Health 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. Page 1 of 3 055247 055247 02/19/2025 Country Oaks Care Center 215 W Pearl St Pomona, CA 91768

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 2/19/2025 at 10:45 a.m. with the ADON, Resident 1's medical records containing Resident 1's care plans were reviewed. The ADON stated Resident 1 was at risk of contracting a UTI because Resident 1 was incontinent. The ADON stated due to Resident 1's incontinence and risk of contracting a UTI, facility staff needed to ensure Resident 1 was changed every 2 hours if she was wet with urine. The ADON stated the facility should have created a care plan addressing Resident 1's behavior of refusing to be changed when wet with urine. The ADON confirmed Resident 1's medical record did not include a care plan addressing Resident 1's behavior of refusing to be changed when wet with urine. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, revised 12/19/2023, 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, The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. 055247 Page 2 of 3 055247 02/19/2025 Country Oaks Care Center 215 W Pearl St Pomona, CA 91768

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of three sampled residents (Resident 1) when a trash can liner was tied to the end of a pull cord which operated Resident 1's overhead light. This failure had the potential for Resident 1 to feel uncomfortable in her room. 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 telephone interview on 2/18/2025 at 10:06 a.m. with RP 1, RP 1 stated RP 1 visited Resident 1 at the facility and observed a trash bag tied to the end of Resident 1's call light (a device used by a resident to signal his or her need for assistance from staff) pull cord. RP 1 stated the trash bag was tied on Resident 1's call light pull cord so Resident 1 could reach the call light pull cord. During a concurrent observation, interview, and record review on 2/19/2025, at 9:10 a.m. with the Assistant Director of Nursing (ADON), the pull cord attached to the overhead light for Resident 1 was observed and the facility's Maintenance and Repair Log was reviewed. There was a small trashcan liner tied to the end of Resident 1's overhead light pull cord. The ADON stated maintenance staff should have replaced the overhead light pull cord if Resident 1 was not able to reach the pull cord. The ADON stated the need for maintenance should have been entered into the facility's Maintenance and Repair Log. The Maintenance and Repair Log binder indicated no documentation Resident 1's overhead light pull cord needed to be lengthened for Resident 1 to reach. During an interview on 2/19/2025 at 10:20 a.m. with the Maintenance Supervisor (MS), the MS stated the MS had just replaced Resident 1's overhead light pull cord. The MS stated Resident 1's overhead light pull cord was too short. The MS stated no one had informed the MS until now that the pull cord needed to be replaced. During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, revised 12/19/2022, the P&P indicated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . The P&P indicated, This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 055247 Page 3 of 3