Inspection Reports for
Pomona Vista Care Center

The facility was found deficient in multiple areas including resident privacy, care planning, hygiene, pressure ulcer prevention, nutrition, feeding tube care, respiratory care, trauma-informed care, nurse staffing posting, medication administration, medication storage, infection control, and resident room size compliance.

The facility was found deficient in multiple areas including failure to ensure resident privacy during personal care, incomplete care plans addressing residents' specific needs, inadequate hygiene and pressure ulcer prevention, failure to meet nutritional intake goals, improper management of feeding tubes, respiratory care deficiencies, lack of trauma-informed care, incomplete medical records, infection control lapses, improper medication storage, and failure to post nurse staffing information accessibly. Additionally, some resident rooms did not meet minimum size requirements.

The complaint investigation focused on an allegation of abuse between Residents 1 and 2 on 1/18/2025. The facility did not interview Resident 3, a witness, during the investigation. The complaint was substantiated with findings of incomplete investigation and inadequate care planning and documentation related to Resident 2's wandering behavior.

The facility failed to conduct a thorough investigation of an abuse allegation by not interviewing a witness resident. Additionally, the facility did not develop or implement a timely comprehensive care plan to address Resident 2's wandering behavior and failed to accurately document close monitoring and one-to-one supervision for Resident 2, potentially compromising resident safety and care consistency.

The complaint investigation involved two residents: Resident 2 was physically abused by Resident 3 on 8/6/2024, and Resident 1 reported being punched and hit by another resident earlier in July 2024. The facility failed to protect Resident 2 and failed to timely report the abuse allegation involving Resident 1. The allegations were substantiated based on interviews, record reviews, and observations.

The facility failed to protect Resident 2 from physical abuse by Resident 3, who hit Resident 2 on the chest. Additionally, the facility failed to timely report an allegation of abuse involving Resident 1 to the appropriate authorities within two hours as required by policy.

The complaint investigation found substantiated failure in hand hygiene practices by staff, including Certified Nursing Assistants, leading to potential infection spread.

The facility failed to ensure proper hand hygiene by staff, including Certified Nursing Assistants, who did not wash or sanitize their hands after glove removal or when moving between residents' rooms. This failure posed a risk of spreading infection to residents and staff.

The facility failed to ensure that Certified Nursing Assistants (CNA 1 and CNA 2) performed hand hygiene in accordance with the infection prevention program, potentially exposing residents and staff to infection. Observations and interviews confirmed multiple instances of staff not washing or sanitizing hands after glove removal or before and after resident contact.

The complaint investigation found that Resident 8 wandered into other residents' rooms frequently without adequate supervision, with staff and residents confirming the behavior. The facility did not provide 1:1 supervision despite the known risk and dementia diagnosis. The complaint was substantiated with findings of inadequate monitoring and supervision.

The facility failed to provide adequate supervision to Resident 8, who had dementia and a history of wandering into other residents' rooms without a 1:1 sitter. Staff and residents confirmed Resident 8's wandering behavior, and the facility lacked a specific monitoring schedule for Resident 8 despite awareness of the risk. The facility's policy required adequate supervision to prevent accidents, but this was not effectively implemented for Resident 8.

The investigation was complaint-driven, focusing on substantiated incidents of physical abuse by Resident 3 against Residents 1 and 2, confirmed by interviews, progress notes, and care plans indicating suspected abuse.

The facility failed to ensure Resident 3 received 1:1 supervision as required by the care plan, resulting in Resident 3 physically abusing Residents 1 and 2. Resident 3 had severe cognitive impairment and behavioral issues, but the facility did not provide adequate supervision or appropriate treatment to prevent abuse incidents.

The complaint investigation focused on Resident 1 who was transferred to a hospital and the facility's refusal to readmit the resident despite the hospital's request. The facility also failed to perform required neurological checks after Resident 1 sustained a head injury. Interviews with hospital case managers and facility administrators confirmed the refusal to readmit and acknowledged the failure to perform neuro checks.

The facility failed to readmit Resident 1 from the hospital as required by policy and violated the resident's right to return. Additionally, the facility failed to perform neurological checks on Resident 1 after a head injury, potentially placing the resident at risk for undetected neurological issues.

