Inspection·February 11, 2026

F 0584 hazards. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 2 of 11 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 02/11/2026 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote and protect the rights of two of three sampled residents (Residents 6 and 17) and/or their representatives to voice grievances (any formal or informal complaint about care or living conditions) and to have those grievances addressed promptly and thoroughly when:Facility staff failed to guide complainants (in general) on how to file written grievances and/or were unaware of grievance form locations or the identity of the facility's Grievance Officer.For Resident 6, the facility failed to investigate thoroughly and document the investigation regarding the grievances Resident 6's family member (RR 1) submitted to the facility on [DATE]. The facility also failed to inform (verbally and in writing) RR 1 of the findings of the investigation and the actions that will be taken to correct any identified problems.For Resident 17, the facility failed to investigate and document the investigation regarding the grievance Resident 17 submitted to the facility on 1/23/2026. The facility also failed to inform (verbally and in writing) Resident 17 of the findings of the investigation and the actions that will be taken to correct any identified problems.This failure resulted in Resident 6's representative and Resident 17 not receiving complete investigations, resolutions, verbal discussions, and written notifications regarding grievances and had the potential to result in residents and representatives feeling their grievances being ignored or disrespected.(Cross Reference F711, F790, and F804)Findings:1. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 6 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing. The MDS indicated Resident 6 required partial/moderate (helper does less than half the effort) assistance from staff for dressing and oral, toileting, and personal hygiene.2. During a review of Resident 17's AR, the AR indicated the facility admitted Resident 17 on 12/5/2023 and readmitted Resident 17 on 7/5/2024 with diagnoses including history of falling, disorder of bone density and structure, and osteoarthritis (a type of arthritis [swelling and tenderness of joints] that occurs when flexible tissue at the ends of bones wears down).During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 was moderately impaired in cognitive skills. The MDS indicated Resident 17 required substantial/maximal assistance from staff for bathing, lower body dressing, and personal and toileting hygiene.During an interview on 1/30/2026 at 10:28 AM with Resident 6's family member (RR 1), RR 1 stated RR 1 filled out a grievance form on 10/15/2025 and slid the grievance form under the door of the Social Services Department at the facility. RR 1 stated the facility never responded to RR 1 about the grievance RR 1 submitted on 10/16/2025.During an interview on 2/11/2026 at 11:25 AM with Registered Nurse (RN) 4, RN 4 stated that upon hearing a complaint from a resident or resident representative, RN 4 did not guide the complainant on how to file a written complaint with the facility.During an interview on 2/11/2026 at 11:41 AM with RN 3, RN 3 stated RN 3 did not know where the grievance forms were located. RN 3 stated RN 3 did not know who the Grievance Officer was at the facility.During a concurrent interview and record review on 2/9/2026 at 12:02 PM with Social Services Director (SSD), Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 3 of 11 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 02/11/2026 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6's Grievance/Complaint Reporting Form (GCRF) dated 10/16/2025, was reviewed. The GCRF indicated RR 1 had multiple complaints regarding the care of Resident 6, including: The facility had not changed Resident 6's clothing and bedding for an entire week. The facility was not showering Resident 6. The facility was not answering Resident 6's call light in a timely manner. The facility was not serving Resident 6 warm food. Resident 6 lost weight due to not getting hot food. The doctor was not visiting Resident 6. The facility had not arranged for Resident 6 to see a dentist.The SSD stated the SSD informed the Director of Staff Development (DSD) of the grievances and that the DSD was responsible for addressing the concerns since the complaints involved care Certified Nursing Assistants (CNAs) provided to residents (in general). The SSD stated the SSD called RR 1 and left a message regarding the report of findings. The SSD stated the SSD did not speak to RR 1 about the investigation results of the GCRF.During a concurrent interview and