Inspection·December 17, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete [related to] psychosis manifested by: behaviors of agitation, date initiated 8/21/25, the BCP intervention indicated, Offer warm beverage of preference, such as warm milk or hot tea. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 265), Choosing suitable nursing interventions requires applying your nursing knowledge and the best scientific evidence for a patient's health problems. During a concurrent interview and record review on 9/25/25 at 3:45 p.m. with LN1, Resident 1's BCPs titled Resident has the following dietary orders Resident is NPO. Currently on G-tube, and The resident is on Seroquel r/t psychosis manifested by: behaviors of agitation, dated 8/21/25 were reviewed. LN1 stated the interventions were not right and should have been changed. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 399), Most computer documentation systems allow these care plans to be modified by creating individualized interventions and outcomes for each patient. Event ID: Facility ID: 055342 If continuation sheet Page 2 of 14 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 12/17/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided care according to accepted professional nursing standards (actions that ensure safe nursing practice) when the facility failed to: Develop a baseline care plan (BCP- initial instructions for care right after admission developed by using the nursing process) for diabetes management. 2. Develop care plans (CP- a detailed outline of health needs, goals, and preferences that guides care to ensure consistent and appropriate care) with resident specific interventions. 3. Clarify conflicting orders for the way to (route) administer medication. 4. Follow physician order for monitoring blood pressure (BP). 5. To communicate with the physician to clarify PRN (as needed) Seroquel order when ordered for an excessive duration without an end date and with conflicting physician indications for its use. 6. To include an intervention for a psychiatric assessment and a review of the results of the psychiatric assessment. 7. Ensure Licensed Vocational Nurses (LVNs) worked within their scope of practice (legally permitted actions based on their education, training, and licensure). As a result of these failures, Resident 1 was transferred to an acute care hospital due to abnormally high blood sugar (593) for evaluation and treatment and ultimately died.Findings:1. During a review of the facility's policy and procedure (P&P - expected employee conduct and detailed patient care instructions) titled, Baseline Care Plan, dated 1/25, the P&P indicated, The facility develops and implements a baseline care plan for each resident. that meet professional standards of quality care. based on the resident's admission orders, information available from the transferring provider. includes the minimum healthcare information necessary to properly care for a resident.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's Baseline Care Plans (BCPs), were reviewed. A BCP for diabetes management was not found. LN1 stated there should have been a BCP developed for diabetes management and there wasn't.During a concurrent interview and record review on [DATE] at 2:15 p.m. with DON, Resident 1's BCPs, were reviewed. DON stated there should have been a care plan developed for diabetes management and there wasn't.2. During a review of Resident 1's CPs, titled:- BCP [baseline care plan] Resident has the following dietary orders Resident is NPO [nothing by mouth]. Currently on G-tube, initiated [DATE], the CP indicated, Interventions (actions to be taken) . Monitor meal intake.- The resident is on Seroquel (Antipsychotic Medications), initiated [DATE], the CP indicated, Offer warm beverages of preference, such as warm milk or hot tea.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's CPs were reviewed. The CPs indicated Resident 1 was to have nothing by mouth. The CPs also indicated interventions to monitor meal intake and offer warm beverages of preference. LN1 stated, I should have changed those, interventions.During a concurrent interview and record review on [DATE] at 2 p.m. with the DON, Resident 1's CPs were reviewed. The CPs indicated Resident 1 was to have nothing by mouth. The CPs also indicated interventions to monitor meal intake and offer warm beverages of preference. DON stated the interventions were not specific to Resident 1.3. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 648), It is essential to verify the accuracy of every medication you give to your patients with the patients' orders. If the medication order is incomplete, incorrect, or inappropriate or if there is a discrepancy between the original order and the information on the MAR, consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration.During a review of the facility's P&P titled, Administering Medications, dated 3/23, the P&P indicated, To provide employees with guidelines for the safe and timely administration of medications per physician order. Medications must be administered in accordance with the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 3 of 14 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 12/17/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few orders.During a review of Resident 1's AR, Initial admission date [DATE], the AR indicated, Diagnosis. Dysphagia [difficulty swallowing].During a review of Resident 1's OSR, dated [DATE] - [DATE], the OSR indicated:-NPO diet [nothing by mouth]During a review of Resident 1's OSR, dated [DATE] to [DATE], the OSR indicated, Order Date [DATE]. Start Date [DATE]. NPO [nothing by