Health inspection·October 23, 2024

F 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure abdominal X-ray (pictures of the inside of the abdomen) results were received timely for 2 of 3 sampled residents (Resident 1 and Resident 2). Residents Affected - Few These failures resulted in Resident 1 and Resident 2 not receiving their gastrostomy tube (G-tube, a feeding tube inserted through the abdomen that brings nutrition directly to the stomach) feeding (liquid nutrition given through the G-tube) and medications for 3 days. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure and dysphagia (difficulty swallowing foods or liquids). The AR indicated Resident 1 had a tracheostomy tube (a tube inserted in a surgically created hole in the windpipe to provide an alternative airway for breathing) and a G-tube. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 7/8/24, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/15/24, the MDS indicated Resident 1 was dependent on staff for oral hygiene, toileting hygiene, showering/bathing, personal hygiene, dressing, and putting on/taking off footwear. The MDS indicated Resident 1 had a feeding tube and received 51 percent or more of Resident 1's total calories through the tube feeding. During a review of the Physician's Order (PO), dated 10/10/24 and timed 5:47 am, the PO indicated Resident 1 may have a G-tube replacement by the wound consultant and to verify G-tube placement by abdominal X-ray. During a review of the Change In Condition Evaluation (CIC), dated 10/10/24 and timed 6:19 am, the CIC indicated at 5:45 am a Certified Nursing Assistant (CNA) (unknown) found Resident 1 sitting on the edge of the bed with Resident 1's G-tube dislodged. During a review of Wound Care Expert Progress Report (WCEPR), dated 10/10/24 and untimed, the progress report indicated Resident 1's G-tube was replaced by the wound care consultant and the wound care consultant ordered a stat (immediately/urgently) abdominal X-ray to verify the placement of the (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 3 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 10/23/2024 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)