Health inspection·July 30, 2021

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 a discharge Minimum Data Set (MD- assessment data of resident ) was timely done for one resident (Resident 1) Residents Affected - Few This facility failure had the potential to result in wrong entry to the federal data base . Findings: Review of Resident 1's overall assessment history indicated a discharge occurence . During an interview and concurrent record review with licensed nurse (LN 6) on 07/30/21, at 02:54 PM, LN 6 stated Resident 1 was discharged home on 3/25/21 and it was a planned discharge. LN 6 further stated a planned discharged assessment should be opened on the last covered day of skilled services ( physical , occupational, and nursing). Further review of the clinical record of Resident 1, no discharge assessment dated [DATE] was noted on record review. LN 6 acknowledged she missed opening and closing the discharge MDS on time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 2 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review the facility failed to ensure a resident's careplan ( planned measures, interventions to direct care) was updated after a fall occurence for one out of 18 sampled residents (Resident 54). This failure has the potential for interventions and measures in place that won't be effective to prevent a fall recurrence . Findings: Review of the clinical record for Resident 54 indicated the resident had a fall incident on 6/7/21. The careplan in place for fall showed no review of interventions to address the fall on 6/7/21. During an interview on 7/27/2021 at 4 PM , licensed nurse (LN7) indicated she was on duty when the resident fell on 6/7/21. LN7 acknowledged Resident 54's care plan was not updated after the fall. The facility policy and procedure titled Fall Incidents Management and Prevention dated 4/22/15 indicates a care plan will be initiated or updated with interventions to prevent further falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 3 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 care services provided to residents met professional standards when: Residents Affected - Some 1. Pain medications given for three residents (Resident 34, 51, and 414) were not documented as administered on the facility's Medication Administration Record ( MAR). 2. The pre (before) and post (after) pain assessments for two residents (Resident 34 and 51) were not documented on the Pain Assessment Flow Sheet (PAFS) after pain medication administration. These failures had the potential to unknowingly administer additional doses of pain medications to residents resulting to double dosing which is a medication error. Findings: Review of [NAME] and [NAME], 6th Edition, Mosby's Fundamentals of Nursing, page 847 in the section titled, Medication Administration indicated, After administering a medication, the nurse records it immediately on the appropriate record form. The nurse never charts a medication before administering it. Recording immediately after administration prevents errors. Review of Fuller,J & Schaller-Ayers Health Assessment - Nursing Approach 3rd edition, Philadelphia:[NAME] (2000) stated, Health Assessment is an essential nursing function which provides foundation for quality nursing care and intervention. It helps to identify the strengths of the clients in promoting health. Health assessment also helps to identify client's needs, clinical problems or nursing diagnoses to evaluate responses to health problems and intervention. An accurate and thorough health assessment reflects the knowledge and skills of a professional nurse. During a review of the Controlled Drug Record (CDR- count form of controlled medication) for Resident 51's indicated on 7/24/21 at 5 PM, Norco 10-325 mg. 1 tablet was administered to the resident for pain. Review of the MAR for 7/24/21 indicated no documentation Norco was administered. The PAFS dated 7/24/21 indicated no pre or post pain assessment was performed for Resident 51. Review of the CDR for Resident 34 indicated on 7/2/21 at 6 PM, Tylenol with Codeine #3 300-30 mg. tablet was administered to the resident. The MAR for 7/2/21 did not have any documentation or notation Tylenol with Codeine #3 was administered. The PAFS of 7/2/21 for Resident 34 had no documentation of pre or post pain assessment. During an interview and concurrent record review with the infection preventionist (IP) on 07/28/21, at 12:05 PM, the IP confirmed the MAR and PAFS for Residents 51 and 34 did not indicate pain medication administration and pain assessment when Norco and Tylenol with Codeine # 3 were counted out from the CDR. The IP further confirmed documentation should have been