mouth], and Enteral [through the feeding tube directly into the stomach] Feeding Order. Every shift Flush feeding tube 30 ml [milliliter] water before and after medication administration.During a concurrent interview and record review on [DATE] at 12 p.m. with DON, Resident 1's OSR, dated [DATE] to [DATE] and MAR, dated 8/25 were reviewed. DON stated that based on the documentation all the medications were given by mouth. DON also stated it should have been clarified with the physician whether to give the medications by mouth or feeding tube. DON further stated the issues were because of the nurses' inexperience.During a review of Resident 1's BCP titled, Resident has the following dietary orders Resident is NPO. Currently on G-tube [nutrition by tube directly into the stomach], initiated [DATE], the BCP indicated Resident 1's goal was to adhere to diet as ordered.During a concurrent interview and record review on [DATE] at 1:15 p.m. with LN6, Resident 1's MAR, dated 8/25 was reviewed. LN6 stated Resident 1's medications were administered by mouth. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 640), The National Coordinating Council for Medication Error Reporting and Prevention (2021) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and /or failing to administer a medication.4. During a review of Resident 1's OSR, dated [DATE] to [DATE], the OSR indicated, Seroquel [antipsychotic]: Monitor orthostatic hypotension [a significant drop in blood pressure upon sitting from a lying position] blood pressure [BP] while lying and sitting every day shift for 10 days. Order Date. [DATE]. Start Date. [DATE].During a review of Resident 1's BCP titled, The resident is on Seroquel (antipsychotic medications) r/t psychosis manifested by: behaviors of agitation, initiated [DATE], the BCP indicated, Monitor orthostatic hypotension [a drop in blood pressure (B/P)] - B/P while lying and sitting . Call MD for changes noted.During a record review of Resident 1's MAR, dated 8/25, the MAR indicated:- [DATE]: lying 128/72, sitting 128/72,- [DATE]: lying 128/63, sitting 128/63,- [DATE]: lying 158/83, sitting 158/83, and- [DATE]: lying 147/69, sitting 147/69.During a concurrent interview and record review on [DATE] at 1:15 p.m. with LN6, Resident 1's OSR dated [DATE] to [DATE] and MAR dated 8/25 were reviewed. LN6 stated the lying and sitting BPs are identical. The lying BP was used for the sitting BP because it was too difficult to get Resident 1 into the sitting position. LN6 further stated LN6 did not notify the physician of the difficulty in trying to sit-up Resident 1 or of the BPs recorded as sitting when they were actually lying BPs.During a concurrent interview and record review on [DATE] at 2:15 p.m. with the DON, Resident 1's OSR dated [DATE] to [DATE] and MAR dated 8/2025 were reviewed. DON stated the nurses should have notified the physician instead of duplicating the BPs.5. During a review of the facility's policy and procedure (P&P) titled, Dignity and Respect Psychoactive Medications, dated 1/25, the P&P indicated, Based on a comprehensive assessment of a resident, the facility shall ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. PRN (as needed) orders for psychotropic drugs shall be limited to 14 days. The resident's medication management plan is documented in their medical record. (such as. vital signs.) is essential to evaluate the ongoing effectiveness, benefits as well as risks of. psychotropic medications.During a review of Resident 1's OSR, dated [DATE] - [DATE], the OSR indicated, Seroquel. Give 0.5 tablet by mouth every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 4 of 14 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 12/17/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 24 hours as needed for psychosis m/b [manifested by] agitation. Order Date. [DATE]. Start Date. [DATE]. End Date. [not indicated].During a review of Resident 1's New Prescription Summary (NPS), dated [DATE], the NPS indicated, Seroquel. Give 0.5 tablet by mouth every 24 hours as needed for psychosis m/b agitation.Refills: 99.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's OSR, dated [DATE] - [DATE] and NPS, dated [DATE] were reviewed. LN1 stated, Yes, the Seroquel PRN order was for three months. During a concurrent interview and record review on [DATE] at 2:15 p.m. with DON, Resident 1's OSR, dated [DATE] - [DATE] and NPS, dated [DATE] were reviewed. DON stated there should have been a stop date at 14 days. DON also stated all consultation notes, including the Psychiatric Intake Note (PIN), should have been reviewed and communicated to the ordering physician. DON further stated these issues are because of the nurses' inexperience.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's NPS, dated [DATE], OSR, dated [DATE] [DATE], and PIN, dated [DATE] were reviewed:- The NPS indicated, Seroquel [antipsychotic] Oral Tablet 25 MG [milligram]. Give 0.5 tablet by mouth every 24 hours as needed for psychosis m/b [manifested by] agitation. Refills: 99. Start Date: [DATE].- The OSR indicated, Seroquel Oral Tablet 25 MG. Give 0.5 tablet by mouth every 24 hours as needed for psychosis m/b agitation . Order Date [DATE]. Start Date [DATE]. End Date [none indicated].- The PIN indicated, History of Present Illness. According to sister [Resident 1's sister's name], Resident had no history of mental illness. Mental Status Examination. Thought Content: (Hallucinations) Denied. Delusions: Denied. Hx [history] of Aggression: No. Treatment Plan/Recommendation. Continue Seroquel 12.5 mg qhs [every bedtime] for psychosis w/o [without] agitation.