Other·August 9, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health, Licensing and Certification, during a federal abbreviated survey of one complaint. Complaint CA00625160 - Substantiated under

F689 Representing the Department: 40056-HFEN The inspection was limited to the specific complaint investigated and does not reflect the findings of a full inspection of the facility.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 07/04/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1) assessed by the facility as a fall risk and requiring toileting assistance LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC5S11 Facility ID: CA050001409 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555794 (X3) DATE SURVEY COMPLETED 06/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHERWOOD OAKS POST ACUTE 250 Fairview Rd Thousand Oaks, CA 91361 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was provided supervision and assistance when the resident verbalized the need to go to the toilet. This failure resulted in Resident 1, standing up with no supervision then falling and sustaining a left hip fracture requiring surgical repair. Findings: During a review of the clinical record for Resident 1 the "Admission Record" dated 1/11/19 indicated Resident 1 was admitted to the facility with diagnoses including muscle weakness, falls, and dementia. Review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 1/17/19 indicated Resident 1 had memory problems but can communicate needs. Resident 1 required extensive assistance of two persons physical assist for transfers and extensive assistance with one person physical assist with toilet use. Resident 1 was unable to walk by self, not steady, able to stabilize self with staff assistance from moving on and off toilet and with moving from seated to standing position. Review of Initial Fall Risk Assessment dated 1/11/19 identified Resident 1 as a "Moderate Risk" for falls due to history of falls within the last six months, memory problems, and was unable to independently come to a standing position. Review of Fall Care Plan initiated on 1/11/19 indicated "The resident is (High) risk for falls" related to hip fracture, repeated falls and unsteady gait . Interventions to prevent falls included, anticipating and meeting Resident 1's needs, prompt response to all requests for assistance and toileting program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC5S11 Facility ID: CA050001409 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555794 (X3) DATE SURVEY COMPLETED 06/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHERWOOD OAKS POST ACUTE 250 Fairview Rd Thousand Oaks, CA 91361 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the progress notes authored by the Director of Nursing (DON) dated 2/16/19 at 15:07 (3:07 P.M.) indicated, Resident 1 was sitting in the hallway outside the room when noted by licensed vocational nurse (LN 1) who was passing medications trying to get up from the wheelchair (WC). Resident 1 stated to LN 1, he wanted to use the toilet. LN 1 went to look for a Certified Nursing Assistant (CNA) to transfer the resident to the toilet. When LN 1 returned to the hallway, Resident 1 was found on the floor. Resident 1 stated, "I was trying to go to the bathroom and fell." Review of the Progress Notes dated 2/18/19 at 12:05 P.M. (two days after the fall) indicated Resident 1 was noted with a small bruise (skin discoloration) on the left eyelid under the left eyebrow. At 15:31 (3:31 P.M.) bruising was noted on the resident's left arm, at 16:10 (4:10 P.M.), pain medication (Norco- controlled pain medication) was administered for a pain level of 4-6 (moderate). Review of the physical therapy notes dated 2/18/19 at 4:21 P.M., indicated Resident communicated pain using face pain scale with all movement and range of motion (ROM) of the upper extremities (UE) and lower extremities (LE). Review of the Progress Notes dated 2/18/19 at 19:16 (7:16 P.M.) indicated Resident 1 was transferred out to the hospital due to confusion. During an interview with the DON on 2/22/19 at 11:21 A.M., the DON confirmed LN 1 left Resident 1 who was actively trying to get up and out of the wheelchair. The DON stated "I think the fall was preventable." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC5S11 Facility ID: CA050001409 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555794 (X3) DATE SURVEY COMPLETED 06/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHERWOOD OAKS POST ACUTE 250 Fairview Rd Thousand Oaks, CA 91361 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the hospital Emergency Department (ED) document dated 2/18/19 indicated Resident 1 was admitted to the ED. The ED physician notes indicated the Resident 1's chief complaint was left hip pain, and the computerized tomography (CT- X-ray visualization thru a tube like machine) results demonstrated a left femoral neck fracture (broken bone in the neck of the femur -left largest longest bone from hip to knee). The CT results dated 2/18/19 further indicated severe compression fracture of the Lumbar 1 vertebrae body (collapse of the bone of the lower spine). Review of the hospital's pre and post operative document dated 2/21/19 indicated Resident 1 underwent a left hip arthoplasty (left hip repair) on 2/21/19 (three days after admission 2/18/19). Review of the hospital Diagnosis, Assessment and Plan document dated 3/11/19 pages 1 to 3 of 6, indicated Resident 1 was hospitalized from 2/18/19 to 3/11/19 and was discharged to another nursing facility. During a phone interview with LN 1 on 3/20/19 at 11:47 A.M., LN 1 stated, "Looking back the fall could have been prevented. I could have taken him (Resident 1) with me to find the CNA or taken him (Resident 1) to the restroom myself." During an interview with the DON on 4/2/19 at 2:43 P.M. the DON stated,"Yes, the fall was preventable. LN 1 could have taken the resident (Resident 1) to the bathroom himself (LN 1)or took the resident with him to find the CNA". The facility's policy and procedure titled,"Falls Management", dated revised 11/2012, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC5S11 Facility ID: CA050001409 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555794 (X3) DATE SURVEY COMPLETED 06/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SHERWOOD OAKS POST ACUTE 250 Fairview Rd Thousand Oaks, CA 91361 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated, Residents will be assessed for fall risk and interventions will be implemented to reduce the risk for falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC5S11 Facility ID: CA050001409 If continuation sheet 5 of 5