Country Oaks Care Center

F-F584

Findings:

During an observation on 3/3/25 at 12:45 p.m., in Bathroom [ROOM NUMBER] (shared bathroom between Residents 16, 34, 166, and 167) the following were observed:

1. On the left corner and right corner of the toilet and along the baseboard was a dark black substance.

2. On the left and right side of the toilet the baseboard along the wall was warped.

3. Around the water shut off valve on the left side of the toilet there was a brown substance, and the wall area was cracked and peeling.

4. On the right side of the toilet, the tile floor had a 3-inch crack with a 1/4 inch groove in the tile.

5. The safety grab bar by the left side of the toilet had cracked and peeling plaster with an exposed screw where the grab bar was fastened to the wall.

6. On the right side of the bathroom sink there was a 3-inch crack and black substance where the sink met

the wall.

7. Under the bathroom sink and on/around the plumbing cleanout (an accessible plug or fitting that allows you to access the drain line for cleaning and unclogging) there was a brown color substance and cracked/peeling plaster.

8. Under the bathroom sink along the baseboard was crack/unpainted plaster.

During a review of the Maintenance Department's logs titled, Wall Penetration, dated January 2024 to December 2024, the logs did not indicate any repairs were made to Bathroom [ROOM NUMBER] nor were Bathroom [ROOM NUMBER] listed on the logs as needing repairs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0921 During a review of the Maintenance Department's logs titled, Maintenance Checklist, dated December 2024 to February 2025, the logs did not indicate any bathrooms listed as part of the maintenance checklist. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/5/25 at 10:30 a.m. in Bathroom [ROOM NUMBER] with the Maintenance Supervisor (MS), the MS acknowledged Bathroom [ROOM NUMBER], needed repairs due to the conditions pose a Residents Affected - Some hazard to the health of the residents. MS acknowledged the conditions of the bathroom was not home-like for

the residents. The MS stated he would start all repairs immediately.

During a review of Resident 16's, Resident 34's, Resident 43's, and Resident 45's Admission Record (AR),

the ARs indicated, all four residents were admitted to the facility with a respiratory diagnoses such as chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) or chronic respiratory failure with hypoxia (when your blood does not have enough oxygen), which placed the residents

in a vulnerable state of health.

During a review of the facility's policy and procedure (P&P) titled, Maintenance Inspection, revised 12/19/22,

the P&P indicated, It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

During a review of the facility's P&P titled, Safe and Homelike Environment, revised 12/19/22, the P&P indicated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . The P&P further indicated, Policy Explanation and Compliance Guidelines: . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 37 055247

F-F693

Findings:

During a review of Resident 20's Admission Record, the AR indicated Resident 20 was admitted to the facility on [DATE REDACTED] with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support) and dysphagia (swallowing difficulty).

During a review of Resident 20's Minimum Data Set (MDS, resident assessment tool), dated 1/10/2025, the MDS indicated Resident 20 had severe impaired cognition for daily decision making. The MDS indicated, Resident 20 was dependent on staff for oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.

During a review of Resident 20's Order Summary Report (OSR), dated active as of 3/4/2025, the OSR included a physician's order, dated 1/23/2025, the order indicated, to administer Isosource 1.5 (nutritional formula) rate at 63 cubic centimeter (cc, unit of measurement) per hour (cc/hr) for 20 hours. The order indicated a start time of 12 noon and an off time of 8 AM or until 1260 cc was infused.

During an observation on 3/3/2025 at 9:18 AM, Resident 20 was awake, lying in bed, and CNA 1 was at Resident 20's bedside. Resident 20's GT tubing was hanging on a pole and was disconnected from Resident 20.

During an interview on 3/3/2025 at 9:25 AM, with CNA 1, CNA 1 stated, I disconnected the GT feeding from

the resident [Resident 20] and hung the tubing on the GT machine. I turned [the machine] off and on.