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's PIN, dated [DATE] and OSR, dated [DATE] - [DATE] were reviewed. LN1 stated LN1 does not know who receives the PIN or who reviews it. LN1 further stated that the PIN indicated Resident 1 did not have agitation and the OSR was for agitation. LN1 added they are the opposite of each other.6. During a review of the facility's P&P titled, Baseline Care Plan, dated 1/2025, the P&P indicated, The facility develops a baseline care plan. intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events most likely to occur right after admission.During a review of Resident 1's BCP titled, The resident is on Seroquel (antipsychotic medications) r/t psychosis manifested by: behaviors of agitation, initiated [DATE], the BCP indicated there was no intervention for a psychiatric assessment or a review of the assessment results.During a review of Resident 1's PN titled, Social Service Progress Note, dated [DATE] at 11:58 a.m., the PN indicated, This patient was seen by psychiatrist [name], NP on Saturday [DATE].During a review of Resident 1's Psychiatric Intake Note (PIN- a detailed document of the first session with a new patient), dated [DATE], the PIN indicated, According to sister [name], Resident has no history of mental illness. Medications. Seroquel 12.5 mg [milligrams] qhs [every night at bedtime] . Hx [history] of Aggression: No. continue Seroquel 12.5 mg qhs for psychosis w/o [without] agitation.During a concurrent interview and record review on [DATE] at 2:15 p.m. with DON, Resident 1's PIN, dated [DATE] and OSR, dated [DATE] - [DATE] were reviewed. DON stated all consultant notes should be reviewed and communicated to the physician.7. Review of the California Association of Long Term Care Medicine (CALCM) website, https://www.caltcm.org/index.php?option=com_dailyplanetblog&view=entry&year=2024&month=10&day=14&id=268:why-is accessed on [DATE], indicated, The nursing process (Assessment, planning, implementing, and evaluating), otherwise known as problem-solving or critical thinking, and the care plan document, were identified as the unique domains of RNs. The RN is to perform the nursing process, which includes a clinical assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 5 of 14 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 12/17/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Similarly, the LVN has the authority to conduct basic patient assessments. The limitation is that, in California, the LVN is not allowed to conduct comprehensive health assessment. The responsibility of developing care plans is the responsibility of the RN and physicians.During a review of California Code of Regulations (CCR), Title 16 Professional and Vocational Regulations, Section 2518.5 Scope of Vocational Nursing Practice, the CCR indicated, The licensed vocational nurse performs services requiring technical and manual skills which include the following. Provides direct patient/client care by which the licensee. Contributes to the development and implementation of a teaching plan related to self-care for the patient/client.During a review of Resident 1's CPs titled:- At risk for hypo[low]/hyperglycemia [high blood sugar] . Diabetic Neuropathy [nerve damage], the CP indicated, it was initiated and created on [DATE] and revised on [DATE] by a Licensed Vocational Nurse (LN12), goals initiated and created on [DATE] and revised on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- Hypoglycemic Medications / Insulin, the CP indicated, it was initiated and created on [DATE] and revised on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- The resident has hemiplegia [paralysis on one side of the body]/Hemiparesis [weakness or paralysis on one side of the body], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] and revised on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- The resident has potential for complications, s/sx [signs and symptoms] r/t [related to] Dx [diagnosis] of Anemia [blood condition], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- The resident is at nutrition risk secondary to: Dysphagia [difficulty swallowing], pain, stroke, enteral feeding [tube feeding into the stomach], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- Alteration in musculoskeletal [muscles and bones], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12. The resident requires Enteral Feeding, the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- The resident has GERD [stomach contents flow back up the throat], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.During a current interview and record review on [DATE] at 2 p.m. with the DON, Resident 1's CPs were reviewed. The CPs indicated they were initiated and created by LVNs. DON stated there are Registered Nurses in the assigned areas who should be developing the care plans. Event ID: Facility ID: 055342 If continuation sheet Page 6 of 14 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 12/17/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided quality care when the facility failed to: Administer Glargine (insulin used for regulating blood sugar) for 3 days, on 8/21 at 9 p.m., 8/22 at 9 a.m. and 9 p.m., and 8/23 at 9 a.m. 2. Notify/Communicate to the charge nurse and physician the missed doses of Glargine. 3. Acquire insulin to meet Resident 1's needs. 4. Administer Glargine from a properly labeled medication container. 5. Clarify the order for finger stick blood sugar (FSBS- a method of monitoring blood sugar levels) with the physician. 6. Failed to monitor blood glucose (BG- blood sugar). 