/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm the facility assessment. The P&P indicated staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment. During a review of the facility's P&P titled, Perineal Care, revised February 2018, the P&P indicated, The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin conditions. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 4 of 4