During an interview on 3/3/2025 at 9:26 AM, Licensed Vocational Nurse 1 (LVN 1) stated, the GT feedings should not be disconnected from the residents [by CNAs]. LVN 2 stated, CNAs should not turn on or off the GT machine because they were not licensed to do it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0726 During an interview on 3/5/2024 at 11:21 AM, with the facility's DON, the DON stated, CNAs (in general) were not trained or allowed to [disconnect] turn on/off resident GT feedings. The DON stated, this action was Level of Harm - Minimal harm or outside of CNAs scope of practice (specific types of activities and tasks that a healthcare professional is potential for actual harm legally allowed and qualified to perform, based on their training, education, and license).

Residents Affected - Few During a review of the facility's P&P, titled, Care and Treatment of Feeding Tube, revised 12/19/2022, the P&P indicated, it is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729

Residents Affected - Some Based on interview and record review, the facility failed to ensure accurate acquiring and dispensing of medications by failing to:

A. Ensure accountability of the narcotic (medications that have compounds with paralyzing [causing a person or part of the body to become partly or wholly incapable of movement] or numbing properties) medications stored in one of two medication carts (Med Cart #2) between the off-going nurse and the on-coming nurse on 3/1/2025 for the morning (AM) and the evening (PM) shifts.

B. Ensure, the correct dose of Polyvinyl Alcohol Ophthalmic Solution (eyedrops, medication used to relieve eye dryness an soreness, particularly where the dryness is caused by a reduced flow of tears) was administered as ordered by the physician for one of one sampled resident (Resident 50).

This deficient practice had the potential to lead to diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of narcotic medications and resulted in an inadequate eyedrop dose administered to Resident 50 with a potential for worsening of Resident 50's eye condition.

Findings:

A. During an interview on 3/6/2025 at 7:31 AM with Licensed Vocational Nurse (LVN) 6, LVN 6 stated at the beginning of each shift change, the off-going nurse and on-coming nurse counted all the narcotics for the residents designated to the nurse's assigned medication cart. [This was important] to ensure there were no missing medications. LVN 6 stated each nurse signed a log titled, Controlled Substances Shift Count Log (SCL). LVN 6 stated, the signature indicated the licensed nurse had reviewed all the narcotics in the cart and all narcotics from that medication cart were accounted for.

During a concurrent interview and record review on 3/6/2025 at 4:38 PM with the Director of Nursing (DON),

the facility's SCL for Med Cart #2 was reviewed. The SCL indicated a space for signatures from the off-going nurse and on-coming nurse from 3/1/2025 to 3/31/2025. The DON stated on 3/1/2025 the off-going nurses' signatures (for AM and PM shifts) were missing, and the off-going nurse should have signed the SCL but did not. The DON stated the nurse's signature showed that the narcotics were counted and without the off-going nurse's signature, it was certain if both nurses counted the narcotics together which could lead to the diversion of narcotic medications.

During a review of the facility's in-service titled, Medication Administration, dated 2/10/2025. The in-service indicated controlled drug quantities will be verified and reconciled at the change of each nursing shift and this count needed to be documented.

42781

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0755 B. During a review of Resident 50's Admission Record, the AR indicated Resident 50 was admitted to the facility on [DATE REDACTED] with diagnoses that included chronic respiratory failure (a condition where the lungs cannot Level of Harm - Minimal harm or get enough oxygen into the blood) with hypoxia (absence of enough oxygen in the tissues to sustain bodily potential for actual harm functions), and dependence on supplemental oxygen (colorless, odorless gas) and encounter for attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing). Residents Affected - Some

During a review of Resident 50's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/9/2025, the MDS indicated, Resident 50 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 50 was dependent (helper does all of the effort) on staff for oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene.

During a review of Resident 50's Order Summary Report (OSR), dated active as of 3/4/2025, the OSR indicated a physician's order, dated 7/31/2024, the order indicated to instill two (2) drops of Polyvinyl Alcohol Ophthalmic Solution on both eyes every 12 hours for dry eyes.