7. Realize the need for monitoring blood sugar. As a result of these failures, Resident 1 was transferred to an acute care hospital due to abnormally high blood sugar (593) for evaluation and treatment and ultimately died. FindingsDuring a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was 65-years-old admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (stroke, loss of blood flow to a part of the brain) and secondary diagnoses diabetes mellitus (a disorder characterized by difficulty in blood sugar control), hypertension (high blood pressure), hemiplegia (paralysis of one side of the body), chronic myelogenous leukemia (a type of cancer), anemia (inadequate number of red blood cells), drug induced polyneuropathy (a painful condition caused by medications), atrial fibrillation (irregular heart beat), dysphagia (difficulty swallowing), gastrostomy tube (G-tube- feeding tube directly into the stomach), and other psychotic disorder not due to a substance or known physiological condition (the state of the body and how its different parts and systems are working).According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 328), Standards of nursing care reflect the knowledge and skill ordinarily possessed and used by nurses to perform within the scope of practice.1. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 640), Administering medications requires unique nursing knowledge, clinical judgment, and skills. As a nurse you need to. administer medications correctly, and then closely monitor their effects.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 3/23, the P&P indicated, Medications must be administered in accordance with the orders.During a review of Resident 1's Order Summary Report (OSR- a breakdown of all the orders placed for a specific time period), dated [DATE] - [DATE], the OSR indicated, Insulin Glargine. every 12 hours for DM2 [type 2 diabetes] . Start Date. [DATE].During a concurrent interview and record review on [DATE] at 12 p.m. with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR), dated 8/25 and Progress Notes (PN), dated [DATE] - [DATE] were reviewed. The DON stated the insulin was not given on [DATE]-[DATE], the insulin was first given on [DATE]. DON stated, These were significant medication errors.During a review of Resident 1's MAR, dated 8/25, the MAR indicated, Glargine (insulin) was ordered to be administered every 12 hours for diabetes mellitus starting at 9 p.m. on [DATE]. Glargine was not administered as ordered on 8/21 at 9 p.m., 8/22 at 9 a.m. and 9 p.m., and 8/23 at 9 a.m. Each of the boxes had a number nine indicating other / see NN [progress note]. During a review of Resident 1's PNs titled, Medication Administration Note, dated:- [DATE] at 9:41 p.m., the PN indicated Glargine (insulin) was not given due to new admission. The PN did not indicate if the nurse contacted the physician or pharmacist.- [DATE] at 9 a.m. and 9 p.m., no PNs indicating why Insulin Glargine was not administered was found. - [DATE] at 9 a.m., no PN indicating why Insulin Glargine was not administered was found. - [DATE] at 8:58 p.m., the PN indicated the Glargine was not available. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated [DATE] at 5:57 p.m., the SBAR indicated, Situation - abnormal lab results. Glucose level 593, sent to ER per MD; Assessment - Received Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 7 of 14 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 12/17/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few abnormal lab results and noted with elevated glucose level 593. MD notified and received orders to send out via regular ambulance.During a review of Resident 1's Health Status Note, dated [DATE] at 4:22 p.m., the PN indicated, Will send patient to hospital. Needs admission for fluids and diabetes control. 2. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 3/23, the P&P indicated, To provide employees with guidelines for the safe and timely administration of medications. Medications must be administered in accordance with the orders.During a concurrent interview and record review on [DATE] at 12 p.m. with the DON, Resident 1's MAR, dated 8/25 and PNs, dated [DATE] - [DATE] were reviewed. The DON stated the missed insulin doses were not reported to Resident 1's physician.During an interview on [DATE] at 1:15 p.m. with a licensed nurse (LN6), LN6 stated did not realize the physician needed to be notified when the insulin was not delivered and when Resident 1 missed doses of their medication.3. During a review of the facility's P&P titled, Medication Ordering and Receiving From Pharmacy, dated 6/16, the P&P indicated, To access medication from the emergency kit [E-Kit] secondary to a new order or when medication for which there is a current prescription is not readily available. the nurse confers with the prescriber or the pharmacy.During a review of Resident 1's PN titled, admission Summary, dated [DATE] at 9:08 p.m., the PN indicated, New patient arrived at the facility around 1915 [7:15 p.m.] . All medications have been faxed to the pharmacy.During a review of Resident 1's MAR, dated 8/25, the MAR indicated, Glargine (insulin) was not administered as ordered on 8/21 at 9 p.m.During a review of Resident 1's PN titled, Medication Administration Note, dated [DATE] at 9:41 p.m., the PN indicated Glargine (insulin) was not given due to new admission. The PN did not indicate if the nurse contacted the physician or pharmacist.During a concurrent interview and record review on [DATE] at 12 p.m. with the DON, the DON stated the E- Kit (emergency medicine supply) kept at the facility was not used. DON further stated the LNs did not know what to do and did not ask for help.During a review of the pharmacy's Packing Slip (PS- a document included in the shipment that lists the items inside the package), dated [DATE] at 12:42 a.m., the PS indicated Resident 1's Glargine (common brand name Lantus) medication was delivered to the facility [DATE] at 4 a.m.During a review of the facility's Pharmacy Services Agreement (PSA), signed by the facility Administrator (ADM) [DATE], dated effective [DATE], the PSA indicated, All new drug orders shall be available on the same day ordered unless the drug would not be started until the next day.4. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 643), An important step in safe medication administration is being sure that you give the right medication to the right patient.During a concurrent interview and record review on [DATE] at 1:15 p.m. with LN6, Resident 1's MAR dated 8/25 was reviewed. The MAR indicated LN6 administered Glargine on [DATE], for the 9 a.m. and 9 p.m. administration times and on [DATE], for the 9 a.m. administration time. LN6 stated Resident 1's Glargine was not located; another resident's Glargine was found and used for Resident 1. LN6 further stated was aware medications cannot be shared between residents.During a review of the facility's P&P titled, Medication Ordering and Receiving From Pharmacy, dated 6/16, the P&P indicated, Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency box, from the provider pharmacy or a back-up pharmacy that is determined by the provider pharmacy.During an interview on [DATE] at 12 p.m. with the DON, DON stated you can't borrow medications.5. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 271), A consultation is vital if you need to seek procedural assistance or clinical expertise for a specific problem to ensure a patient receives needed clinical interventions or insights.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's OSR, dated [DATE] - [DATE] was reviewed. The OSR indicated, on [DATE], FSBS [finger stick blood sugar] Q [every] AC [before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 8 of 14 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 12/17/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete meals] &HS [bedtime]. Call MD if < 70 or > 400, was ordered as part of the batch orders (a group of multiple orders compiled together). LN1 stated it is the facility process for the nurse to add the batch orders. If the nurse fails to add the batch orders, it gets audited and returned to the nurse to correct. The resident's physician is usually not communicated with about the batch orders and LN1 does not know how the physician finds out about them. LN1 further stated the FSBS order was not the correct order for monitoring Resident 1's blood sugar and LN1 did not clarify the order with the physician.During a concurrent interview and record review on [DATE] at 12 p.m. with the DON, Resident 1's MAR, dated 8/25, was reviewed. DON stated the FSBS was ordered incorrectly. The FSBS should have been clarified with the physician and ordered every six hours. DON further stated the new nurses were not experienced to know the FSBS was needed.During a concurrent interview and record review on [DATE] at 1:15 p.m. with LN6, Resident 1's MAR, dated 8/25 was reviewed. LN6 stated inexperience was reason for not clarifying the missing blood sugar monitoring with the physician.6. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 1220), Blood Glucose Monitoring. Review health care provider's order for time or frequency of measurement. Rationale. Health care provider determines test schedule on basis of patient's physiological status and risk for glucose imbalance.During a review of the facility's P&P titled, Diabetes Clinical Protocol, dated 2/24, the P&P indicated, The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate parameters into the Medication Administration Record.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's MAR, dated 8/25, was reviewed. The MAR indicated that the order for FSBS monitoring did not appear on it. LN1 stated no blood sugar monitoring was done.During a concurrent interview and record review on [DATE] at 12 p.m. with the DON, Resident 1's electronic medical record (eMR- digital version of patient's paper chart) was reviewed. DON stated there was no BG monitoring while Resident 1 was at the facility.During a review of Resident 1's Health Status Note (HSN), dated [DATE] at 4:22 p.m., authored by Resident 1's physician, the HSN indicated, Will send patient to hospital. Needs admission for. diabetes control.7. Review of the National Institute of Health website, https://pubmed.ncbi.nlm.nih.gov/30969870/, accessed on [DATE], indicated, All nurses should be familiar with the importance of blood glucose monitoring. Appropriate and timely monitoring of blood glucose will allow for successful management of blood glucose that is out of target range. This will ensure ongoing patient safety.During a review of the facility's policy and procedure (P&P) titled, Diabetes Clinical Protocol, dated 2/2024, the P&P indicated, The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will. note parameters as ordered to the resident's care plan.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's Medicare Skilled Charting (MSC- details of the patient's condition, their response to treatments, and any changes), dated [DATE] at 8:25 p.m. was reviewed. The MSC indicated the skilled nursing services being provided did not include diabetic care and the most recent BG result was not included in the section for vital signs. LN1 stated the BG should have been done and wasn't. Event ID: Facility ID: 055342 If continuation sheet Page 9 of 14 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 12/17/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1):1. Had appropriate alternatives to bed rails identified and tried.2. Was adequately assessed for bed rail use. 3. Had their bed and mattress assessed for bed rails (metal bars attached to the bed) prior to the bed rail installation. 