Health inspection·July 17, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete PM, The Director of Staff Development (DSD) stated a CP must be created upon admission, especially for residents who have medical devices such as a Pleurx catheters. The DSD stated [creating CPs] ensured appropriate interventions, monitoring, and staff guidance were in place from [admission].The DSD stated if a CP was not created timely, the team lacked clear direction on how to safely manage the catheter. The DSD stated staff were expected to create CPs for medical devices promptly and upon admission to ensure continuity and quality of care.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, revised 12/19/2022, the P&P indicated it is the policy of the facility to develop and implement a comprehensive person-centered CP for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. During a review of the facility's P&P titled, Provision of Quality Care, revised 12/19/2022, the P&P indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered CPs, and the residents' choices. The policy explanation and compliance guidelines indicated:1. A comprehensive CP will be developed for each resident in accordance with procedures for development of the CP.2. Responsibility for interventions on the CP will be clearly identified. Event ID: Facility ID: 055247 If continuation sheet Page 2 of 5 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 07/17/2025 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and services in accordance with professional standards of practice. The facility failed to obtain a physician's order prior to draining Resident 1's Pleurx catheter (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs) on 7/5/2025. This failure placed Resident 1 at risk for complications like hypotension (low blood pressure, complication from Pleurx drainage due to rapid fluid shifts), infection, respiratory complications, and fluid imbalance. Additionally, the failure had the potential to result in a physical decline to Resident 1.Cross Reference: F656 and F726Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/3/2025, and re-admitted the resident on 7/11/2025, with diagnoses including malignant neoplasm of the prostate (a cancerous lump or growth on the small gland in men that helps make fluid for semen), pleural effusion (when extra fluid builds up between the lungs and the chest wall, making it harder to breathe), and neutropenia (when you have too few neutrophils [a type of white blood cell that helps the body fight off infections, especially bacteria]). During a review of Resident 1's Section GG Data Collection Tool, dated 7/3/2025, the data collection tool indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent (helper does all of the effort) and mobility.During a review of Resident 1's History and Physical (H&P), dated 7/5/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's General Acute Care Hospital (GAHC) Progress Notes, dated 7/2/2025, the GAHC progress notes indicated that Resident 1 had recurrent right pleural effusion with multiple hospital admissions and the ultrasound-guided Pleurx catheter was placed on 6/7/2025. During a concurrent interview and record review on 7/16/2025 at 1:34 PM, Resident 1's Progress Notes, dated 7/5/2025, timed at 5:37 PM, were reviewed with Treatment Nurse (TN) 1. TN 1 confirmed Registered Nurse Supervisor (RNS) 1 and TN 2 drained approximately 1,100 milliliters (mL- a unit of volume) from Resident 1's Pleurx catheter on 7/5/2025, as documented in the progress notes by RNS 1. TN 1 stated there was a physician's order to drain Resident 1's catheter every Monday, Wednesday, and Friday during the day shift and the start date for that order was 7/7/2025. TN 1 stated there was no active order on 7/5/2025 indicating drainage of Resident 1's catheter. TN 1 confirmed drainage of Resident 1's catheter should not have occurred without a valid physician order. TN 1 stated performing a medical procedure like Pleurx catheter drainage without a physician's order [was not in agreement with] professional standards of practice and could place Resident 1 at risk for harm, including hypotension, infection, respiratory complications, or fluid imbalance.During an interview on 7/17/2025 at 12:45 PM, The Director of Staff Development (DSD) stated staff were expected to always ensure a valid physician order was in place prior to performing Pleurx catheter drainage. The DSD emphasized this [obtaining a physician's order prior to performing the drainage] was critical for Resident 1's safety. The DSD stated draining a Pleurx catheter without an active physician order placed the resident at serious risk, such as stress on internal organs, hypotension, or fluid imbalance, particularly if the drainage volume or frequency was not clinically appropriate.During a review of the facility's policy and procedure (P&P) titled, Ambulatory Drainage Catheter (Pleurx), revision dated 12/19/2022 the P&P indicated it is the policy of the facility to establish procedures for care of residents who have an ambulatory drainage catheter such as a Pleurx tube in