record review on 2/10/2026 at 12:17 PM with the Director of Staff Development (DSD), Resident 6's GCRF, dated 10/16/2025, was reviewed. The Follow Up/ Investigation Report section of the GCRF indicated the facility investigated RR 1's complaint that the facility was not showering Resident 6 or changing Resident 6's clothes and bed linens. The DSD confirmed the GCRF failed to indicate the facility investigated RR 1's following complaints: The facility was not answering Resident 6's call light in a timely manner. The facility was not serving Resident 6 warm food. Resident 6 lost weight due to not getting hot food. The doctor was not visiting Resident 6. The facility had not arranged for Resident 6 to see a dentist.During a concurrent interview and record review on 2/11/2026 at 12:17 PM with Social Service Assistant (SSA) 1, Resident 17's GCRF, dated 1/23/2026, was reviewed. The GCRF indicated Resident 17 complained that Resident 17 waited 2 hours to get assistance from the CNA (unidentified) to help Resident 17 get into bed. The GCRF indicated the facility failed to document an investigation report into Resident 17's complaint. SSA 1 stated the facility had five business days to provide a report about the investigation into the complaint to Resident 17. SSA 1 stated the complainant of grievance must be provided with a written report of the investigation.During an interview on 2/11/2026 at 12:30 PM with Resident 17, Resident 17 stated Resident 17 filed a grievance with the SSD on 1/23/2026. Resident 17 stated Resident 17 was very angry because Resident 17 was left in the hallway and wanted help to get back into bed. Resident 17 stated no one from the facility spoke to Resident 17 about Resident 17's grievance after Resident 17 reported the incident to the SSD.During an interview on 2/11/2026 at 12:51 PM with the SSD, the SSD stated the SSD did not follow up with Resident 17 regarding Resident 17's grievance filed on 1/23/2026. The SSD also stated the SSD had not provided a written report to RR 1 about RR 1's GCRF, dated 10/16/2025.During a concurrent interview and record review on 2/11/2026 at 1:40 PM with the DSD, Resident 17's GCRF, dated 1/23/2026, was reviewed. The DSD stated the DSD did not investigate Resident 17's grievance because the DSD was not informed about the grievance.During a review of the facility's policy and procedure (P&P) titled, Grievances/Complaints, Recording and Investigating, dated April 2017, the P&P indicated, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). The P&P indicated: 1. The Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer.2. Upon receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations.3. The department director(s) of any named employee(s) will be notified of the nature of the complaint and that an investigation is underway.4. The investigation and report will include, as applicable:a. The date and time of the alleged incident;b. The circumstances surrounding the alleged incident;c. The location of the alleged incident;d. The names of any witnesses and their accounts of the alleged incident;e. The resident's account of the alleged incident;f. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 4 of 11 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 02/11/2026 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete The employee's account of the alleged incident;g. Accounts of any other individuals involved (i.e., employee's supervisor, etc.); andh. Recommendations for corrective action.During a review of the facility's P&P titled, Grievances/Complaints, Filing, dated April 2017, the P&P indicated, The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. The P&P indicated Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The P&P indicated The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.During a review of the facility's P&P titled, Grievances/Complaints - Staff Responsibility, dated October 2017, the P&P indicated, .Should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative (sponsor), or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the staff member is encouraged to guide the resident, or person acting on the resident's behalf, as to how to file a written complaint with the facility. 3. Staff members will inform the resident or the person acting on the resident's behalf as to where to obtain a Resident Grievance/Complaint Form and where to locate the procedures for filing a grievance or complaint (e.g., posted on the residents' bulletin board) . Event ID: Facility ID: 056431 If continuation sheet Page 5 of 11 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 02/11/2026 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse Reporting and Investigation, for one of two sampled residents (Resident 2) by failing to ensure Social Services Assistant (SSA) 1 reported Resident 1's episode of yelling at Resident 2 and at Resident 2's family member (RR 2) and Resident 1's verbalization of harming Resident 2 on 1/28/2026.This deficient practice resulted in Resident 1's verbalization of harming Resident 2 to not be investigated and reported and placed Resident 2 at risk for abuse or harm by Resident 1.