done. Review of the CDR for Resident 414 indicated on 7/28/21 art 8:50 AM , Oxycodone 10 mg. one tablet was administered to the resident for pain. The MAR for 7/28/21 indicated no documentation and not initialed to signify Oxycodone 10 mg. was administered to Resident 414. During an interview and concurrent record review on 07/28/21, at 12:58 PM, LN 5 indicated administering the Oxycodone 10 mg. one tablet to Resident 414 but forgot to document the administration in the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 4 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy and procedure titled, Medication Administration General Guidelines, dated 2019, indicated in part . The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given . complaints or symptoms for which the medication was given . results achieved from giving the dose and the time results were noted. Review of the facility policy and procedure titled, Pain Management, undated, indicated in part . Pain assessment on each resident shall be done every shift and as needed if a resident complains of pain using the following scale and this will be documented on the Medication Administration Record (MAR). Event ID: Facility ID: 055597 If continuation sheet Page 5 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure consumption of therapeutic (to cure or restore to health) nutritional supplements was accurately documented and monitored in two of 18 sampled residents (Resident 6 and Resident 18). Residents Affected - Few This failure had the potential to ineffectively evaluate and delay timely revision of interventions needed to meet residents' nutrition needs. Findings: 1. During a review of Resident 6's admission Record, with printed date of 7/27/21, indicated an admission date of 1/18/19, with medical diagnoses, including, Unspecified Sequelae of Other Cerebrovascular Disease (a range of conditions that affect the blood flow through the brain), Difficulty in Walking, Abnormal Posture, Essential Hypertension (high blood pressure), Allergic Rhinitis (an allergic reaction that causes sneezing, itchy and stuffy nose, and sore throat), Dry Eye Syndrome (a condition where the eyes don't make enough tears), History of Falling, and Personal History of COVID-19 (a severe, respiratory infection caused by the Corona Virus 2). During a review of Resident 6's Mini Nutritional Assessment (MNA - questionnaire with a response-based scoring system/points of nutrition status, categorized as: 0-7 = Malnutrition, 8-11 = At risk for Malnutrition, and 12-14 = Normal nutritional status, dated 12/23/20, the MNA indicated Resident 6 had a moderate decrease in food intake, a weight loss greater than three kg (kilogram or 6.6 lbs. (pounds) in the last three months and a total score of nine (- At Risk for Malnutrition ) while the MNA dated 1/22/21 documented a total score of eight indicating the resident remained at risk for malnutrition. During a review of Resident 6's Weight Change Note (WCN) dated 11/12/20, the WCN indicated, the resident was on a Regular -NAS (No Added Salt) Diet. The WCN further indicated Resident 6 was started on a three-day trial of downgrading diet to Mechanical Soft (a diet for chewing or swallowing issuesincludes chopped, ground, or pureed foods) to see if oral (PO) intake improves resident was displaying some difficulty chewing meats with recommendation of Ensure ( liquid nutritional drink for adults) three times a day (TID) with meals and daily (QD) at 2 PM. During a review of Resident 6's Order Audit Report- (OAR) dated 11/12/20, indicated a physician telephone order for Ensure 237 cc (cubic centimeter) QD at 2 PM and TID with meals per resident's request. The OAR orders for Ensure were confirmed by the Director of Nursing (DON). During a lunch observation and concurrent interview with a Certified Nursing Assistant (CNA 1), on 7/27/21 at 12:05 PM at the facility's North Side Hall, Resident 6's lunch tray card (LTC) was requested. The LTC presented by CNA 1 indicated for Diet: NAS, Consistency: Mechanical Soft, Beverage: 8 oz. (ounce) Water, Sherbet, and Ensure. Observed on Resident 6's lunch tray was one carton (237 ml) of Ensure. When CNA 1 was asked about the resident's Ensure consumption during mealtimes a facility logbook, titled,Resident Meal Intake Log (RMIL) was presented. CNA 1 stated, We write down the resident's daily meal intake in this book, referring to the RMIL. During another interview and concurrent record review with CNA 1, on 7/27/21 at 12:30 PM, Resident 6's RMIL dated 6/27/21 to 7/24/21 was reviewed. The RMIL indicated the following instruction: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 6 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0692 