Inspection·April 25, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A facility policy titled, Accuracy of Assessment, revised 01/2025, revealed the section titled, Definition, included Accuracy of Assessment: The appropriate, qualified health professionals correctly document the resident's medical, functional, and psychological problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the RAI [Resident Assessment Instrument]. The policy revealed, 5. The assessment must represent an accurate picture of the resident's status during the observation period of the MDS. 1. An admission Record revealed the facility admitted Resident #213 on 04/09/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. An admission MDS, with an Assessment Reference Date (ARD) of 04/13/2025, revealed Resident #213 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed Section O indicated the resident did not require continuous or intermittent oxygen therapy. Resident #213's Care Plan Report, included a focus area initiated 04/11/2025, that indicated the resident had COPD. Interventions directed staff to give oxygen therapy as ordered by the physician. Resident #213's Order Summary Report, with active orders as of 04/25/2025, contained an order dated 04/09/2025, for supplemental oxygen at 2-5 liters per minute (lpm) via nasal cannula as needed (pro re nata, PRN) for shortness of breath. Resident #213's nursing Progress Notes, dated 04/10/2025 at 2:13 PM, revealed the resident needed their PRN supplemental oxygen and inhaler; both were effective. Resident #213's nursing Progress Notes, dated 04/10/2025 at 9:27 PM, revealed the resident needed their PRN supplemental oxygen and it was effective. Resident #213's nursing Weights and Vital Summary, for the timeframe from 04/09/2025 to 04/13/2025, revealed the resident received oxygen therapy on 04/11/2025 and 04/13/2025. During an interview on 04/25/2025 at 8:49 AM, Licensed Vocational Nurse (LVN) #2 confirmed Resident #213 received supplemental oxygen as needed for shortness of breath. During an interview on 04/25/2025 at 9:06 AM, MDS Coordinator #3 stated that when the resident was assessed, they only referred to their physician order and electronic medication administration record (EMAR). MDS Coordinator #3 confirmed that Resident #213 received oxygen therapy and the MDS was coded incorrectly. During an interview on 04/25/2025 at 10:06 AM, the Director of Nursing (DON) stated that it was important for the MDS to be coded accurately to ensure residents were provided with proper care. The DON stated that if a resident received supplemental oxygen, it should be coded under Section O in the MDS. 3. An admission Record indicated the facility admitted Resident #22 on 02/26/2013. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), idiopathic interstitial pneumonia, and dependence on supplemental oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 2 of 6 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 04/25/2025 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A quarterly MDS, with an Assessment Reference Date (ARD) of 01/20/2025, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not use supplemental oxygen during the assessment's lookback period. Resident #22's Care Plan Report, included a focus area initiated 04/04/2024, that indicated the resident had oxygen therapy related to congestive heart failure and COPD. Interventions directed staff to change the resident's position every two hours to facilitate lung secretion movement and drainage, give medications as ordered by the physician, and monitor and document side effects and effectiveness. The Care Plan Report included a focus area revised 11/10/2023, that indicated the resident had COPD and was at risk for impaired breathing and shortness of breath (SOB). Interventions directed staff to give oxygen therapy as ordered by the physician (initiated 08/30/2020), administer oxygen at two liters per minute (LPM) via nasal cannula as needed (pro re nata, PRN) for SOB and may titrate to maintain oxygen saturation greater than 90% (revised 03/20/2025). Resident #22's Order Summary Report, for active orders as of 01/20/2025, revealed an order dated 06/13/2024, for supplemental oxygen at two LPM via nasal cannula PRN for SOB, with instructions that the staff may titrate to maintain oxygen saturation greater than 90%. Resident #22's Weights and Vitals Summary with an effective date range of 01/06/2025 through 01/20/2025, revealed staff documented that the resident received supplemental oxygen via nasal cannula 14 days during the timeframe from 01/06/2025 through 01/20/2025. Resident #22's Progress Notes, revealed a Health Care Practitioner Note, dated 01/20/2025, that indicated the resident remained on monitoring for COPD and SOB and was on continuous oxygen by nasal cannula at two liters with nebulizer treatments. The note indicated the resident was wearing oxygen at two liters via nasal cannula during the physical exam. The note revealed the plan indicated the resident would continue on two liters of oxygen via nasal cannula, and they would monitor and document the oxygen saturation every shift. During an interview on 04/25/2025 at 10:55 AM, Licensed Vocational Nurse (LVN) #1 stated Resident #22 wore their supplemental oxygen all the time at their request. During an interview on 04/25/2025 at 9:04 AM, MDS Coordinator #3 stated she was one of two MDS Coordinators at the facility, and since they were both LVNs, the Director of Nursing (DON) signed the completion of the MDSs. She stated the accuracy of the MDS was important to make sure it showed the specific care the resident required and helped them to develop a plan of care. She stated she would do a chart review, review hospital records and the resident's history, then interview the resident to gather information for the MDS. She stated she would observe the resident to see if they were using supplemental oxygen and then check the records for supplemental oxygen orders and the MAR to see if the supplemental oxygen was being used. She stated Resident #22's supplemental oxygen was ordered PRN, and it was not coded on the MAR that the resident used the supplemental oxygen during the time of the MDS. After reviewing Resident #22's vital signs tab in the electronic health record and progress notes during the time of the MDS, MDS Coordinator #3 confirmed that the resident was using oxygen intermittently and the MDS was coded incorrectly. During an interview on 04/25/2025 at 10:06 AM, the DON stated it was important for the MDS to be accurate because it was what was submitted to the Centers for Medicare and Medicaid (CMS) and to ensure that they provided the proper and correct care for their residents. She stated the MDS staff, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 3 of 6 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 04/25/2025 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the DON were responsible for ensuring the accuracy of the