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/25/2025 with diagnoses that included essential hypertension (high blood pressure) and hyperlipidemia (high level of fats in the blood).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 8/25/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1 was independent with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 12/31/2025 with diagnoses that included hyperlipidemia, history of falling and depression (a feeling of severe sadness or hopelessness).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (thinking, knowing, and being aware). The MDS indicated Resident 2 was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 1's Social Services Notes (SSN), dated 1/28/2026 and timed at 5 PM, the SSN indicated SSA 1 spoke to Resident 1 regarding not yelling at Resident 2's family. The SSN indicated Resident 1 stated that if Resident 2's family ever addressed Resident 1 again, Resident 1 was going to do something bad to Resident 2.During a concurrent record review and interview on 1/29/2026 at 12:13 PM with SSA 1, Resident 1's SSN, dated 1/28/2026 and timed at 5 PM, was reviewed. SSA 1 stated Resident 1 stated if Resident 2's family address or talk to Resident 1 again, Resident 1 was going to do something bad to Resident 2. SSA 1 stated, SSA 1 reported what Resident 1 said to Social Services Director (SSD) on 1/28/2026 and SSD stated SSD was going to talk to the administrator (ADM). SSA 1 stated SSA 1 did not report Resident 1's threat to harm Resident 2 to the ADM because SSA 1 already informed SSD. SSA 1 stated the ADM should have been notified of Resident 1's threat to harm Resident 2 right away according to the facility's abuse policy. During an interview with the ADM on 1/29/2026 at 12:33 pm, the ADM stated the SSD and SSA 1 did not report Resident 1's threat to harm Resident 2 to the ADM. The ADM stated the SSD and SSA 1 were both mandated reporters (legally required to by law to report any observation or suspicion of abuse) and should have reported Resident 1's verbalization of harming Resident 2 to the ADM right away.During an interview with the SSD on 1/29/2026 at 12:55 pm, the SSD stated the SSD did not remember SSA 1 informing the SSD regarding Resident 1's verbalization to harm Resident 2. The SSD stated SSA 1 should have notified the ADM within 2 hours of Resident 1's threat to Resident 2. During an interview on 1/29/2026 at 1:06 pm, with Resident 2's family member (RR 2), RR 2 stated, on 1/28/2026, Resident 1 yelled at everybody inside the room (Resident 1 and Resident 2's room). RR 2 stated Resident 1 threatened Resident 2 and Resident 1 stated, (Resident 1) will show (Resident 2) who (Resident 1) was. During an interview on 2/5/2026 at 9:47 am, with the Director of Nursing (DON), the DON stated any type of abuse once identified will be reported within two (2) hours to the California Department of Public Health, Ombudsman (a representative who assists (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 6 of 11 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 02/11/2026 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents with issues related to day-to-day care, health, safety, and personal preferences) and police. The DON stated verbal threat was a form of verbal abuse and SSA 1 should have reported it to the abuse coordinator, which was the ADM, immediately. The DON stated allegations of abuse should have been reported to avoid conflict and harm between residents.During a review of the facility's P&P titled, Abuse Reporting and Investigation, dated 5/2025, the P&P indicated, The Facility staff will report all allegations of abuse, unless indicated below, as required by law and regulations to the appropriate agencies within 2 hours. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of an unknown source when appropriate. It is the responsibility of any and all staff members to exercise their right as a mandated reporter to ensure the SOC 341 is sent to appropriate authorities within 2 hours and to notify the facility Abuse Prevention Coordinator (APC) and their supervisor immediately. Event ID: Facility ID: 056431 If continuation sheet Page 7 of 11 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 02/11/2026 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide foot care and treatment and failed to assist the resident in making appointments with a podiatrist (medical doctor focused on the treatment of disorders of the foot, ankle, and the lower leg) for one of three sampled residents (Resident 6).This failure had the potential in Resident 6 to experience compromised foot health and overall quality of life.Findings:During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 6 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing. The MDS indicated Resident 6 required partial/moderate (helper does less than half the effort) assistance from staff for dressing and oral, toileting, and personal hygiene.During a review of Resident 6's Order Summary Report (OSR), dated 2/10/2026, the OSR indicated there was a physician order, dated 12/26/2025, that Resident 6 may consult with a podiatrist.During an interview on 1/30/2026 at 10:28 AM with Resident 6's family member (RR 1), RR 1 stated Resident 6's toenails were turning dark brown with the nails peeling. RR 1 stated when RR 1 mentioned Resident 6's toenails condition to the Director of Nursing (DON), the DON informed RR 1 that Resident 6 would need to be seen by a foot doctor (podiatrist).During a concurrent interview and record review on 2/10/2026 at 2:40 PM with Social Services Assistant (SSA) 1, Resident 6's podiatry progress notes titled, Nursing Home Visit (NHV), dated 10/12/2025, was reviewed. The NHV indicated Resident 6 had dystrophic (deformed, thickened, or discolored nails resulting from damaged nail growth) toenails and elongated toenails. The podiatrist recommended routine foot care again in 60 days. SSA 1 stated Resident 6's last podiatry visit was on 10/12/2025. SSA 1 stated Resident 6 was not seen by the podiatrist in 60 days as recommended because there was a change to Resident 6's insurance and Resident 6's name was on the wrong podiatry list.During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated 10/2022, the P&P indicated, Residents receive appropriate care and treatment in order to maintain mobility and foot health. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 8 of 11 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 02/11/2026 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on record review and interview, the facility failed to ensure that the attending physician or designee wrote, signed, and dated original progress notes at each required visit for one of three sampled residents (Resident 6) when Resident 6's Nurse Practitioner (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) photocopied the previous month's progress notes for visits on 8/4/2025, 9/5/2025, 10/6/2025, 11/7/2025, 12/7/2025, and 1/26/2026.This failure had the potential to result in overlooked changes in Resident 6's health status and had the potential for compromised physician oversight of Resident 6's total program of care.(Cross Reference F585, F790, and

F804)Findings:During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 6 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing. The MDS indicated Resident 6 required partial/moderate (helper does less than half the effort) assistance from staff for dressing and oral, toileting, and personal hygiene.During a review of Resident's Health Status Notes (HSNs), dated 8/4/2025 and timed at 7:01 AM and at 7:22 AM, the HSNs indicated Resident 6 complained of pain across the abdomen.During a concurrent interview and record review on 2/9/2026 at 3:36 PM with the NP, Resident 6's Attending Progress Note (APN), dated 7/3/2025, 8/4/2025, 9/5/2025, 10/6/2025, 11/7/2025, 12/7/2025, and 1/26/2026 were reviewed. Each APN indicated Resident 6 did not have any complaints and Resident 6's abdomen was non-tender. Each APN was identical to the previous month's APN except for the date written at the top of the documents, indicating the APNs were photocopied from the previous month. The NP stated the NP photocopied the previous month's APN since Resident 6 had no changes from the previous month.During a review of the facility's policy and procedure (P&P) titled, Physician Services, revised 2/2021, the P&P indicated, .Physician orders and progress notes are maintained in accordance with current OBRA regulations and facility policy . Event ID: Facility ID: 056431 If continuation sheet Page 9 of 11 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 02/11/2026 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to assist one of three sampled residents (Resident 6) in obtaining routine dental services to meet the resident's oral health needs, when the facility did not ensure timely follow-up or coordination after the dentist visit on 12/8/2025.This failure resulted in Resident 6's ongoing untreated dental deterioration (missing most upper teeth, loose teeth), with the potential to result in further oral health decline, pain, difficulty eating/chewing, nutritional compromise, infection risk, or reduced quality of life related to untreated dental needs.(Cross Reference F585, F711, and