4. Had the appropriately trained staff install the bedrails.These failures had the potential to result in an increased risk of entrapment (caught, trapped, entangled, or strangled in the space in or about the bed rail).Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (type of stroke- brain cells die) and secondary diagnoses including flaccid (floppy and weak) hemiplegia (paralysis of one side of the body), muscle weakness, drug-induced polyneuropathy (nerve damage that occurs as a side effect of certain medications), dysphagia (swallowing difficulties) with gastrostomy (surgical opening in the abdomen to insert a feeding tube directly into the stomach for nutrition). During a review of the facility's policy and procedure (P&P) titled, Siderail-Bedrail Safety Evaluation, dated 3/23, the P&P indicated, The facility attempts to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. 1. During a review of Resident 1's progress note (PN) titled, admission Summary, dated 8/21/25 at 9:08 p.m., the PN indicated, New patient arrived to the facility around 1915 [7:15 p.m.]. During a review of Resident 1's Bed/Side Rail Entrapment Risk Assessment (BSRERA), dated 8/21/25 at 7:52 p.m., the BSRERA indicated, Alternative Interventions. Low Bed. Upper body mechanics. During a review of Resident 1's Devices / Physical Restraint Assessment/ Re-evaluation (DPRAR), dated 8/28/25 for effective date 8/21/25 at 8:15 p.m., the DPRAR indicated, Less restrictive measures / alternatives attempted. No. During a concurrent interview and record review on 9/25/25 at 3:45 p.m. with a licensed nurse (LN1), Resident 1's BSRERA, dated 8/21/25 at 7:52 p.m. and DPRAR, dated 8/28/25 for effective date 8/21/25 at 8:15 p.m. were reviewed. LN1 stated No alternatives were attempted. LN1 also stated Resident 1's family requested the bed rails and LN1 complied to keep the family from complaining. During a review of the facility's P&P titled, Respect and Dignity - Physical Restraints, dated 3/23, the P&P indicated, The facility does not implement the use of a restraint at the resident or resident representative request in the absence of an evaluation and identification of a medical symptom that must be treated and includes the practitioner in the review and discussion. 2. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 433), Side rails also can lead to patients becoming caught, trapped, entangled, or strangled, especially in those who are frail, elderly, or confused (FDA, 2017). Therefore, an assessment of a patient's mobility and responsiveness to instructions helps determine whether using a side rail is safe. During a review of Resident 1's PN titled, Health Status Note, dated 8/25/25 at 4:22 p.m., the PN indicated, A&OX0 [alert but not oriented to person, place, time, or situation]. Non-verbal. Unable to follow commands. During a review of Resident 1's PN titled, IDT [interdisciplinary team] Progress Note, date 8/22/25 at 4:08 p.m., the PN indicated, AOx0, cannot follow simple commands, does not follow with eyes, left facial droop, resident grips hard onto staff. Review of the U.S. Food and Drug Administration (FDA) website, https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-consumers-and-caregivers-about-adu accessed on 11/7/25, indicated, Some people are at high-risk for entrapment, falls, or other injury from adult portable bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 10 of 14 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 12/17/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete rails. High-risk people include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, or a combination of these factors. Additionally, people who are cognitively impaired. from a medical condition, such as. stroke. are at a higher risk of entrapment and injury. Consider other alternatives when bed rails are not appropriate. Alternatives include roll guards, foam bumpers. using concave mattresses that can help reduce rolling off the bed. During a review of Resident 1's Bed / Side Rail IDT (BSRIDT), dated 8/21/25 at 7:52 p.m., the BSRIDT indicated, Why is a bed/ side rail being considered? . Patient / Resident request. During a review of Resident 1's Section GG - Functional Abilities - admission (SGGFAA), dated 8/25/25, the SGGFAA indicated, Resident 1 was dependent (resident does none of the effort to complete the activity) on staff to be able to roll left and right in bed, to move from sitting on the side of the bed to lying, to move from lying in bed to sitting, to move from sitting to standing, and to transfer to and from the bed to a chair. During a review of Resident 1's BSRERA, dated 8/21/25 at 7:52 p.m., the BSRERA indicated, Is the resident dependent for bed mobility [no response] . Does the resident display poor bed mobility or difficulty in moving? [no response] . Does the resident have difficulty with balance or poor trunk control (e.g. leans forward, leans sideways, slides down)? [no response] . Reason for device use [no response] . RECOMMENDATIONS. Use of bed/side rail [no response]. 3. During an interview on 10/14/25 at 2 p.m., with the Director of Nursing (DON), DON stated the nurse is not supposed to assess the bed, mattress or bed rail. It's maintenance that should. During a concurrent interview and record review on 10/14/25 at 4:50 p.m. with the Maintenance Director (MD), MD stated no request for bed rail installation was made between 8/21/25 and 8/25/25. During an interview on 9/25/25 at 3:45 p.m. with LN1, LN1 stated Resident 1's bed was not measured or assessed. 