F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident
1), had an accurate diagnosis recorded on their Minimum Data Set Assessment ([MDS] a tool for
implementing standardized assessment and for planning care).
Residents Affected - Few
This facility failure resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid
Services (CMS).
Findings:
During a concurrent interview and record review on 5/28/25 at 3:34 p.m. with the Minimum Data Set
Coordinator (MDSC), Resident 1's MDS 3.0 Section I - Active Diagnoses was reviewed. The section
indicated, an active diagnosis of benign prostatic hyperplasia ([BPH], condition in older men where the
prostate gland enlarges but is not cancerous). MDSC stated that MDS Section I - Active Diagnoses for BPH
should not have been marked yes and acknowledged that MDS Section I was incorrectly coded, as
Resident 1 did not have this diagnosis.
During a review of the facility 's MDS manual titled, CMS's RAI Version 3.0 Manual, dated 10/2024, the
MDS manual indicated, Active Diagnoses Intent: The items in this section are intended to code disease that
have a direct relationship to the resident's functional status . One of the important functions of the MDS
assessment is to generate an updated, accurate picture of the resident's current health status.
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 2
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
05/28/2025
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 0777
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to promptly notify the physician of the
x-ray results for one of two sampled residents (Resident 1).
Residents Affected - Few
This failure resulted in a delay in treatment for Resident 1's dislocated hip and increased the potential for
Resident 1 to experience unnecessary pain or worsening of her condition.
Findings:
During a review of Resident 1's admission Record (AR), dated 5/28/25, the AR indicated, Resident 1 was
admitted in the facility on 2/24/25 with diagnoses including but not limited to, midcervical fracture of right
femur (a break in the upper bone near the hip) and aftercare following joint replacement surgery.
During a review of Resident 1's Radiology Results Report (RRR), dated 5/19/2025 at 7:13 p.m., the RRR
indicated, postsurgical changes from a right hip hemiarthroplasty with superior dislocations (the femoral
component of the hip implant had moved upward out of place).
During a review of Resident 1's Change of Condition (COC), dated 5/20/25 at 7:41 p.m., the COC
indicated, Resident 1 was sent out to [hospital name] via regular transport per physician order. [physician's
name] called nurse with an order to send resident out.
During an interview on 5/28/25 at 4:07 p.m. with Nurse Supervisor (NS), NS stated they received the RRR
on 5/19/2025 around 7 p.m. NS stated that the findings were communicated to [physician's name] via text
message at 10:44 p.m., but the physician did not respond or contact the facility until the afternoon of
5/20/25.
During an interview on 6/16/25 at 5:08 p.m. with Director of Nursing (DON), DON stated that the staff
should have continued attempting to contact [physician's name] and if there was no response after three
call attempts, the staff should have escalated the radiology report by notifying the medical director to avoid
delays in care.
During a review of the facility's policy and procedure (P&P) titled, Notifying Clinicians Diagnostic Results,
dated 3/2023, the P&P indicated, Abnormal test results outside of the accepted range or the physician's
documented range for the resident are reported promptly to the ordering provider to address potential
concerns including but not limited to: diagnose or treat the resident's condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055342
If continuation sheet
Page 2 of 2
