Health inspection·February 27, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to provide information about the right to formulate an advanced directive (a legal document that states a person's wishes for medical care if they are unable to communicate them) for four of four sampled residents (Residents 4, 18, 20, and 42). In addition, the facility failed to establish, maintain, and implement written policies and procedures regarding the residents right to formulate an advanced directive. These failures had the potential for the residents' decisions regarding their health care and treatment not being honored. Findings: During a review of Residents 4, 18, 20, and 42's admission Packet Forms, the Packets did not contain any written form indicating, a review of the process in the formulation of an advanced directive was discussed with and acknowledged by the resident or resident's representative. During an interview on 02/26/25 at 10:30 a.m. with Licensed Nurse (LN 1), LN 1 confirmed there was no written evidence regarding a discussion about advanced directives during or anytime after admission present in Residents 4, 18, 20, and 42 electronic and paper records. During an interview on 02/26/25 at 10:45 a.m. with the Social Services Director (SSD), SSD stated there was no policy pertaining to the documentation about advanced directive discussion during resident's admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055861 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 055861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ojai Health & Rehabilitation 601 North Montgomery Street Ojai, CA 93023 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure: Residents Affected - Few 1. The toilet grab bar in room [ROOM NUMBER] was present. 2. room [ROOM NUMBER]'s room temperature was within ideal temperature range, as per facility policy. These failures had the potential to compromise resident safety and comfort. Findings: 1. During an observation on 02/24/25 at 10:59 a.m. in room [ROOM NUMBER]'s restroom, the restroom was observed without a grab bar next to the toilet seat and on the wall were holes where the grab bar should have been. During an interview on 02/24/25 at 11:05 a.m. with Resident 42 in room [ROOM NUMBER], the resident stated using the toilet in room [ROOM NUMBER] because the bathroom in room [ROOM NUMBER] does not have a grab bar next to the toilet, making it hard to move from sitting to standing and stated mentioning the concern to the maintenance supervisor (MS) about three weeks ago. During an interview on 02/26/25 at 10:30 a.m. with the MS, MS stated not being aware of the missing grab bar in room [ROOM NUMBER] because nobody informed maintenance of the issue. During an interview on 02/26/25 at 10:41 a.m. with the Activity Director (AD), AD stated the maintenance log was checked and the missing grab bar in room [ROOM NUMBER] was not documented in the report. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated December 2009, the P&P indicated, Functions of maintenance personnel include maintaining the building in good repair and free from hazard. 2. During a concurrent observation and interview on 2/24/25 at 4:30 p.m. with Resident 58 in room [ROOM NUMBER], Resident 58 was observed wearing a sweatshirt and hat while in bed, with a blanket covering the lower half of body. Resident 58 stated there has been issues with the cold temperature in the room since October 2024 and has communicated this multiple times to staff. The outside temperature was 83 degrees Farenheit (F). During a concurrent observation and interview on 2/27/25 at 3 p.m. with MS in room [ROOM NUMBER], MS checked the temperature and stated the reading was 65 degrees F. During an interview on 02/27/25 at 3:10 p.m. with Director of Nursing (DON), DON stated, It's everybody's responsibility to make sure the environment feels comfortable. During review of the facility's policy and procedure (P&P) titled, Heating, Cooling, Air Conditioning and Ventilation Systems, dated 12/31/15, the P&P indicated, .Check thermostats to ensure that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055861 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 055861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ojai Health & Rehabilitation 601 North Montgomery Street Ojai, CA 93023 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 0584 they are set at correct temperature (ideal temperature ranges from 72 degrees to 74 degrees depending on Center and weather conditions) . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055861 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 055861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ojai Health & Rehabilitation 601 North Montgomery Street Ojai, CA 93023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - screening for individuals with a mental disorder and individuals with intellectual disability) Level II Evaluation (a person-centered evaluation that is completed for anyone identified as positive for Level I screening or as having or suspected of having serious mental illness, intellectual disability, developmental disability or related condition) was completed for one of four sampled residents (Resident 51). Residents Affected - Few This failure had the potential to result in the resident not receiving appropriate care and services. Findings: During a review of Resident 51's admission Record (AR), dated 2/27/25, the AR indicated, Resident 51 is a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses including, disorganized schizophrenia (a mental disorder characterized by disorganized thinking, speech, and behavior), unspecified psychosis (a collection of symptoms that involves a disconnection from reality and the world around you), and suicidal ideations. During a review of Resident 51's PASRR Level I Screening, dated 4/26/24, the Screening result indicated, Result of Level I Screening: Level I - Positive. The screening result indicated further, Re: Positive Level I Screening indicates a Level II Mental Health Evaluation is Required During a review of Resident 51's PASRR Determination Letter, dated 5/1/24, the Letter indicated, Unable to Complete Level II Evaluation . After reviewing the Positive Level I Screening and speaking with staff, a Level II Mental Health Evaluation was not scheduled for the following reason: The individual was unable to participate in the evaluation. The case is now closed. To reopen, please submit a new Level I Screening. The letter indicated further, Please note this letter is a courtesy notice for administrative purpose only and does not comprise a completed individualized determination. During a concurrent interview and record review on 2/27/25 at 2:15 p.m. with the Director of Nursing (DON), Resident 51's PASRR records were reviewed. DON verified Resident 1 had a positive Level I screening but has not completed a Level II evaluation and verbalized that the case was closed. After thoroughly reviewing Resident 51's PASRR Determination Letter, dated 5/1/24, DON acknowledged that the resident required a Level II evaluation and should have undergone a new Level I screening. During a review of the facility's policy and procedures (P&P) titled, PASARR, revised 3/21, the P&P indicated in part, 1) All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The P&P indicated further, . b) If the level I screen indicates the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055861 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 055861 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ojai Health & Rehabilitation 601 North Montgomery Street Ojai, CA 93023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the care plan of one of four sampled residents (Resident 46) was revised to address the significant decline of the Brief Interview for Mental Status (BIMS a 15-point cognitive screening measure that evaluates memory and orientation impairments in older adults; 0-7 points suggests severe cognitive impairment, 8-12 points suggests moderate cognitive impairment, 13-15 points suggests cognition is intact) scores of the resident. This failure had the potential to result in appropriate care and services not being provided to the resident. Findings: During a review of Resident 46's, admission Record (AR), dated 2/27/25, the AR indicated in part, Resident 46 is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including, Wernicke's encephalopathy (a brain and memory disorder due to a lack of Vitamin B1 requiring immediate treatment) and major depressive disorder (a mood disorder that affects how a person feels, thinks, and handles daily activities). During a review of Resident 46's, BIMS reports, Resident 46's BIMS scores were as follows: - Quarterly Assessment (10/25/23) - Score = 11 (Moderately Impaired) - Quarterly Assessments (1/14/24 - 1/10/25) - Score = 3 (Severe Impairment) - Annual Assessment (4/12/24) - Score = 3 (Severe Impairment) During a review of Resident 46's, Care Plan Report, dated 5/2/23, the Report indicated, Focus . Cognition: Resident has impaired cognitive function/impaired thought processes r/t (related to) Wernicke's encephalopathy, memory loss. The report indicated further, Interventions/Tasks . Monitor/document/report to MD any changes in cognitive function specifically changes in decision-making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. During a concurrent interview and record review on 2/27/24 at 10:15 a.m. with the Director of Nursing (DON), Resident 46's Care Plan Report, dated 5/2/23 and BIMS Score reports, conducted on various dates, were reviewed. DON confirmed there was a significant decline in Resident 46's BIMS scores which should have been addressed in the resident's care plan. DON acknowledged that Resident 46's care plan should have been revised to reflect appropriate care and interventions that will need to be implemented to address this decline. During a review of the facility's policy and procedures (P&P) titled, Comprehensive Person-Centered Care Plan, revised 5/2024, the P&P indicated in part, Policy Statement . A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated further, Policy Interpretation and Implementation . 11) Assessment of residents are ongoing and care plans are revised as information about the residents and residents' condition change . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055861 If continuation sheet Page 6 of 6