a. For the resident meal intake calculation (expressed in % (percentage). Level of Harm - Minimal harm or potential for actual harm b. Record supplements on Medication Administration Record (MAR) c. Or other designated form per facility's practice Alternate: T=Taken, R=Refused. Residents Affected - Few CNA 1 stated, We record the amount (of Ensure consumed) below the percentage of meal intake underAlt -for alternate foods offered to residents eating less than 75 percent. CNA 1 indicated Alt stands for the Ensure order. CNA stated, That is what it meant. The RMIL dated 6/27/21 to 7/24/21 indicated no entries pertaining to Resident 6's Ensure consumption on the following dates for Breakfast (B) and Lunch (L) 6/27, 6/29, 6/30/21, 7/1, 7/2, 7/4, 7/5, 7/7, 7/10, 7/11, 7/12, 7/13, 7/14, 7/17, 7/19, 7/21, 7/22, and 7/23/21. For Dinner (D) the following dates were with no entries for Ensure consumption by the resident, 7/2, 7/3, 7/6, 7/8, 7/9, 7/10, 7/12, 7/13, 7/15, 7/16, 7/17, 7/18, 7/19, 7/21, 7/22, and 7/24/21. CNA 1 verified the missing entries and stated, I'm not sure why the rest are blanks. During a concurrent interview and record review with a Licensed Nurse (LN 1) on 7/27/21 at 12:40 PM, Resident 6's MAR dated 6/2021 and 7/2021 were reviewed. The MAR indicated from 6/27/21 through 7/24/21, Resident 6 received and consumed 237 cc (or ml) of the Ensure drink daily during mealtimes (7:15 AM, 12:15 PM and 5:15 PM) and 2 PM. LN 1 indicated the documentation on the MAR was retrieved from the RMIL. LN 1 stated, We usually get verbal confirmation of the amount from the CNA's, and we rely heavily on the logbook (referring to the RMIL) for information. LN 1 was not able to provide an explanation on the no entries in the RMIL for Resident 6's Ensure consumption for Breakfast (B) and Lunch (L) on 6/27, 6/29, 6/30/21, 7/1, 7/2, 7/4, 7/5, 7/7, 7/10, 7/11, 7/12, 7/13, 7/14, 7/17, 7/19, 7/21, 7/22, and 7/23/21 and Dinner (D) on 7/2, 7/3, 7/6, 7/8, 7/9, 7/10, 7/12, 7/13, 7/15, 7/16, 7/17, 7/18, 7/19, 7/21, 7/22, and 7/24/21 During an interview and concurrent record review on 7/29/21 at 3:50 PM with DON, Resident 6's MAR Ensure documentation from 6/27/21 to 7/24/21 was reviewed and cross check with the blank entries in the RMIL from 6/27/21 to 7/24/21 . The DON confirmed the discrepancies. 2. During a review of Resident 18's admission Record, date printed 7/29/21, indicated and admission date of 7/3/2010, with the medical diagnoses, including, Type 2 Diabetes Mellitus (inability of the body to absorb insulin-resulting to high blood sugar levels), Gastroesophageal Reflux Disease (GERD - stomach acid reflux- flows back), Irritable Bowel Syndrome ( IBS disorder of large intestine, with belly pain, gas, diarrhea and constipation), Colostomy Status (an operation that creates an opening for the large intestine through the abdomen), and Partial Intestinal Obstruction (a blockage that keeps food or fluid from passing through the small or large intestine). During an observation, and concurrent interview with Resident 18 on 7/27/21 at 12:05 PM, resident was eating lunch by self lunch inside the room. Resident 18 stated, I can manage. The LTC on the resident's lunch tray indicated a diet of Puree (blended) NAS ,LCS (Low Concentrated Sweets) . During a review of Resident 18's Nutrition/Dietary Note-(NDN), dated 3/27/20, indicated, the resident is receiving Glucerna (a nutritional shake for Type 2 Diabetes) BID (twice a day). The MAR dated 7/2021 indicated an order of Glucerna 1 can PO BID for High Cal/Pro (Calorie/Protein) Nourishment at 9 AM and 5 PM. The MAR did not indicate the amount of Glucena consumption of Resident 18. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 7 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/29/21 at 3:50 PM the DON verbally acknowledged the missing documentation and indicated the importance of documentation to evaluate effectiveness when an alternative nutrition approach may be warranted. During a review of Resident 18's Health Status Note -HSN, dated 10/10/20, the note indicated, in part 8-lbs. weight loss in one month from, 149 to 141 lbs., Attending Physician notified, no new orders at this time, responsible party (RP) was notified, aware, while the HSN dated 11/10/20, indicated Resident 18 had a 9 lbs. weight loss in a month, RP informed of weight loss, resident at times does not want to be assisted by staff when eating, pushing staff away at mealtime and resident making statement of ' I'm not hungry. During a review of Resident 18's NDN dated 5/18/21, indicated an order for House Supp (HS- healthshake a-liquid nutrition supplement with calories and protein) BID with lunch and dinner. Resident