The facility was found deficient in multiple areas including failure to assess resident ability to self-administer medications, incomplete PASRR follow-up, inadequate care planning and care plan revisions, failure to provide preferred activities, medication administration errors including expired medication use and crushing non-crushable meds, infection control lapses including improper use of PPE and sanitation, failure to ensure hearing aids availability, improper catheter care, expired medication storage, and inadequate resident room size.

The complaint involved Resident 1 being discharged to an Independent Living Facility despite being at risk for elopement. The resident left the facility unsupervised, leading to a missing person report filed by family. The investigation found the discharge was inappropriate and lacked proper preparation and orientation.

The facility failed to ensure a safe discharge for Resident 1 by discharging him to an Independent Living Facility that was not secured, despite his elopement risk. There was no documented evidence of sufficient preparation or orientation prior to discharge. Resident 1 left the facility unsupervised, walked 1.4 miles to a hospital, and was reported missing by family. Interviews revealed miscommunication and misunderstanding about the level of care and security at the receiving facility.

The complaint investigation was substantiated. Resident 1 eloped from the facility on 1/4/2024 after staff failed to provide adequate supervision and a comprehensive care plan addressing elopement risk. Resident 1 was found by police and returned to the facility with minor injury.

The facility failed to develop a comprehensive, person-centered elopement care plan and adequate supervision for Resident 1, who eloped from the facility on 1/4/2024. The interdisciplinary team did not evaluate the unique factors contributing to Resident 1's elopement risk, and staff monitoring was insufficient prior to the incident.

The complaint investigation found that the Licensed Vocational Nurse 1 was rehired on 3/9/22 but her background check was completed on 4/4/22, after she had already worked as a Charge Nurse on 3/15/22 and 3/21/22. The previous Director of Staff Development failed to complete the background check before the employee started work.

The facility failed to ensure that one of seven sampled employees had a completed background check before starting work, contrary to the facility's policy. This failure posed a potential risk to resident safety.

The facility failed to ensure that one of seven sampled employees (Licensed Vocational Nurse 1) had a complete background check done prior to providing care, which posed a potential risk to resident safety. The background check was completed after the employee started working, contrary to the facility's policy.

The complaint involved an allegation by Resident 1 that she was touched inappropriately by two male nurses during the night shift. The allegation was not reported immediately by staff, including Licensed Vocational Nurse 1 (LVN 1), who was aware of the incident on 7/22/2023 but did not report it until 7/24/2023. The Director of Nursing (DON) was first made aware on 7/24/2023 and took immediate action by suspending the involved staff. The facility's policy requires reporting within two hours of notification, which was not followed.

The facility failed to report an allegation of sexual abuse involving Resident 1 within the required timeframe to the State Survey Agency, Ombudsman, and local law enforcement. The failure to report had the potential to result in further abuse of Resident 1 or other residents.

The complaint investigation found that the facility did not notify Resident 1's Conservator and/or friend about the discoloration under Resident 1's right eye, despite Resident 1 lacking decision-making capacity. Licensed Vocational Nurse 1 documented the resident as self-responsible and did not make follow-up calls or notify the next shift. The Director of Nursing confirmed the failure and stated the discoloration was considered a change in condition requiring notification.

The facility failed to inform Resident 1's Conservator and/or friend about the discoloration under Resident 1's right eye despite the resident lacking capacity to make decisions. Licensed Vocational Nurse 1 documented the resident as self-responsible and did not notify the Conservator or friend, contrary to facility policy. This failure had the potential to prevent the Conservator and friend from being aware of any new treatment recommendations.

The facility had multiple deficiencies including failure to maintain resident dignity, inadequate skin and wound care, inaccurate assessments, failure to implement care plans, medication monitoring issues, improper food preparation and serving, infection control lapses, and staffing licensure concerns.

The facility failed to obtain signatures for all admission documents for one sampled resident, resulting in potential lack of informed consent. Additionally, the facility failed to maintain proper infection control practices when staff entered the room of a COVID-19 infected resident without proper personal protective equipment (PPE).