Health inspection·May 28, 2025

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 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. Page 1 of 2 055342 055342 05/28/2025 Thousand Oaks Post Acute, LLC 93 West Avenida DE Los Arboles Thousand Oaks, CA 91360

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. 055342 Page 2 of 2