Health inspection·July 3, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review and interview, the facility failed to demonstrate it notified a physician of a change in condition in a timely manner and per policy and procedure, for one of two sampled residents (Resident 1). Residents Affected - Few This facility failure had the potential for emergency medical care to be delayed for Resident 1. Findings: During a review of Resident 1's Change In Condition form dated 6/7/24, indicated in part, Resident 1 had a change in condition when experiencing Hypoxia (a potentially life-threatening situation which results in low levels of oxygen in a person's tissues and cells) during PT (physical therapy). The Change In Condition form indicated this event started on 6/7/24, in the morning. The Change In Condition form indicated in part Resident (Resident 1) noted with hypoxia and diaphoresis (excessive sweating) during PT, resident (Resident 1) was fluctuating between 88%-95% RA (room air). Resident (Resident 1) moaning when transferred back to bed. The Change In Condition form indicated in part Resident 1's physician was notified at 12:00 p.m. on 6/7/24 of Resident 1's change in condition, wherein physician orders were given to transfer Resident 1 To the ER (emergency room) for hypoxia. During a review of Resident 1's Physical Therapy Treatment Encounter Note dated 6/7/24, indicated in part During rest break while seated in Wheel Chair patient (Resident 1) appeared to be increasingly fatigued and became diaphoretic. We immediately notified charge nurse and returned patient back .over to nursing. During an interview on 6/24/24, starting at 12:36 p.m., with the physical therapy assistant (PTA 1), the PTA 1 verbalized Resident 1 became diaphoretic and lethargic (decreased, or lack of energy) during a physical therapy session on 6/7/24. The PTA 1 verbalized a belief this occurred between 10:30 a.m. to 11:00 a.m. During an interview on 6/4/24, starting at 1:00 p.m., with licensed nurse (LN 1), the LN 1 verbalized at around 11:00 a.m., Resident 1 was returned to bed due to becoming hypoxic and diaphoretic during a physical therapy session on 6/7/24. The LN 1 verbalized Resident 1 was placed on two liters of oxygen due to hypoxia at around 11:00 a.m. The LN 1 was asked why two liters of oxygen was administered to Resident 1, as Resident 1 had no physician orders for oxygen. The LN 1 stated We just did it because it was an emergency. During a review of the facility's policy and procedure titled REPORTING CHANGES IN RESIDENT CONDITION undated, indicated in part Report changes in condition to MD immediately and follow up on (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 07/03/2024 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)