Inspection·August 15, 2024

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) who had a colostomy (an opening that connects the digestive tract to the surface of the belly to allow for waste material and gas to leave the body) received care consistent with professional standards of practice when Resident 1's colostomy bag was removed, emptied, and placed back on by unlicensed staff. This failure had the potential to place Resident 1 at risk for complications such as infections or dislodgment of the colostomy bag. Findings: During a review of Resident 1's admission Record (AR), dated 7/12/24, the AR indicated, Resident 1 was admitted with diagnoses including, colostomy, artificial opening of urinary tract, hypertension (high blood pressure) and hyperlipidemia (build-up of fats in the blood). During a review of Resident 1's, MDS (Minimum Data Sheet - a federally mandated process of clinical assessment for nursing home patients) Assessment, dated 7/16/24 , the MDS indicated, Section C - Brief Interview of Mental Status (BIMS) assessment indicated, Resident 1 had a BIMS Score of 15 (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact.) During an interview on 8/15/24 at 12:15 p.m. with Resident 1, Resident 1 verbalized concerns that a staff was reusing a colostomy bag. During an interview on 8/16/24 at 2:30 p.m. with Certified Nurse Assistant (CNA 2), CNA 2 stated she was instructed by the licensed nurse to clean the bag. CNA 2 further stated they removed, rinsed, and then placed the colostomy bag on Resident 1. During an interview on 8/16/24 at 3:30 p.m. with the Licensed Nurse (LN 4), LN 4 stated that CNA 2 was instructed only to empty the colostomy bag, not remove it. During an interview on 8/16/24 at 4 p.m. with Director of Nursing (DON), DON verbalized that unlicensed staff are only permitted to empty the colostomy bag, not to remove it. DON verbalized the removal of a colostomy bag is a task for a licensed nurse. During a review of the facility's policy and procedure (P&P) titled, Colostomy Urostomy or (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: 055342 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 055342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thousand Oaks Post Acute, LLC 93 West Avenida DE Los Arboles Thousand Oaks, CA 91360 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)