During a medication administration observation on 3/5/2025 at 9:08 AM, Licensed Vocational Nurse 2 (LVN 2) administered one drop of Polyvinyl Alcohol Ophthalmic Solution to Resident 50's left eye.

During a medication pass observation on 3/5/2025 at 9:11 AM, LVN 2 administered one drop of Polyvinyl Alcohol Ophthalmic Solution to Resident 50's right eye.

During a concurrent interview and record review on 3/5/3035 at 9:21 AM of Resident 50's Medication Administration Record (MAR) with LVN 2. The MAR indicated to instill 2 drops of Polyvinyl Alcohol Ophthalmic Solution in both eyes to Resident 50. LVN 2 stated, I administered 1 [eye]drop [to] each eye. LVN 2 stated, Resident 50 would not get the adequate dose of the medication as ordered by the physician.

During a concurrent interview and record review on 3/5/2025 at 11:28 AM with the facility's Director of Nursing (DON), Resident 50's electronic medical records (PointClickCare - PCC, a cloud-based software used in long-term and post-acute care facilities) was reviewed. The DON stated, medications would not have

the maximum expected effect if the physician's order was not followed correctly.

During a review of the facility's policy and procedure (P&P), titled, Medication Administration, revised 12/19/2022, the P&P indicated, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice. The P&P indicated to review the MAR to identify the medication to be administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42781 Residents Affected - Few Based on interview and record review, the facility failed to ensure specific indication for the use of Ativan (medication used to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) for one of five sampled residents (Resident 55) as indicated in

the facility's policy and procedure (P&P), titled Use of Psychotropic [medications that affect the brain and nervous system, used to treat mental health conditions], Medications.

This deficient practice had the potential to result in the use of unnecessary psychotropic drugs and result in

an adverse drug event (injuries resulting from medication use including physical and mental harm, or loss of function) to Resident 55.

Findings:

During a review of Resident 55's Admission Record (AR), the AR indicated Resident 55 was admitted to the facility on [DATE REDACTED] with diagnoses that included difficulty with walking and chronic respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) with hypoxia (low levels of oxygen in the body tissues).

During a review of Resident 55's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/15/2025, the MDS indicated Resident 55 had moderate impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 55 was dependent (helper does all of the effort) on staff for toileting hygiene, showers, lower body dressing, and personal hygiene.

During a review of Resident 55's Order Summary Report (OSR), dated active as of 3/4/2025, the OSR included a physician order, dated 2/24/2025, the order indicated Ativan 1 milligram (mg, unit of measurement) via gastrostomy tube (GT, a tube inserted into the stomach through a surgical incision used for feeding and administration of medications for a residents who are unable to swallow) every six hours as needed for agitation for 14 days manifested by constant fidgeting.

During a concurrent interview and record review on 3/5/2025 at 11:09 AM with the facility's Director of Nurses (DON), Resident 55's medical records were reviewed. The DON stated Resident 55's indication for use [agitation] for Ativan was not a specific diagnosis. The DON stated, to administer Ativan, the medication needed to have a proper and specific diagnosis with symptoms. The DON stated, agitation is not a specific diagnosis or indication for Ativan use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0758 During a review of the facility's P&P, titled, Use of Psychotropic Medications, revised 12/19/2022, the P&P indicated, residents are not given psychotropic drugs (psychiatric medicines that alter chemical levels in the Level of Harm - Minimal harm or brain which impact mood and behavior) unless the medication is necessary to treat a specific condition, as potential for actual harm diagnosed and documented in the clinical record, and the medication is beneficial to the resident. The P&P indicated, PRN (given as needed or requested) orders for all psychotropic drugs shall be used only when the Residents Affected - Few medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45553

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure proper food handling practices by one of three dietary staff observed during lunch tray line.

This deficient practice had the potential for cross-contamination of food that could result in food borne illness (any illness resulting from eating contaminated/spoiled foods) for 31 of 64 residents who received food from

the kitchen.

