Health inspection·August 28, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a review of Resident 9's AR, the AR indicated, Resident 9 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis(MS- a long-lasting disease of the central nervous system), chronic respiratory failure (when the lungs can't get enough oxygen into the blood), and paraplegia (paralysis that affects your legs, but not your arms). During a review of Resident 9's untitled CP, dated 12/8/2022, the CP indicated, Resident 9 had functional bowel and bladder incontinence related to MS and paraplegia. The CP goal indicated, Resident 9's risk for septicemia would be minimized/prevented via prompt recognition and treatment of symptoms of UTI. The CP interventions included for staff to clean peri-area with each incontinence episode and check every two hours and as required for incontinence, wash, rinse, and dry perineum, and change clothing as needed after incontinence episode. During a review of Resident 9's MDS, dated 5/31/2024, the MDS indicated, Resident 9 was severely impaired (never/rarely made decisions) in cognitive skills (the ability to make daily decisions). The MDS indicated, Resident 9 was dependent on staff for toileting, dressing, and bathing. The MDS indicated Resident 8 was always incontinent of bowel and bladder. During an interview on 8/26/2024 at 1:18 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated sometimes CNA 1 noticed incontinent residents (in general) were soaked with urine when the previous night shift was short staffed of CNAs (in general). CNA 1 stated CNA 1 would notice the residents (in general) were wet with urine at around 8:15 a.m. CNA 1 stated sometimes the residents' (in general) gowns and sheets were also soaked with urine. During an interview on 8/26/2024 at 1:40 p.m. with CNA 2, CNA 2 stated there were mornings at the beginning of his shift when CNA 2's assigned residents (in general) who were incontinent were soaked with urine. CNA 2 stated Saturday mornings were the days CNA 2 most often saw residents (in general) soaked with urine. CNA 2 stated the last time CNA 2 noticed residents (in general) being soaked in urine was at the beginning of CNA 2's shift on 8/24/2024 (a Saturday). CNA 2 stated Resident 8 was soaked in urine at the beginning of the shift on 8/24/2024. During an interview on 8/27/2024 at 6:05 a.m. with Registered Nurse (RN) 1, RN 1 stated RN 1 was the night shift supervisor. RN 1 stated the next morning shift staff (in general) should not find residents (in general) who are soaked with urine. During an interview on 8/27/2024 at 6:35 a.m. with CNA 3, CNA 3 stated last night, CNA 3 was assigned to care for 16 residents because the facility was short staff by one CNA. CNA 3 stated CNA 3 just finished changing all the residents assigned to CNA 3 but knew some of the residents (unidentified) would already be wet (incontinent) again because CNA 3 last changed the residents around 3:30 a.m. CNA 3 stated CNA 3 last changed Resident 8 and Resident 9 at 3:45 a.m. CNA 3 stated CNA 3 would not be changing the residents again because it was the end of CNA 3's shift. During a concurrent observation and interview on 8/27/2024 at 10:30 a.m. with CNA 4, CNA 4 cleaned and changed Resident 8. Resident 8's diaper was wet and soiled with urine and stool. The urine and stool were contained in Resident 8's diaper. During an interview on 8/28/2024 at 8:00 a.m. with CNA 2, CNA 2 stated all incontinent residents (in general) needed to be checked, and changed if soiled, every two hours. During a follow up interview on 8/28/2024 at 8:08 a.m. with CNA 4, CNA 4 stated CNA 4 was assigned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055247 If continuation sheet Page 2 of 8 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 055247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to care for Resident 8 on 8/27/2024. CNA 4 stated the first time CNA 4 had checked Resident 8 on 8/27/2024 was at 8:00 a.m. (more than four hours since last time Resident 8 was checked for incontinence). CNA 4 stated CNA 4 changed Resident 8's diaper at that time because Resident 8 was wet with urine. CNA 4 stated the residents (in general) needed to be checked for incontinence every two hours. CNA 4 stated sometimes some residents (in general) were soaked in urine when CNA 4 checked the residents the first time at the beginning of CNA 4's shift. During a concurrent interview and record review on 8/28/2024 at 11:54 a.m. with the Assistant Director of Nursing (ADON), Resident 8's and Resident 9's untitled care plans for bladder incontinence were reviewed. The ADON stated both Resident 8 and Resident 9 were incontinent of bowel and bladder all the time. The ADON stated neither Resident 8 nor Resident 9 could communicate to staff when they had incontinent episodes. The ADON stated when facility staff (in general) did not check and clean Resident 8 and Resident 9 every two hours (if incontinent) then Resident 8 and Resident 9 could experience skin break down and/or end up with a UTI. During a review of the facility's P&P titled, Incontinence, dated 12/19/2022, the P&P indicated, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. The P&P indicated, Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055247 If continuation sheet Page 3 of 8 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 055247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure incontinence (cannot holding in urine or stool) care was provided for two of four sampled residents (Residents 8 and 9) in a timely manner. This failure had the potential to result in Residents 8 and 9 to experience skin breakdown and/or placed Residents 8 and 9 at risk of experiencing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). (Cross Reference