Health inspection·March 10, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review, the facility failed to promptly respond to call lights (a device used by a resident to signal his or her need for assistance from staff) for three of five sampled residents (Residents 7, 11, and 12) according to the facility ' s Policy and Procedure (P&P) titled, Communication - Call System, revised January 1, 2012. This failure had the potential to result in residents care needs not being met. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 8/27/2024 and readmitted Resident 7 on 10/28/2024 with diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and difficulty in walking. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 12/12/2024, the MDS indicated Resident 7 had no impairments in cognitive skills (ability to make daily decisions). The MDS indicated Resident 7 required partial/moderate (helper does less than half the effort) from staff for bathing, dressing, and toileting and personal hygiene. During a review of Resident 7 ' s untitled care plan, initiated on 2/6/2025, the care plan indicated Resident 7 had limited physical mobility. The care plan indicated the intervention of, Encourage the resident to use bell to call for assistance. b. During a review of Resident 11's AR, the AR indicated the facility admitted Resident 11 on 9/14/2017 and readmitted Resident 11 on 11/29/2023 with diagnoses including quadriplegia (the condition in which both the arms and legs are paralyzed), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Resident 11's MDS, dated 2/25/2025, the MDS indicated Resident 11 had no impairments in cognitive skills. The MDS indicated Resident 11 was dependent (helper does all the effort) on staff for all activities of daily living (ADL, a term used to describe the skills required to independently care for oneself). During a review of Resident 11 ' s untitled care plan, initiated on 9/11/2021, the care plan (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 5 Event ID: 555852 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 555852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Avenue Healthcare & Wellness Center 1550 North Park Avenue 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)