MDS. She stated information for the MDS came from the chart, reports from the hospital, information obtained from the family, interviews with the resident, and input from the physician. She stated they should conduct observations and interviews. She stated the use of supplemental oxygen should be coded on the MDS, and if the resident was only wearing it PRN, then there was a place to code intermittent use on the MDS. She stated supplemental oxygen should have been coded on Resident #22's MDS if they were using it at the time of the assessment. During an interview on 04/25/2025 at 10:27 AM, the Administrator stated the MDS should be accurate to the best knowledge of the MDS Coordinators. He stated it was important to be accurate because it would drive the way they cared for the residents. He stated supplemental oxygen use should be coded on the MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 4 of 6 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 04/25/2025 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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) as required for 1 (Resident #64) of 3 residents reviewed for PASRR. Residents Affected - Few Findings included: A facility policy titled, Preadmission Screening and Resident Review (PASRR), revised 01/2025, revealed the section titled GUIDELINES, included, 4. A negative Level I screen permits admission to proceed and ends the pre-screening process unless possible serious mental disorder or intellectual disability arises later. Further review revealed, 16. If the State program permits the use of the exceptions and the resident remains in the facility longer that 30 days, the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD [mental disease], ID [intellectual disability] or a related condition to the appropriate state-designated authority for Level II PASARR [PASRR] evaluation and determination. An admission Record indicated the facility admitted Resident #62 on 11/28/2023. According to the admission Record, the resident had a medical history that included diagnoses of psychotic disorder not due to a substance or known physiological condition (onset date 11/28/2023), dementia with other behavioral disturbance (onset date 11/28/2023), and anxiety disorder (onset date 12/13/2024). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/21/2025, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had a diagnosis of a psychotic disorder. The MDS revealed the resident received antipsychotic and antianxiety medications during the assessment's lookback period. Resident #62's Care Plan Report, included a focus area initiated 11/28/2023, that indicated the facility would facilitate review of the PASRR results upon submission for the newly admitted resident. Interventions directed the admission committee to review if the resident was an appropriate admission to the facility; consult PASRR guidelines by the state health department; designated staff will review results of the submitted PASRR; provide social service support as needed; when a level 2 is applicable, the facility will follow-up on the level 2 recommendation. Resident #62's Care Plan Report included a focus area, revised 03/11/2025, that indicated the resident was on an antipsychotic medication related to psychosis manifested by delusions and non-command auditory hallucinations. Interventions (initiated 11/29/2023) directed staff to administer medications as ordered, and monitor, record, and report to the physician side effects and adverse reactions. Resident #62's Order Summary Report, for active orders as of 04/24/2025, included an order dated 03/18/2025, for olanzapine 5 milligrams (mg), with instructions to give a half of a tablet by mouth at bedtime for psychosis manifested by hallucinations. The Order Summary Report included an order dated 03/15/2025 for staff to monitor episodes of psychosis manifested by hallucination command auditory hallucination every shift. The Order Summary Report included an order dated 05/23/2024 for staff to monitor side effects of anti-psychotic agent, olanzapine, every shift. The Order Summary Report included an order dated 05/23/2024 for staff to document non-pharmacological approaches attempted prior to the administration of anti-psychotic medication, olanzapine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 5 of 6 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 04/25/2025 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #62's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 11/21/2023, indicated the resident had no serious diagnoses of mental disorder or was not prescribed psychotropic medications for mental illness; therefore, the screening was negative, and a Level II would not be required. During an interview on 04/24/2025 at 9:13 AM, Admissions Co-Director #4 stated they got the PASRR from the hospital prior to admission via the file exchange, and they reviewed it to ensure that it was complete. During an interview on 04/24/2025 at 9:44 AM, the Business Development Director stated the Director of Nursing (DON) reviewed the PASRR for accuracy and had access to the portal to submit a new one if needed. During an interview on 04/24/2025 at 9:45 AM, the DON stated admissions ensured that the PASRR was received and accurate, then if there were any changes with diagnoses or addition of a psychotropic medication either she or the MDS Coordinator would redo the assessment. She stated Resident #62's PASRR should have been resubmitted when there were changes with their medications, behaviors, and diagnoses. During an interview on 04/25/2025 at 9:04 AM, MDS Coordinator #3 stated she had just recently got access to the PASRR portal. She stated that upon admission they received the PASRR from the hospital. She stated for long-term care residents, if they got a new diagnosis or medication then she would submit for a new PASRR. She stated admissions checked the PASRR for accuracy when received prior to admission. During an interview on 04/25/2025 at 10:06 AM, the DON stated the hospital sent the PASRR and the admission staff reviewed it. The DON stated then during the resident's stay, if there was an addition of a psychotropic medication or diagnosis, a new PASRR would need to be completed. She stated she, the clinical department, and MDS department were responsible for ensuring the PASRR was completed and correct. She stated she believed Resident #62's first PASRR was correct but during the resident's stay, a new PASRR should have been done when the resident was put on a routine psychotropic medication. During an interview on 04/25/2025 at 10:27 AM, the Administrator stated that the residents come to the facility from the hospital with the PASRR, and the clinical team should ensure accuracy. He stated the clinical team would need to review the PASRR if there were any changes to determine what would need to be done next, but they should be following the PASRR guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 6 of 6