F690) Findings: 1. During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (when the lungs can't get enough oxygen into the blood), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and encephalopathy (brain disease that alters brain function or structure). During a review of Resident 8's untitled care plan (CP), dated 12/23/2023, the CP indicated, Resident 8 had bladder incontinence related to impaired mobility and physical limitations. The CP goal indicated, Resident 8's risk for septicemia (a potentially life-threatening infection that occurs when bacteria, viruses, or fungi enter the bloodstream) would be minimized/prevented via prompt recognition and treatment of symptoms of UTI. The CP interventions included for staff to clean perineal (peri- an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum area) area with each incontinence episode and check every two hours and as required for incontinence, wash, rinse, and dry perineum (perineal area), and change clothing as needed after incontinence episode). During a review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/27/2024, the MDS indicated, Resident 8 was severely impaired (never/rarely made decisions) in cognitive skills (the ability to make daily decisions). The MDS indicated, Resident 8 was dependent on staff for toileting, dressing, and bathing. The MDS indicated, Resident 8 was always incontinent of bowel and bladder. 2. During a review of Resident 9's AR, the AR indicated, Resident 9 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (MS- a long-lasting disease of the central nervous system), chronic respiratory failure (when the lungs can't get enough oxygen into the blood), and paraplegia (paralysis that affects your legs, but not your arms). During a review of Resident 9's untitled CP, dated 12/8/2022, the CP indicated, Resident 9 had functional bowel and bladder incontinence related to MS and paraplegia. The CP goal indicated, Resident 9's risk for septicemia would be minimized/prevented via prompt recognition and treatment of symptoms of UTI. The CP interventions included for staff to clean peri-area with each incontinence episode and check every two hours and as required for incontinence, wash, rinse, and dry perineum, and change clothing as needed after incontinence episode. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055247 If continuation sheet Page 4 of 8 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 055247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 9's MDS, dated 5/31/2024, the MDS indicated, Resident 9 was severely impaired (never/rarely made decisions) in cognitive skills (the ability to make daily decisions). The MDS indicated, Resident 9 was dependent on staff for toileting, dressing, and bathing. The MDS indicated Resident 8 was always incontinent of bowel and bladder. During an interview on 8/26/2024 at 1:18 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated sometimes CNA 1 noticed residents (in general) were soaked with urine when the previous night shift was short staffed of CNAs (in general). CNA 1 stated CNA 1 would notice the residents (in general) were wet with urine at around 8:15 a.m. CNA 1 stated sometimes the residents' (in general) gowns and sheets were also soaked with urine. During an interview on 8/26/2024 at 1:40 p.m. with CNA 2, CNA 2 stated there were mornings at the beginning of his shift, when CNA 2's assigned residents (in general) were soaked with urine. CNA 2 stated Saturday mornings were the days CNA 2 most often saw residents (in general) soaked with urine. CNA 2 stated the last time CNA 2 noticed residents (in general) being soaked in urine was at the beginning of CNA 2's shift on 8/24/2024 (a Saturday). CNA 2 stated Resident 8 was soaked in urine at the beginning of the shift on 8/24/2024. During an interview on 8/27/2024 at 6:05 a.m. with Registered Nurse (RN) 1, RN 1 stated there were currently three CNAs assigned to the subacute unit of the facility (on 8/26/2024, during the night shift, 11 p.m. to 7 a.m.). RN 1 stated two of the CNAs were assigned to care for 16 residents each. RN 1 stated the other CNA was assigned to care for 6 residents including one resident (unidentified) who needed closer supervision from the CNA. RN 1 stated night shift CNAs (in general) would normally start at 4:00 a.m. to do their last round of changing soiled residents (in general). During an interview on 8/27/2024 at 6:35 a.m. with CNA 3, CNA 3 stated staffing during the night shift could be better. CNA 3 stated that normally, CNA 3 was only assigned to care for 11 residents. CNA 3 stated last night, CNA 3 was assigned to care for 16 residents because the facility was short staff by one CNA. CNA 3 stated whenever she was assigned 16 residents , CNA 3 would have to start CNA 3's last round of changing incontinent residents (in general) at 3 a.m. or 3:30 a.m. CNA 3 stated she would normally start the last round at 4:30 a.m. CNA 3 stated the only way to complete her job of changing all 16 residents was if she started at 3 or 3:30 a.m. instead of at 4:30 a.m. CNA 3 stated CNA 3 just finished changing all the residents but knew some of the residents would already be wet (incontinent) again because CNA 3 last changed the residents around 3:30 a.m. CNA 3 stated CNA 3 last changed Resident 8 and Resident 9 at 3:45 a.m. CNA 3 states CNA 3 would not be changing residents again because it was the end of CNA 3's shift. CNA 3 stated CNA 3 was assigned to care for 18 residents on 8/25/2024. During a follow up interview on 8/28/2024 at 8:08 a.m. with CNA 4, CNA 4 stated CNA 4 was assigned to care for Resident 8 on 8/27/2024. CNA 4 stated the first time CNA 4 had checked Resident 8 on 8/27/2024 was at 8:00 a.m. (more than four hours since last time Resident 8 was checked for