Inspection·February 19, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) by failing to develop and implement interventions to address Resident 1's behavior of refusing to be changed after becoming soiled with urine. This failure had the potential for Resident 1 to contract a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/15/2022, and readmitted Resident 1 on 11/29/2023, with diagnoses including metabolic encephalopathy (brain disease that alters brain function or structure), functional quadriplegia (the condition in which both the arms and legs are paralyzed), and hypertension (high blood pressure). The AR indicated Resident 1's Responsible Party (RP) was RP 1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 1 had no impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) assistance from staff for oral and personal hygiene and dressing. The MDS indicated Resident 3 was dependent (helper does all the effort) on staff for toileting hygiene and bathing. During a review of Resident 1's care plan (CP) titled, Care Plan Report, revised 9/25/2024, the CP indicated Resident 1 was occasionally incontinent (lack of voluntary control over urination or defecation) of bowel and bladder functioning and was at risk for recurrent UTI. The CP interventions indicated facility staff were to ensure Resident 1 was clean and dry every two hours. During an interview on 2/18/2025 at 1:45 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA 1 provided care to Resident 1. CNA 1 stated Resident 1 was incontinent of urine. CNA 1 stated Resident 1 would refuse to let CNA 1 change Resident 1's soiled incontinence brief until after lunch time. CNA 1 stated CNA 1 would often notice Resident 1 was wet with urine at 9 a.m. but that Resident 1 would not let CNA 1 change Resident 1's soiled diaper until after lunch time. During an interview on 2/18/2025 at 1:55 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was incontinent of urine. LVN 1 stated Resident 1 had a history of refusing to be changed even when wet with urine. (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 02/19/2025 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)