Findings:

During an observation of the kitchen tray line on 3/5/25 at 12:03 p.m., the cook, who was assisting the dietary assistant (DA) with plating lunch food, was observed wearing blue nitrile gloves and using silver oven mittens to hold plates, and then passing the plates to the DA who was placing food on the plates. The cook was observed using silver oven mittens to remove hot plates from the oven. The cook was observed touching the top of table with blue gloves, then touching the top of the oven mittens that were lying off to the side on the table. Next, the cook was observed slicing bread (to be served with lasagna); the cook holding

the knife in her right hand (with the blue glove) and holding the bread as it was sliced with her left hand (with

the blue glove). The cook did not change gloves before touching the bread (after touching the oven, the table, and then touching the top of the silver mitten). The cook was also observed wearing on the left hand (silver oven mitten) and on the right hand (with blue glove) receiving a plate with food on it from the DA, then

the cook placed the plate cover over the food and gave the plate to another dietary staff to place on the food rack.

During an interview on 3/5/25 at 12:15 p.m. with the Dietary Supervisor (DS), the DS stated the cook should change her gloves before touching the bread because of cross-contamination from touching other areas in

the kitchen. The DS stated when handling ready-to-eat foods like bread, staff should not transfer potential bacteria from surfaces like tables to the food directly, which can lead to a food borne illness for the residents.

During a review of the facility's policy and procedure (P&P) titled, Personal Hygiene-Safety Food Handling-Infection Control, revised 12/19/22, the P&P indicated, Policy: Guidelines for personal hygiene to promote a safe and sanitary department must be followed. Gloves should be used when touching ready-to-eat (RTE) foods. RTE foods are foods that will not receive additional cooking. Examples of RTE foods are sandwiches, salads, ice, and similar foods. Utensils such as scoops, tongs, or ladles can also be used to handle RTE foods. Ice is considered an RTE food and must be handled accordingly. When retrieving ice from the ice machine, use a scoop or gloves. If using gloves, the gloves have to be changed if staff touch equipment or other items that might cause cross-contamination of the ice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0812 During a review of the facility's policy and procedure (P&P) titled, Food Safety and Food Storage, revised 11/4/24, the P&P indicated, Food will also be stored, prepared, distributed and served in accordance with Level of Harm - Minimal harm or professional standards for food service safety. The P&P indicated, Policy Explanation and Compliance potential for actual harm Guidelines: Food safety practices shall be followed throughout the facility's entire food handling process.

This process begins when food is received from the vendor and ends with delivery of the food to the resident Residents Affected - Few . Preparation of food, including thawing, cooking, cooling, holding and reheating . Distribution and service of food to the resident, including transportation, set up, and assistance. The P&P indicated, When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards . Foods and beverage shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. The P&P indicated, Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects . Additional strategies to prevent foodborne illness include, but are not limited to . Preventing cross contamination of foods.

During a review of the U.S. Food and Drug Administration Food Code, dated 2017, the food code indicated, 3-304.15 Gloves, Use Limitation. (A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. (B) Except as specified in (C) of this section, slash-resistant gloves that are used to protect the hands during operations requiring cutting shall be used in direct contact only with FOOD that is subsequently cooked as specified under Part 3-4 such as frozen FOOD or a PRIMAL CUT of MEAT. (C) Slash-resistant gloves may be used with READY-TO-EAT FOOD that will not be subsequently cooked if the slash-resistant gloves have a SMOOTH, durable, and nonabsorbent outer surface; or if the slash-resistant gloves are covered with a SMOOTH, durable, nonabsorbent glove, or a SINGLE-USE glove. (D) Cloth gloves may not be used in direct contact with FOOD unless the FOOD is subsequently cooked as required under Part 3-4 such as frozen FOOD or a PRIMAL CUT of MEAT.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729 potential for actual harm Based on observation, interview, and record review, facility staff failed to implement infection control Residents Affected - Some practices to reduce and/or prevent the spread of infection when:

A. One of two staff (Respiratory Therapist, RT) failed to properly wear an isolation (staying away/kept away from others) gown during tracheostomy care (procedure performed routinely to keep tracheostomy [surgical opening created through the neck into the windpipe to allow air to fill the lungs] and the surrounding area clean and reduce the induction of bacteria [living organism that can cause an infection] into the windpipe and lungs) for one of six sampled residents (Resident 6) who was under enhanced barrier precaution (EBP-infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs] that employs targeted gown and gloves use during high contact resident care activities).

