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F0725
E

Insufficient Staffing Leads to Delayed Incontinent Care

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

The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delays in toileting and incontinent care for two residents. One resident, with diagnoses including epilepsy, type 2 diabetes, and a history of falls, was assessed as having severely impaired cognitive skills and required supervision to extensive assistance for activities of daily living. This resident reported being left wet during nighttime hours due to staffing shortages. Another resident, with diabetes and hypertension and intact cognitive skills, was dependent on staff for toileting hygiene and reported being left soiled for an extended period during the night, also attributing this to insufficient staffing. Staff interviews and assignment sheet reviews confirmed that CNAs were assigned to care for more than 16 residents during the night shift, exceeding the facility's own staffing assessment. CNAs reported being unable to complete all assigned care tasks due to excessive workloads, resulting in residents being left wet and unkempt by morning. The facility's policies indicated that staffing should be based on resident needs and care plans, but actual assignments did not align with these requirements, leading to unmet care needs for residents.

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