refusing the HS, eating yogurt and agrees to try yogurt for dinner too with recommendation to discontinue HS and will add extra foods to trays as requested by resident. The NDN further indicated no documentation by CNA's regarding the resident's consumption of the HS. During a review of the facility's undated, Policy and Procedure (P&P), titled, Policy and Procedure Nutrition Care, the P&P indicated in part, C.Residents at nutritional risk are identified and monitored closely to prevent or minimize deterioration ., .5. Nutrition interventions (actions taken to improve a situation) to prevent deterioration (the process of becoming worse) are selected based on resident's individual needs. The P&P further indicated, E.Supplements are used to promote adequacy (the state of being sufficient for the purpose concerned) of the diet as a nutrition intervention for at risk or nutritionally impaired residents to prevent or reduce deterioration of nutritional status., .4. Regular documentation of the amount of supplement consumed and tolerance is completed by designed personnel to monitor effectiveness of supplement use., F.Food and fluid intake is documented for all residents to screen for inadequate nutrient intake., .2. Supplements offered at meals are clearly designated on the meal observation form separate from their meal items., and .3. Trained staff record intake on the appropriate forms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 8 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and recored review the facility failed to ensure the use of PRN (as needed) psychotropic (medication that can affect a person's mental state) medication does not exceed 14 days for 2 out of 18 sampled residents ( Residents 23 and 60). This facility failure had the potential for unneccessary use of medication with no evaluation and assessment of need. Findings: During a review of the clinical record for Resident 23 indicated a physician order for PRN Temazepam 15 mg. one capsule at night (sleep aid) with a start of 5/21/2021. A pharmacist's recommendation located in the resident's clinical record dated 6/28/2021 indicated for facility to ask the physician to renew or discontinue the Temazepam order and document the rationale on the resident's clinical record. No documentation in the clinical record was located the resident's attending physician was contacted or notified of the pharmacist's recommendation dated 6/28/21. During an interview on 7/30/2021 at 3:30 PM the infection preventionist (IP) acknowledged no discontinue or renew orders from the physician was obtained . Review of the clinical record for Resident 60's indicated a physician order for PRN Trazodone (anti depressant) dated 7/4/2021 with no stop date. No documentation in the clinical record was located of the attending physician being notifued regarding the missing stop date of the PRN medication order for Trazadone. During an inteview on 7/30/2021 at 4:30 PM the IP acknowledged no discontinue of renew orders from the physician was obtained. The facility policy and procedure titled Psychotropics Medication and Behavior Management dated 3/2/16 indicates for evaluation the facility may use additional resources such as CDPH survey tool for Antipsychotic Drug Use, pharmacy-provided guidelines, black box warnings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 9 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dietary staff had the competency and skills to keep and maintained food contact surfaces were sanitized effectively. This failure had the potential to spread food borne diseases to residents and occupants of the facility. Findings: During an observation and concurrent interview with the facility's [NAME] and Assistant [NAME] (AC), on 7/28/21 at 8:50 AM, the [NAME] and AC indicated food contact surface countertops were sanitized by using a cloth soaked in sanitizer from the red bucket (red container with sanitizing solution). The [NAME] return demonstrated the sanitizing process in the prsence of the facility's Registered Dietician (RD), Dietary Services Supervisor (DSS), Department's RD and surveyor by filing up the red bucket with sanitizing solution and checking the solution concentration (parts per million -PPM) with a chemistry test strip (CTS[NAME] QAC 2951) via a colored coded graph chart (color indicates amount of concentration with 200 as the gauge).The [NAME] indicated the test strip result by stating It's 200 (PPM) and further stated for the requirement, It should be at least 100 PPM and we change it every two hours. During another observation and concurrent interview in the kitchen on 7/28/21 at 9:20 AM, with the AC, RD, DSS, the facility's AC demonstrated the