B. One of two staff (Certified Occupational Therapy Assistant, COTA) failed to wear proper personal protective equipment (PPE, protective clothing or equipment, designed to protect the wearer from injury or

the spread of infection or illness) while assisting one of six sampled residents (Resident 117), who was on contact isolation.

This deficient practice had the potential to result in the spread infections throughout and affect the health of

the residents and/or facility staff.

Findings:

A. During a review of Resident 6's Admission Record (AR), the AR indicated Resident 6 was initially admitted to the facility 3/22/2011 and the resident was readmitted on [DATE REDACTED] with multiple diagnoses including chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen) and quadriplegia (paralysis below the neck that affects all of a person's limbs [arms or legs]).

During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 1/31/2025, the MDS indicated Resident 6 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all the effort) on facility staff for bathing and toileting.

During a review of Resident 6's Medication Review Report (MRR), dated 3/6/2025, the MRR indicated Resident 6 had a physician's order with a start date of 9/4/2024, for EBP related to tracheostomy, gastrostomy tube (feeding tube inserted through the abdomen directly into the stomach), CRE (carbapenem-resistant Enterobacterales, a type of bacteria resistant to most available antibiotics) and a history of ESBL (extended spectrum beta lactamase - enzymes produced by some bacteria that may make them resistant to some antibiotics).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0880 During a concurrent observation and interview on 3/6/2025 at 3:30 PM with the RT, outside Resident 6's room, the RT donned (put on) an isolation gown but failed to secure the ties located on the back of the gown. Level of Harm - Minimal harm or The RT did not fully cover the RT's clothing and the RT's scrubs (sanitary clothing worn by healthcare potential for actual harm workers) touched Resident 6's bed. The RT stated the RT forgot to secure the back ties of the gown. The RT stated the isolation gown was required for infection control purposes and a loose gown could lead to Residents Affected - Some contamination and potential spread of infection to other residents.

During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated, 2024, the P&P indicated it is the policy of this facility to implement enhanced barrier precautions for the prevention of multidrug-resistant organisms. The P&P indicated, EBP was defined as an infection control intervention designed to reduce transmission of MDROs that employs gown, and gloves use during high contact resident care activities.

42781

B. During a review of Resident 117's AR, the AR indicated the facility initially admitted Resident 117 on 2/19/2025 with diagnoses that included type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) and Urinary tract infection (UTI- infection that affects part of the urinary tract).

During a review of Resident 117's MDS, dated [DATE REDACTED], the MDS indicated, Resident 117 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 117 required maximum (helper does more than half of the effort) assistance with toileting hygiene, upper body/lower body dressing and putting on/taking off footwear. The MDS indicated Resident 117 required moderate (helper does less than half of the effort) assistance for oral hygiene, and personal hygiene.

During a review of Resident 117's Situation-Background-Assessment-Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/4/2025, timed at 3:15 PM, the SBAR indicated Resident 117 was noted with two episodes of loose stool. The SBAR indicated, to collect stool to rule out Clostridium difficile (C. diff, a type of bacteria that can cause diarrhea and inflammation of the colon).

During a review of Resident 117's care plan initiated on 3/5/2025, the care plan indicated Resident 117 was placed on contact isolation. The care plan's interventions included for staff to observed good hand hygiene, to provide education on the importance of maintaining contact precautions and provide an isolation cart in Resident 117's room.

