Health inspection·September 25, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure four of six sampled staff (Licensed Vocational Nurses [LVN] 1, 2, 3, and 4) received In-service training (a type of professional training or staff development that is given to staff while they are employed) before signing the facility's document titled, In-Service Form (signing the In-service Form indicated the staff received training). This failure had the potential for facility staff to not receive the required training while employed at the facility and had the potential to negatively affect residents' safety and the provision of care to the residents of the facility. Findings: During a review of the facility's document titled, In-Service Form, initiated 9/13/2024, the In-Service Form indicated the training topic was, Dementia (a group of thinking and social symptoms that interferes with daily functioning). The In-Service Form indicated LVNs 1, 3, and 4 signed the form to indicate LVNs 1, 3, and 4 received the training about Dementia. During a review of the facility's document titled, In-Service Form, initiated September (exact date unspecified), the In-Service Form indicated the training topic was, Care of Visually Impaired Resident. The In-Service Form indicated LVNs 1, 3, and 4 signed the form to indicate LVNs 1, 3, and 4 received the training about care of visually impaired residents. During a review of the facility's document titled, In-Service Form, initiated 9/13/2024, the In-Service Form indicated the training topic was, Abuse. The In-Service Form indicated LVNs 1, 3, and 4 signed the form to indicate LVNs 1, 3, and 4 received training about Abuse. During a review of the facility's documented titled, In-Service Form, initiated 9/13/2024, the In-Service Form indicated the training topic was, Medication Administration. The In-Service Form indicated LVNs 1, 3, and 4 had signed the form to indicate LVNs 1, 3, and 4 received training about medication administration. During a telephone interview on 9/24/2024 at 10:50 a.m. with LVN 1, LVN 1 stated facility management instructed LVN 1 to sign multiple In-service Forms without providing LVN 1 with the actual training. LVN 1 stated LVN 1 had signed multiple In-service Forms the previous week without receiving training from the facility management. LVN 1 stated the In-service Forms were left at the nurse's station and that facility staff were told to sign the In-service Forms. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055247 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 09/25/2024 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)