place. Compliance guidelines indicated:1. The bottle should be drained as per the practitioner's orders and per the manufacturer's instructions. During a review of the facility's P&P titled, Provision Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055247 If continuation sheet Page 3 of 5 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 07/17/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of Quality Care, revised 12/19/2022, the P&P indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered CPs, and the residents' choices. The policy explanation and compliance guidelines indicated:1. Each resident will be provided with care and services to attain and maintain his/her highest practicable physical, mental, and psychosocial well-being.During a review of the facility's job description titled, Licensed Vocational Nurse [LVN], dated 2023 indicated LVNs: Provide direct care skills such as colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) changes, tube feedings, wound care, suctioning, intravenous (IV, a soft flexible tube placed inside a vein, usually in the hand or arm and used to give a person medicine or fluids) administration, etc. in accordance with current policies and procedures. Transcribe physician orders to medical record and carries out orders as written. Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.During a review of the facility's job description titled, Registered Nurse [RN], dated 2023, the P&P indicated the RNs: Provide direct care skills such as colostomy changes, tube feedings, wound care, suctioning, IV administration, etc. in accordance with current policies and procedures. Transcribe physician orders to medical record and carries out orders as written. Establishe a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines. Event ID: Facility ID: 055247 If continuation sheet Page 4 of 5 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 07/17/2025 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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 six of six licensed nurses (Treatment Nurses [TN], 1, 2, 3, 4, 5 and 6) had assessments to demonstrate competency for the handling and management of Pleurx catheters (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs).This failure had the potential to result in compromised safety for the residents with Pleurx catheters and the potential to result in TNs 1, 2, 3, 4, 5, and 6 not to deliver high quality of care when handling Pleurx catheters due to lack of competency validation. Cross Reference:

F656 and F684Findings:During an interview on 7/17/2025 at 10:55 AM, Treatment Nurse (TN) 3 stated TN 3 received in-service training on Pleural effusion (a condition where excess fluid builds up in the space between the lungs and the chest wall) and Pleurx catheters a few months ago (no date recall). TN 3 stated TN 3 did not remember completing an assessment to demonstrate TN 3's competency to properly care for resident with or manage Pleurx catheters.During an interview on 7/17/2025 at 1:41 PM with the Director of Staff Development (DSD), the DSD was unable to provide documentation that indicated completed assessments to demonstrate competency for Pleurx catheter handling by TNs (responsible for draining Pleurx catheters). The DSD stated in-service training courses were important for providing information [to staff] and competency assessments were critical to ensure staff could safely and effectively apply the knowledge and put the knowledge into practice. The DSD stated without documented competency assessments, there was no verification to show staff could properly manage Pleurx catheters. The DSD stated this, [lack of assessments] placed residents at risk for complications such as infections, improper drainage, or delayed care.During a review of the facility's Policy and Procedure (P&P) titled, Provision of Quality Care, revised 12/19/2022, the P&P indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered CPs, and the residents' choices. The policy explanation and compliance guidelines indicated:1. Each resident will be provided with care and services to attain and maintain his/her highest practicable physical, mental, and psychosocial well-being.During a review of the facility's assessment (FA) titled, Facility Assessment Tool, updated 1/23/2025, the FA indicated if any staff require certification the facility validate that it's happened upon hire and routinely thereafter. The FA indicated in addition to the regulatory-required training, the facility takes into account the diagnoses, characteristics, and any new conditions of its resident population. The FA indicated the facility develops additional training and skills competencies as needed to provide the level and types of support and care needed by the resident population. The FA indicated the facility also looks at any new regulations and P&Ps when assuring staff competency. The FA indicated the facility may consider the following training and education topics.1. Specialized care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care. Event ID: Facility ID: 055247 If continuation sheet Page 5 of 5