During a concurrent observation and interview on 3/6/2025 at 8:18 AM, with the COTA, the COTA was inside Resident 117's room and was not wearing gloves or a gown while assisting Resident 117 with upper body therapy. The COTA stated, he needed to wear [proper PPE] gown and gloves while assisting Resident 117 because Resident 117 was on contact isolation. The COTA stated, proper PPE must be worn to avoid the spread of infections to other residents and staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0880 During an interview on 3/6/2025 at 9:34 AM with the facility's Infection Preventionist Nurse (IPN), the IPN stated, Resident 117 was still on contact isolation to rule out C-diff. The IPN stated, in a contact isolation Level of Harm - Minimal harm or room, staff needed to wear a gown, gloves, and a mask before and while performing activities of daily living potential for actual harm (ADL, term used in healthcare that refers to self-care activities) or when in contact with the resident to prevent the spread of infections to other residents and staff. Residents Affected - Some

During a record review of the facility's P&P, titled, Transmission - Based (Isolation) Precautions, revised 7/18/2023, the P&P indicated contact precautions - donning PPE upon room entry and discarding before exiting the room is done to contain pathogens (an organism that causes disease), especially those that have been implicated in transmission through environmental contamination (e.g. C-diff). The P&P indicated, recommendations included wearing PPE, gloves and gowns for contact precaution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure 11 of 32 resident rooms (rooms 115, 116, 117, 118, 119, 120, 129, 130, 131, 132, 133) met the minimum requirement of 80 square feet (sq.ft. - unit of measure) per resident in bedrooms with more than one resident.

This deficient practice had the potential to result in inadequate space for nursing care or resident care devices.

Findings:

During a review of the facility's Census List, (CL) dated 3/2/2025, the CL indicated rooms 115, 116, 117, 118, 119, 120, 129, 131, 132 and 133 had three beds occupying each room.

During a review of the facility's Client Accommodation analysis, (CAA) dated, 3/3/2025 the CAA indicated the following rooms were less than 80 sq.ft. per resident:

Room No. No. of beds: Room Size: Floor Area:

115 3 190 sq.ft. 10 ft. x 19 ft.

116 3 190 sq.ft. 10 ft. x 19 ft.

117 3 190 sq.ft. 10 ft. x 19 ft.

118 3 190 sq.ft. 10 ft. x 19 ft.

119 3 190 sq.ft. 10 ft. x 19 ft.

120 3 190 sq.ft. 10 ft. x 19 ft.

129 3 190 sq.ft. 10 ft. x 19 ft.

130 3 190 sq.ft. 10 ft. x 19 ft.

131 3 190 sq.ft. 10 ft. x 19 ft.

132 3 190 sq.ft. 10 ft. x 19 ft.

133 3 190 sq.ft. 10 ft. x 19 ft.

During a review of the facility's room waiver request letter, dated 3/3/2025 the room waiver request letter indicated the facility was in accordance with the special needs of the residents and maintained the residents' best interest.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0912 During a concurrent observation and interview on 3/6/2025 at 3:50 PM with Certified Nursing Assistant (CNA) 5, room [ROOM NUMBER] was observed with three residents. CNA 5 stated the room was tight and Level of Harm - Potential for felt the smallest, but CNA 5 was still able to provide care to the residents. CNA 5 stated resident care minimal harm devices such as a hoyer lift (mechanical device that assists caregivers in safely transferring individuals with limited mobility, using a sling to lift and support the person) could still be brought into the room for residents if Residents Affected - Some needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 37 055247 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055247 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Oaks Care Center 215 W Pearl St 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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45553

Residents Affected - Some Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary bathroom (Bathroom [ROOM NUMBER]) for 4 of 4 sampled residents (Resident 16, Resident 34, Resident 166 and Resident 167).

This deficient practice had the potential for residents to be exposed to dirt, mold, rust and drywall dust, which can cause respiratory/breathing problems.

Cross Reference