process of testing the sanitizing solution for the right concentration by dumping the contents of the red bucket and refilling it back with the sanitizing solution. The AC then dipped a CTS in the red bucket in the presence of the RD and DSS, and compared the color of the CTS to the graph chart. The color did not match any colors indicated in the graph chart and was verified by the RD. The RD mixed the sanitizing solution with a mixing spoon and re-tested the sanitizing solution with a new chem strip, and stated, It's 200 PPM. The RD indicated the sanitizing solution might need to be stirred a bit before testing. The RD further inidicated the Cook's response of 100 PPM is wrong and the correct concentration to effectively sanitize is 200 PPM. During another observation on 7/28/21 at 9:40 AM in the kitchen with the facility's RD, DSS, the AC checked the temperature of the sanitizing solution in the red bucket by using a digital probe thermometer (a thermometer with a pointy metal stem). The AC dipped the metal stem of the thermometer into the solution and timed it approximately 10-15 seconds, post dipping the sanitizing solution temperature read at 133.7 degrees Fahrenheit. The AC was not able to respond back when asked about the temperature requirement. During a telephone interview with a [NAME] Company Customer Representative (Rep), on 7/28/21 at 9:58 AM, the Rep indicated the [NAME] QAC Test Strips, Code 2951, is temperature sensitive.The sanitizing solution must be brought to room temperature prior to testing due to false readings. The Rep further indicated safe sample temperature range is from 65 degrees Fahrenheit to 85 degrees Fahrenheit. During a review of the facility's undated Policy and Procedure (P&P), titled, Use and Storage of Wiping Cloths, and Sanitizing Bucket Solution, the P&P indicated, in part, The sanitizing solution must be tested before using it. Should it not meet the required ppm, it will be replaced with a new solution, and test it again until it meets the required ppm before using it .Quaternary Solution (or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 10 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0802 Quat - chemicals used for disinfection) - 200 ppm. Level of Harm - Minimal harm or potential for actual harm During a review of FDA (Food & Drug Administration) Food Code, 2017, the FDA Food Code indicated, After the surface is clean to sight and touch, a sanitizing solution of adequate temperature with the correct chemical concentration should then be applied to the surface. (3-304.14) Residents Affected - Some During a review of FDA (Food & Drug Administration) Food Code, 2017, the FDA Food Code indicated, Pathogens can be transferred to food from utensils that have been stored in surfaces which have not been cleaned and sanitized. (3-304.11) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 11 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the ice machine was sanitized according to manufacturer's guidelines. Residents Affected - Many This failure have the potential to placed the residents at risk for gastrointestinal illnesses and other water borned illnesses. Findings: During a concurrent observation, and interview on 7/27/21, at 10:25 AM with Maintenance Supervisor (MS), in a room adjacent to the kitchen housing the facility's Ice Machine, the inside lower panel that goes over the Ice Machine bin was observed with white-colored substance and small, black-colored spots. The MS indicated the white spots were calcium deposit build-up, was unsure what the black spots were, but it can be wiped off. The MS further indicated an outside company cleans the Ice Machine and the MS was not sure when was the last time it was cleaned . The MS stated, I don't like to be in here when they spray. During a review of the facility's service agreement with the outside company, titled, Proposal, dated 8/20/19, indicated, . Scope of Work - bid price on the preventive maintenance on refrigeration units and ice machine. This will include the following work: clean out condenser coils (a part of the ice machine that maintains its cooling properties), check temperatures on units, flush out ice machine with approved ice machine fluid cleaner, check door gaskets (a seal between two flat surfaces), and check general operation of equipment. This service will be performed every three months. Reviewed the facility copies of [name of outside company] HVAC (Heating, Ventilation, and Air Conditioning) Service Order Invoice, dated 1/26/21 and 4/29/21. The invoices indicated, in part . Description of work performed - performed PM service to refrigeration. Cleaned out condenser coils, checked