incontinence). CNA 4 stated CNA changed Resident 8's diaper at that time because Resident 8 was wet with urine. CNA 4 stated the residents (in general) needed to be checked for incontinence every two hours. CNA 4 stated sometimes some residents (in general) were soaked in urine when CNA 4 checked them the first time at the beginning of CNA 4's shift. During a concurrent interview and record review on 8/28/2024 at 8:38 a.m. with the Director of Staff Development (DSD), the facility's Nursing Staffing Assignment and Sign-In Sheet (Staff Assignment), dated 8/26/2024 for 11 p.m. to 7 a.m. shift, was reviewed. The Staffing Assignment indicated 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055247 If continuation sheet Page 5 of 8 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 055247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm CNAs were assigned to care for residents of the sub-acute unit during the night (NOC) shift. The DSD stated the facility needed a fourth CNA for the 8/26/2024 NOC shift, but the fourth CNA was not available. The DSD stated residents (in general) needed to be repositioned and checked to see if they were wet or soiled every two hours. The DSD stated the weekends were difficult to staff due to facility staff calling off from work. Residents Affected - Some During a concurrent interview and record review on 8/28/2024 at 11:54 a.m. with the Assistant Director of Nursing (ADON), Resident 8's and Resident 9's untitled care plans for bladder incontinence were reviewed. The ADON stated both Resident 8 and Resident 9 were incontinent of bowel and bladder all the time. The ADON stated neither Resident 8 nor Resident 9 could communicate to staff when they had incontinent episodes. The ADON stated when facility staff (in general) did not check and clean Resident 8 and Resident 9 every two hours (if incontinent) then Resident 8 and Resident 9 could experience skin break down and/or end up with a UTI. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 12/19/2022, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated, Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. During a review of the facility's P&P titled, Incontinence, reviewed 12/19/2022, the P&P indicated, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. The P&P indicated, Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. During a review of the facility's P&P titled, Nursing Services and Sufficient Staff, dated 12/19/20222, the P&P indicated, It is the policy of this facility to provide sufficient staff . to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. The P&P indicated, The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. The P&P indicated, The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. a. Except when waived, licensed nurses; and b. Other nursing personnel, including but not limited to nurse aides. The P&P indicated, Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. During a review of the facility's facility assessment, titled, Facility Assessment Tool, dated 4/10/2024, the facility assessment indicated the resident population at the facility required bowel/bladder services which included .incontinence prevention and care, . responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. The facility assessment indicated, Nursing staffing is reviewed by leadership daily . Changes in acuity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055247 If continuation sheet Page 6 of 8 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 055247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 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 0725 are addressed as they occur to meet residents' needs at any given time. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055247 If continuation sheet Page 7 of 8 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 055247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift for one of three days, according to the facility's policy and procedure (P&P) titled, Nurse Staffing Posting Information, dated August 2022. Residents Affected - Few This failure had the potential to result in residents (in general) and/or visitors not knowing the facility's nurse staffing information. Findings: During an observation on 8/26/2024 at 10:42 a.m. the nurse staffing posting was located on the wall across from Nurse Station 1. The nurse staffing posting was observed to be dated 8/20/2024. There was no nurse staffing information posted for 8/26/2024. During a concurrent interview and record review on 8/28/2024 at 8:38 a.m. with the Director of Staff Development (DSD), the facility's nurse staffing posting, untitled, dated 8/20/2024, was reviewed. The DSD stated nurse staffing information was posted on the wall across from Nurse Station 1. The DSD stated the nurse staffing information should be posted by the night shift for the upcoming day. The DSD stated she did not know why there was not a nurse staffing posting on the wall for 8/26/2024. The DSD stated the nurse staffing postings (in general) were just the projection of nurse staffing hours for the day. The DSD stated the DSD changed the nurse staffing posting information after payroll provided the updated nurse staffing hours to the DSD. The DSD stated the nurse staffing posting was not updated at the beginning of each shift if a staff person called off. During a review of the facility's P&P titled, Nurse Staffing Posting Information, dated 12/19/2022, the P&P indicated, Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The P&P indicated, The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides. The P&P also indicated, The facility will post the Nurse Staffing Sheet at the beginning of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055247 If continuation sheet Page 8 of 8