Health inspection·October 29, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to remain free from verbal (the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents) and physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), when Certified Nursing Assistant 1 (CNA 1) physically and verbally abused Resident 1 on 10/27/2024. This failure had the potential to result in bodily injury to Resident 1 and/or for Resident 1 to feel afraid and not safe while under the care of the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/20/2022 and readmitted on [DATE] with diagnoses including chronic respiratory failure (when the lungs can't get enough oxygen into the blood), profound intellectual disability (limitations in cognitive functioning and skills) and anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/27/2024, the MDS indicated Resident 1 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent on staff for bathing, toileting, and oral and personal hygiene. During a review of Resident 1's, SBAR (Situation-Background-Assessment-Recommendation) Communication Form (SBAR), dated 10/27/2024 and timed at 8:00 p.m. the SBAR indicated on 10/27/2024 (untimed), an allegation was made that Resident 1 experienced physical and verbal abuse. During a review of Resident 1's Progress Notes (PN), dated 10/27/2024 and timed at 9:20 p.m., the PN indicated at 8:00 p.m., two sitters (a staff who provides supervision and/or companionship to residents who need extra care) reported that CNA 1 was being aggressive and verbally abusing Resident 1 during patient care. During an observation on 10/29/2024 at 9:04 a.m. inside Resident 1 's room, Resident 1 was asleep in bed. During a phone interview on 10/29/2024 at 10:22 a.m. with CNA 1, CNA 1 stated, on 10/27/2024, CNA 1 (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 10/29/2024 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)