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F0677
E

Failure to Provide Peri-Care for Dependent Residents

Pomona, California Survey Completed on 12-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide necessary peri-care for two residents who required physical assistance with toileting hygiene. For one resident with diagnoses including epilepsy, type 2 diabetes mellitus, and a history of falls, records indicated a care plan goal for daily ADL needs to be met, with interventions for staff to keep the resident clean and dry. Despite this, the resident reported being left wet during nighttime hours due to staffing shortages. Documentation showed the resident had severely impaired cognitive skills and required supervision to extensive assistance for ADLs. Another resident, with diabetes mellitus and hypertension, was also dependent on staff for toileting hygiene according to their care plan and assessment. This resident reported being left soiled for an extended period during nighttime hours, again citing staffing shortages as the cause. The resident expressed concern about prolonged incontinence and potential skin breakdown. Facility policies reviewed indicated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene, and that perineal care is intended to provide cleanliness, comfort, and prevent infection and skin irritation.

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