4. During an interview on 9/25/25 at 3:45 p.m. with LN1, LN1 stated the Maintenance Department (MD) usually installs the bed rails and MD goes home around 6 p.m. LN1 also stated the side rails were not installed by MD because they had gone home. LN1 additionally stated LN1 installed the bed rails, was not trained to install the bed rails, and LN1 should not have installed them. Event ID: Facility ID: 055342 If continuation sheet Page 11 of 14 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 12/17/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have competent nurses who possessed the knowledge, skills, and judgment required to provide safe care for one of two sampled residents (Resident 1), when the facility failed to ensure: Licensed nurses knew to contact the physician when they did not administer Glargine (insulin- medicine used to regulate blood glucose levels) as ordered. 2. Licensed nurses knew to communicate to the charge nurse the missed doses of Glargine. 3. Licensed nurses knew to contact the physician when the medication administration record did not include blood glucose monitoring. 4. Licensed nurses knew to clarify conflicting orders for how to (route) administer medication. For Resident 1, these facility failures resulted in unsafe nursing care and admission to the hospital for an avoidable decline.1. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 640), Administering medications requires unique nursing knowledge, clinical judgement, and skills. Medication errors include. failing to administer a medication . When an error occurs, the patient's safety and well being are the top priorities. notify the health care provider of the incident as soon as possible. During a review of Resident 1's Medication Administration Record (MAR), dated 8/2025, the MAR indicated, Insulin Glargine. every 12 hours for DM2 [diabetes mellitus type 2] . start date 08/21/2025 2100 [at 9 p.m.]. The MAR also indicated 8/21/25 at 9 p.m., 8/22/25 at 9 a.m. and 9 p.m., and 8/23/25 at 9 a.m. and 9 p.m. to See Nurses Notes. During a review of Resident 1's progress notes (PN) titled, Administration Note, dated:- 8/21/25 at 9:41 p.m., the PN indicated, Insulin Glargine. New admission.- 8/22/25 no PNs were found for 9 a.m. or 9 p.m. missed doses.- 8/23/25 no PN was found for 9 a.m. missed dose.- 8/23/25 at 8:58 p.m., the PN indicated, Insulin Glargine. not available. During a concurrent interview and record review on 10/14/25 at 12 p.m. with the Director of Nursing (DON), Resident 1's MAR, dated 8/2025 and PNs, dated 8/21/25 - 8/25/25 were reviewed. DON stated the insulin was not given 8/21/25-8/23/25. DON next stated Resident 1's physician was not notified about the missed insulin doses. DON further stated the LNs did not know what to do. During an interview on 10/14/25 at 1:15 p.m. with a licensed nurse (LN6), LN6 stated LN6 did not realize they should have called the physician when Resident 1 missed doses of the insulin when it was not delivered from the pharmacy. 2. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 271), A consultation is vital if you need to seek procedural assistance or clinical expertise for a specific problem to ensure a patient receives needed clinical interventions or insights. During a concurrent interview and record review on 10/14/25 at 12 p.m. with DON, Resident 1's MAR' was reviewed. The MAR indicated Glargine insulin was ordered to start on 8/21/25 at 9 p.m. DON stated the insulin was not given to Resident 1 until 8/24/25. DON also stated the new nurses did not know what to do and did not ask for help from the charge nurse. 3. Review of the National Institute of Health website, https://pubmed.ncbi.nlm.nih.gov/30969870/, accessed on 11/6/25, indicated, All nurses should be familiar with the importance of blood glucose monitoring. Appropriate and timely monitoring of blood glucose will allow for successful management of blood glucose that is out of target range. This will ensure ongoing patient safety. During a concurrent interview and record review on 10/14/25 at 12 p.m. with DON, Resident 1's MAR, dated 8/2025, was reviewed. The MAR indicated the order for FSBS monitoring did not appear on it. DON stated no blood sugar monitoring was done. During a concurrent interview and record review on 10/14/25 at 12 p.m. with the DON, Resident 1's Order Details (OD), dated 8/21/25 at 7:08 p.m., and MAR, dated 8/2025, were reviewed. The OD indicated, FSBS [finger stick blood sugar] Q [every] AC [before meals] & HS [at bedtime]. Call MD [physician] if < [less than] 70 or > [greater than] 400. The MAR indicated the FSBS order did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055342 If continuation sheet Page 12 of 14 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 12/17/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete appear on the document. DON stated the FSBS was ordered incorrectly. DON also stated for Resident 1, the FSBS should have been clarified with the physician and ordered every six hours. DON next stated the OD computer entry for the FSBS did not indicate the scheduling details which would have made the order appear on the MAR. DON further stated the new nurses were not experienced to know the FSBS was needed. During a concurrent interview and record review on 10/14/25 at 1:15 p.m. with LN6, Resident 1's OD, dated 8/21/25 at 7:08 p.m., and MAR, dated 8/2025 were reviewed. LN6 stated inexperience was her reason for not clarifying the missing FSBS order with the physician. During the review of the Administrator's explanation letter (EL) titled, Training Competencies, undated, the EL indicated the LN's training competencies dated prior to 8/21/25 were unable to be located. During a review of Resident 1's PN titled, Health Status Note, a late entry dated 9/2/25 at 1:24 p.m. for 8/25/25 at 4:22 p.m., authored by Resident 1's physician, the PN indicated, Will send patient to hospital. Needs admission for fluids and diabetes control. 4. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 648), It is essential to verify the accuracy of every medication you give to your patients with the patients' orders. If the medication order is incomplete, incorrect, or inappropriate. consult with the health care provider. During a review of Resident 1's Order Summary Report (OSR), dated 8/21/25 to 8/25/25, the OSR indicated, Order Date 8/21/25. Start Date 8/21/25. NPO [nothing by mouth], and Enteral [through the feeding tube directly into the stomach] Feeding Order. Every shift Flush feeding. before and after medication administration. During a review of Resident 1's MAR, dated 8/2025, the MAR indicated:- Enteral Feed Order every shift Flush feeding tube with 30 ml [milliliter] water before and after medication administration. The MAR also indicated the nurses acknowledged this order on 8/21 through 8/25.- Asciminib [cancer treatment] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22, 8/24, and 8/25.- Aspirin [lowers the risk of heart attack or stroke] . give.by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22 through 8/25.Esomeprazole [stomach acid reducer] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22, 8/24, and 8/25.- Gabapentin [nerve pain treatment] . give. by mouth. The MAR also indicated it was administered at 9 p.m. on 8/22 through 8/24.- Lipitor [treats high cholesterol] . give. by mouth. The MAR also indicated it was administered at 9 p.m. on 8/22 through 8/24.- Losartan [treats high blood pressure] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22 through 8/25.Plavix [blood clot prevention] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22, 8/24, and 8/25.- Pyridoxine [vitamin] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22, 8/24, and 8/25.- Acyclovir [treats infection] . give. by mouth. The MAR also indicated it was administered at 9 a.m. and 5 p.m. on 8/22, 8/24, and 8/25 as well as 5 p.m. on 8/23.- Carvedilol [blood pressure treatment] . give. by mouth. The MAR also indicated it was administered at 9 a.m. and 5 p.m. on 8/22 through 8/25.- Ursodiol [gallstone treatment] . give. by mouth. The MAR also indicated it was administered at 9 a.m. and 5 p.m. on 8/22, 8/24,8/25 and at 5 p.m. on 8/23. During a concurrent interview and record review on 10/14/25 at 1:15 p.m. with LN6, Resident 1's MAR, dated 8/2025 was reviewed. LN6 stated LN6 administered Resident 1's medications by mouth. During a concurrent interview and record review on 10/14/25 at 12 p.m. with DON, Resident 1's OSR, dated 8/21/25 to 8/25/25 and MAR, dated 8/2025 were reviewed. DON stated that based on the documentation, all the medications were given by mouth. DON also stated it should have been clarified with the physician. During an interview on 10/14/25 at 2:15 p.m. with DON, DON stated that the issues were because of the nurses' inexperience. Event ID: Facility ID: 055342 If continuation sheet Page 13 of 14 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 12/17/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had complete and accurate documentation in their health record.This failure resulted in the planning and delivery of care based on inaccurate resident assessments.According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 389), Information in a patient's record provides a detailed account of the level of quality of care delivered. The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important nursing responsibility. During an interview on 9/25/25 at 3:45 p.m. with a licensed nurse (LN1), LN1 stated LN1 texted the physician to clarify Resident 1's route of medication administration. LN1 stated there is no record of this text in Resident 1's medical record. During a concurrent interview and record review on 9/25/25 at 3:45 p.m. with LN1, Resident 1's:- Medicare Skilled Charting (MSC- details of the patient's condition, their response to treatments, and any changes), dated 8/21/25 at 8:25 p.m., was reviewed. The MSC indicated, Skilled Nursing Services. [none indicated]. LN1 stated it should have indicated diabetic care and enteral feeding care (nutrition through a tube into the stomach).- Bed / Side Rail Entrapment Risk Assessment (BSRRA), dated 8/21/25 was reviewed. The BSRRA indicated, alternatives attempted prior to bed/ side rales were a low bed and upper body mechanics. LN1 stated LN1 marked them as having been attempted when no alternatives were attempted. During a concurrent interview and record review on 10/14/25 at 1:15 p.m. with LN6, Resident 1's Medication Administration Record (MAR), dated 8/25 was reviewed. The MAR indicated, on 8/22 to 8/25/25 for the day administration time, Resident 1 had the same lying and sitting blood pressure recorded. LN6 stated the blood pressures were not accurate because the same blood pressure was used for lying and sitting. During a concurrent interview and record review on 10/14/25 at 2:15 p.m. with the Director of Nursing (DON), Resident 1's MSC, dated 8/21/25 at 8:25 p.m., BSRRA, dated 8/21/25, and MAR, dated 8/25 were reviewed. DON stated, Inaccurate charting documented. During a review of the facility's policy and procedure (P&P) titled, Documentation Policy, dated 3/23, the P&P indicated, It is the policy of this facility to document relevant findings in the clinical record. Event ID: Facility ID: 055342 If continuation sheet Page 14 of 14