temps. (temperatures), fans, meters, gaskets, etc . Ran cleaner through the unit .working good . The invoices did not indicate the ice machine was sanitized after it was cleaned. During a telephone interview on 7/27/21, at 4:03 p.m.,with a service technician (ST) of the outside company who cleaned the Ice Machine at the facility, in the presence of MS, the ST stated, I used the Nickel-Safe Ice Machine Cleaner to clean the internal components of the ice-making apparatus, it cleans and sanitizes the Ice Machine. When the ST was asked if there was a sanitizing step after the use of the Nickel-Safe Ice Machine Cleaner, the ST stated, The Nickel-Safe Ice Machine Cleaner is the product that cleans and sanitizes the Ice Machine, the cleaner gets circulated in the system for a set period and gets flushed out multiple times until cleared then the Ice Machine is returned to service to make ice. During a review of the Ice Machine manufacturer's guidelines, revised 3/2018, indicated, Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime ., use only approved Ice Machine Cleaner and Sanitizer for this application .Do not mix Cleaner and Sanitizer solutions together. It is a violation of Federal law to use these solutions in a manner inconsistent with their labeling. During further review of the Ice Machine's manufacturer's guidelines, the guidelines also indicated, separate and specific procedures for cleaning and sanitizing the Ice Machine. After the cleaning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 12 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many step, the guidelines indicated a sanitizing step that included, Step 14. Reapply power to the ice machine and place the toggle switch in the CLEAN position. Step 15. Wait until the water trough refills, then add the proper amount of Manitowc Ice Machine Sanitizer to the water trough. Step 16. After the sanitize cycle is complete (approximately 24 minutes), move the toggle switch to the ICE position to start ice making. During a review of FDA (Food & Drug Administration) Food Code and Food Code Annex, 2017, the FDA Food Code indicated, Equipment food-contact surfaces .shall be clean to sight and touch, and nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris ., and nonfood-contact surfaces shall be cleaned at a frequency necessary to preclude accumulation of soil residues ., The presence of food debris or dirt on nonfood-contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. (4-601.11, 4-602.13, 4-602.13 Annex) During a review of FDA (Food & Drug Administration) Food Code Annex, 2017, the FDA Food Code indicated, Ice that has been in contact with unsanitized surfaces .may contain pathogens and other contaminants. (3-303.11) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 13 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 13's), Foley catheter (FC) [a tube that drains urine from the bladder], was documented in the medical record. This failure resulted in inaccurate documentation that can affect the delivery of safe care and treatments. Findings : During a review of the facilities policy & procedure (P&P) titled, Completion and Correction of Resident Records, dated 2/25/2016, the P&P indicated, To ensure that medical records are complete and accurate .in part . Entries will be complete, legible, descriptive, and accurate. During an observation on 07/28/21, 9:19 a.m., in Resident 13' room, Resident 13 was sleeping, FC bag was attached to the bed. During a review of Resident 13's Medical Doctor's Orders (MDO), dated 7/29/21, the MDO indicated, an order for FC. During a concurrent interview and record review, on 07/29/21, at 3:02 p.m., with Licensed Nurse (LN) 2, Resident 13's Licensed Nurse Record Weekly Summary (LNRWS), dated 7/27/21, was reviewed. The LNRWS indicated, no documentation of FC. LN 2 stated, Oh, I missed that one. The patient does have a catheter. During a concurrent interview and record review, on 07/29/21, at 3:21 p.m., with LN 3, Resident 13's LNRWS, dated 7/20/21, was reviewed. The LNRWS indicated, no documentation of FC. LN 3 stated, She has a Foley, I did not check the right box. During a concurrent interview and record review, on 07/29/21, at 3:27 p.m. with the Director of Nursing (DON), Resident 13's LNRWS, dated 7/20/21 and 7/27/21, was reviewed. The LNRWS indicated no FC documentation. DON stated, the documentation was not accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 14 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to clean glucometers (machine used to measure blood sugar) per manufacturer's instructions for use. Residents Affected - Some This failure had the potential to result in cross contamination and spreading of infectious disease to the residents. Findings: Review of the manufacturer's instructions for use titled, Maintenance, undated indicated in part . it is ARKRAY's policy to advise healthcare professionals to clean and disinfect blood glucose meters between each resident test to avoid cross contamination issues . Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe . To use a wipe, remove from container and follow product label instructions to disinfect the meter. Review of the label for wipes, Sani-Cloth Bleach Germicidal, Disposable Wipe, undated indicated in part . Bactericidal, Fungicidal, Tuberculocidal, and Virucidal in 4 minutes . Disinfects in 4 minutes . 4 minute wet time. During an observation of Med Cart 1 and a concurrent interview with licensed nurse (LN 4) on 07/28/21, at 11:55 AM, LN 4 stated, I clean the glucometer with orange wipes (Sani-Cloth Bleach Germicidal, Disposable Wipes). I clean after every use and the wet time (time that disinfectant must remain wet) is 3-5. During an observation of Med Cart 3 and a concurrent interview with LN 5 on 07/28/21, at 12:45 PM, LN 5 stated, I clean the glucometer with orange top wipes and the wet time is 1 minute. Confirmed with LN 5 the wet time for orange top wipes is 4 minutes. During an interview on 07/28/21, at 3:17 PM, with LN 2, LN 2 stated, I use alcohol pads between residents and then at the end of the shift I use the orange top wipes to clean the glucometer. During an interview and concurrent record review on 07/28/21, at 3:50 PM, with the director of nursing (DON) and infection preventionist (IP), the DON and IP confirmed that the wet time is 4 minutes for orange top wipes and alcohol can only be used for outside of glucometer per MFUs meter must be disinfected with appropriate wipes - facility is not following MFUs for cleaning and disinfecting glucometer between residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 15 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide Pneumococcal (bacterial infection) immunizations for one resident (Resident 16). Residents Affected - Few This facility failure had the potential to result in Resident 16 acquiring complications from Pneumococcal disease. Findings: Review of the facility policy and procedure titled, Influenza and Pneumonia Vaccinations, dated 10/1/2018, indicated in part . A physician's order for pneumococci shall be obtained .Nursing Care Duties (Licensed Nurse) Administer vaccination to resident. During an interview and concurrent record review on 07/30/21, at 10:22 AM, with the infection preventionist (IP), Resident 16's Pneumococcal Immunization informed consent dated 5/14/21 indicated Resident gave consent to get vaccine, IP confirmed to date Resident 16 has not received vaccine. IP stated, I admitted Resident 16 and haven't given vaccine I can't keep track. MD order was not obtained until today. During an interview with IP on 07/30/21, at 10:37 AM, IP confirmed the MD order should have been obtained and pneumococcal vaccine should have been given to Resident 16. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 16 of 17 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 055597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maywood Acres Healthcare 2641 South C Street Oxnard, CA 93033 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility had 31 resident rooms that do not meet the required square footage of 80 square feet per resident . These rooms are: Two resident rooms: (Required 160 square footage). rooms [ROOM NUMBERS] are 148 square footage. rooms [ROOM NUMBERS] are 139 square feet. Three resident rooms with three beds occupancy: (Required 240 square footage). Rooms 3, 4, - 217 square feet. Rooms 6,7,8,9 -212 square feet. Rooms 10,11,12 -221 square feet. Rooms 14,15 -221 square feet. Rooms 16,17 -218 square feet. Rooms 20,21,22,23,24,25,26,27 -224 square feet. Rooms 28,29 -234 square feet. Rooms 30,31,32,33 -215 square feet. Findings: Observations made during initial facility tour, on 7/27/2021 thru 7/30/2021, revealed the facility had 31 residents rooms (two to three residents per room) with less square footage than the required 80 square feet per resident. Observations revealed the 31 rooms had sufficient space in each room for the provision of nursing services, placement of resident's equipment, (walkers, feeding pumps, oxygen machines and wheelchairs), residents furniture (chairs, and bedside tables), and space to ambulate in. The existing square footage of the rooms had in no way affected the health, safety, and provision of health services of the residents. It is recommended that the room size waiver of these 31 rooms be continued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 17 of 17