F804)During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 6 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing. The MDS indicated Resident 6 required partial/moderate (helper does less than half the effort) assistance from staff for dressing and oral, toileting, and personal hygiene.During an interview on 1/30/2026 at 10:28 AM with Resident 6's family member (RR 1), RR 1 stated Resident 6 had loose teeth and missing teeth. RR 1 stated Resident 6 needed to be seen by a dentist. RR 1 stated that if Resident 6 was seen by a dentist, then the dentist had not provided any treatment to address Resident 6's deteriorating teeth.During a concurrent observation and interview on 2/5/2025 at 10:19 AM with Resident 6, Resident 6's mouth was observed to be missing most of Resident 6's upper teeth. Resident 6 stated Resident 6 needed to see a dentist because Resident 6 needed some false teeth.During a concurrent interview and record review on 2/10/2026 at 9:35 AM with Social Services Assistant (SSA) 1, Resident 6's Dental Progress Note (DPN), dated 12/8/2025, was reviewed. The DPN indicated Resident 6 refused treatment from the dentist and requested the dentist talk to RR 1 first. SSA 1 stated the dentist should have spoken to RR 1 as Resident 6 requested. SSA 1 stated SSA called the dentist office sometime in December 2025 and informed the dentist office that RR 1 wanted to speak to the dentist.During a concurrent telephone interview and record review on 2/10/2026 at 10:04 AM with the Regional Manager (RM) for Resident 6's dental services provider, Resident 6's DPN, dated 12/8/2025, was reviewed. The RM confirmed the dentist saw Resident 6 on 12/8/2025. The RM stated the dentist did not indicate what treatment Resident 6 refused on 12/8/2025. The RM stated Resident 6 wanted the dentist to talk with RR 1 before providing the treatment. RM stated RM would note on Resident 6's chart for the dentist to reach out to RR 1.During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 12/2016, the P&P indicated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 10 of 11 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 02/11/2026 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure hot foods were served at a palatable, safe, and appetizing temperature for one of three sampled residents (Residents 6), when Resident 6's food was served cold.This failure had the potential for Resident 6 to experience weight loss and/or dehydration.(Cross Reference F585, F711, and F790)During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/18/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 6 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing. The MDS indicated Resident 6 required partial/moderate (helper does less than half the effort) assistance from staff for dressing and oral, toileting, and personal hygiene.During an interview on 2/5/2026 at 10:19 AM with Resident 6, Resident 6 stated that sometimes the food the facility served Resident 6 was too cold.During an observation on 2/5/2026 at 12:01 PM, the meal tray cart was observed to be in the hallway in front of Nurses Station 4. At 12:04 PM, a facility staff (unidentified) opened the meal tray cart and delivered lunch trays to residents' rooms. At 12:10 PM, a facility staff (unidentified) delivered Resident 6's lunch tray to Resident 6.During a concurrent observation and interview on 2/5/2025 at 12:10 PM with Resident 6, Resident 6's lunch tray was observed. Resident 6's lunch tray consisted of pureed chicken with sauce, pureed cauliflower, pureed cauliflower, pureed pasta, and pureed bread. The food temperature was tested using a calibrated probe thermometer. The pureed chicken was 104 degrees Fahrenheit (F, unit of measurement). The pureed cauliflower was 118 degrees F. Resident 6 tasted the chicken and stated the chicken was lukewarm. Resident 6 stated the chicken should be hot.During an interview on 2/5/2026 at 12:35 PM, with the Food Service Manager (FSM), the FSM stated hot foods should be served to residents (in general) at around 145 degrees F. The FSM stated if the meal trays sit in the hallway for too long then the food temperatures will drop.During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. The P&P indicated, Hot food serving temperature must be at or above minimum holding temperature at 140 F. The P&P indicated the recommended temperature at delivery to residents (in general) should be greater than 120 degrees F for hot entrees. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056431 If continuation sheet Page 11 of 11