Health inspection·August 29, 2025

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure when a care plan was not created for 1 of 24 sampled residents (Resident 61) with Dementia (a general term describing a group of conditions that cause a progressive decline in cognitive abilities).This failure had the potential for resident to not receive appropriate care and treatment to attain highest practicable psychosocial well-being. During a concurrent observation and interview on 8/26/25 at 2:45 p.m. with Resident 61, Resident 61 was unable to state the current year, month, or date. Resident 61 was observed in bed and stated he was waiting for a certified nursing assistant (CNA) to shave him, pointing to his face and chin. During a review of Resident 61's admission Record (AR), the AR indicated, Resident 61 was admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease (a type of dementia, a condition that causes a progressive decline in cognitive abilities, such as memory, thinking, and reasoning). During a review of Resident 61's History and Physical (H&P), dated 7/10/25, the H&P indicated, Resident 61 does not have the capacity to understand and make decisions and to monitor for behavior. During a concurrent interview and record review on on 8/27/25 at 10:45 a.m. with Director of Nursing (DON), the DON was unable to find a diagnosis-specific care plan for Dementia in either the hard copy of Resident 61's chart or the electronic health records. DON stated, We don't have a care plan for that. During a review of facility's policy and procedure (P&P) titled, Care Plans, undated, the P&P indicated 1) Assess the resident upon admission and initiate a plan of care for key problems or possible problems identified. The care plan will be completed within seven days. 6) After the resident Assessment Protocol is completed, the care plan will be updated to include any additional information gained within seven days of completion. 7) Any changes in resident's status will be put on the care plan as they occur. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 2 of 6 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 08/29/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to write the open date on the pharmacy sticker for Resident 61's respiratory solution vials located in Medication Cart #3.This failure resulted in the potential for Resident 61 to receive a medication that had been expired or no longer effective, placing Resident 61 at risk for decreased therapeutic benefit and potential adverse health outcome. Findings: During an observation on [DATE] at 12:07 p.m. of Medication Cart #3, an open medication box labeled 'Ipratropium Bromide 0.5 milligrams (mg)/Albuterol Sulfate 3mg' (an inhaled combination medication that contains two different bronchodilators to open the airways and make breathing easier) was noted in the bottom right-hand drawer of Medication Cart #3. Inside the box was an open foil package containing three (3) respiratory solution vials. Neither the foil package nor the box displayed a documented date of opening. During a record review of the pharmacy's expiration instructions located on the medication box indicated, Expires: 7 days if open. Additional review of the manufacture's open foil pouch located inside the medication box, instructions indicated, Once removed from foil pouch, the individual vials should be used within one week. During an interview on [DATE] at 12:11 p.m. with the Infectious Disease Nurse (IDN) stated, Staff who opened this medication did not document the date of opening and should have. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication, dated 2019, the P&P indicated, Medications and biologicals are stored properly, following manufacture's recommendations or those of the supplier to maintain their integrity and to support safe administration FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 3 of 6 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 08/29/2025 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 observation, interview and record review, the facility failed to implement infection prevention and control practices when: 1. A nasal canula (NC) was found on the floor for one of nine residents (Resident 38). This failure had the potential for Resident 38 to acquire an infection from an unclean NC.2. Staff did not perform appropriate hand hygiene practices in the dining room during meal tray service. This failure had the potential to expose residents to cross infection contaminations.Findings: Residents Affected - Few 1.During an observation on 8/27/25 at 2:39 p.m. inside Resident 38's room, a nasal canula (NC) was noted draped over the bed rail and touching the floor. The tubing was dated 8/24/25. During a concurrent observation and interview on 8/28/25 at 8:23 a.m. with Licensed Nurse (LN 5) in Resident 38's room, Resident 38 was observed with ongoing oxygen via nasal cannula. The nasal cannula tubing was dated 8/24/25. The nasal cannula was the same as noted on the floor on 8/27/25. LN 5 confirmed the oxygen tubing Resident 38 was using was the same NC observed on 8/27/25 touching the floor. During a review of the facility's policy and procedures (P&P) titled, Infection Control, dated 8/13/20, the P&P indicated, the facility must Maintain a safe, sanitary and comfortable environment . staff must be trained on infection control policies and procedures . the administrator adopts policies and procedures . for preventing transmission of infections. During an interview on 8/28/25 at 9:36 a.m. with Certified Nursing Assistant (CNA 6) regarding infection control policies on proper storage of a nasal cannula after use. CNA 6 stated a NC when removed is placed in the bag attached to concentrator. During an interview on 08/28/2025 at 10:17 a.m. with Director of Staff Development, (DSD). DSD stated, Training for the care of nasal cannulas or oxygen is on an as needed schedule and annually. DSD was unable to produce the last education for storage of a nasal cannula after use. During an interview on 08/28/2025 at 10:26 a.m. with the Director of Nursing (DON), DON stated a NC should not be on the floor. It should be in the bag on the concentrator when not in use. 2. During an observation on 8/26/25 at 11:17 a.m. in the large dining room, CNAs 3 and 4 were observed not performing hand hygiene between the following activities that included adjusting a resident's wheelchair at the table, touching the residents table, removing plastic wraps and lids off of residents' meal trays and throwing the discarded items into trash and proceeding to retrieve a clean meal tray for another residents. During a review of facility's policy and procedure (P&P) titled, Policy and Procedure Handwashing, the P&P stated, All staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of nosocomial infections. During an interview on 8/26/25 at 11:25 a.m. with CNAs 3 and 4 in the large dining room, CNAs 3 and 4 both acknowledged they did not perform hand hygiene after touching potentially contaminated surfaces and before serving a new meal tray to another resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 4 of 6 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 08/29/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and facility practice review on 8/29/25 at 10:02 a.m. with the Infection Preventionist (IPN) and the Director of Staff Development (DSD), the IPN and DSD stated the facility's hand hygiene process for meal tray service includes: staff must wash hands prior to receiving the meal trays from the kitchen and before passing them in the dining room. Staff must perform hand hygiene after touching dirty surfaces such as wheelchairs, trash cans, tables, residents and any sources that are considered dirty before setting up a meal for another resident. The IPN and DSD acknowledged CNAs 3 and 4 should have performed hand hygiene after coming in contact with dirty sources such as adjusting the resident's wheelchair, touching the table, throwing discards into trash before getting a new meal tray and serving it to another resident. Event ID: Facility ID: 055597 If continuation sheet Page 5 of 6 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 08/29/2025 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement their policy and procedure on smoking.This failure had the potential to result in serious risk of fires and injuries for vulnerable residents with cognitive and physical impairments.Findings:During a concurrent observation and interview on 8/27/25 at 9:30 a.m. with the IPN, a resident on a wheelchair self-propelled towards the nursing station and left a cigarette lighter on the nursing station counter for approximately three minutes without any staff noticing the cigarette lighter. The IPN took the cigarette lighter and stated was going to keep it for safe keeping. IPN also stated only alert residents are allowed to to keep smoking materials.During a review of the facility's policy and procedure (P&P) titled, Smoking Policy and Procedure, [undated], the P&P indicated, 2. Smoking materials/paraphernalia such as cigarettes, cigars, lighters, etc. shall be kept in a locked container for safe keeping. No resident shall be allowed to keep their own smoking materials/paraphernalia for safety purposes. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055597 If continuation sheet Page 6 of 6