Health inspection·May 28, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review and interview, the facility failed to follow their policy and procedures pertaining to Residents going out on a leave of absence, for two of two sampled Residents (Resident 1 and Resident 2). Residents Affected - Few This failure had the potential for the facility not to know where residents were going, while out on pass from the facility or when they returned. Findings: During a review of the facility's policy and procedure titled POLICY AND PROCEDURE FOR RESIDENT'S LEAVE OF ABSENCE/OUT ON PASS dated 3/13/24, indicated in part Residents before leaving the facility shall fill out the Release of Responsibility for Leave of Absence Form. This form shall record the name/signature of the person accompanying the resident. If self-responsible, resident will sign out for himself. The time the resident left the facility and the place/location the resident is going to must also be written in the form. Once the resident is back, License nurse or facility representative shall confirm that the resident came back by filling out the time they came back and by placing his/her signature. During a review of Resident 1's Release Of Responsibility For Leave Of Absence form, undated, indicated in part, Resident 1 left the facility a total of 14 times from 4/24/24, though 5/2/24, to go out on pass. Out of the 14 times Resident 1 left the facility, on 13 occasions, a licensed nurse or facility representative, failed to document when Resident 1 returned to the facility, by signing their name and noting the date and time Resident 1 returned. During a review of Resident 2's Release Of Responsibility For Leave Of Absence form, undated, indicated in part, Resident 2 left the facility a total of 22 times from 5/7/24, through 5/19/24. Out of the 22 times Resident 2 left the facility, on 21 occasions the form did not indicate where Resident 2's destination was. The form also indicated on two occasions on 5/8/24, and once each on 5/15/24, and 5/16/24, a licensed nurse or facility representative, failed to document when Resident 2 returned to the facility, by signing their name and noting the date and time Resident 2 returned. During a concurrent record review and interview, on 5/20/24, starting at 4:24 p.m., with the Director of Nursing (DON 1), both Resident 1 and Resident 2's Release Of Responsibility For Leave Of Absence forms were reviewed. The DON 1 acknowledged both Resident 1 and Resident 2's forms were incomplete and were missing information, as indicated in the facility policy on those specified dates. During a concurrent record review and interview, on 5/22/24, with the Director of Staff Development (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055597 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 05/28/2024 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)