Health inspection·May 14, 2025

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 record review and interview, the facility failed to ensure staff observations of resident skin issues and/or conditions were consistently and accurately documented in the skin monitoring form for two of two sampled residents (Residents 1 and 2). These failures had the potential to result in inaccuracies of information which could affect the delivery of care and services for these residents affecting health and safety. Findings: During a concurrent interview and record review on 5/14/25 at 11:55 a.m., with the facility's (Interim) Director of Nursing (DON), the facility form titled, Skin Monitoring (SM): CNA (Certified Nursing Assistant) Shower Review, was reviewed. DON verbalized that the SM form is used by CNAs to document skin observations of their assigned residents during bed baths/showers. The SM form included a list of skin issues/conditions and a body chart to graph the exact location of the skin issue/condition. DON further verbalized the CNA will report the observed skin issues/conditions to the charge nurse. During a review of Resident 1's Nursing - Comprehensive Skin Evaluation/Assessment, dated 4/8/25, the assessment indicated in part, Section B. Skin Assessment . Noted wound on right medial malleolus (area located on the inner side of the ankle) with light serous drainage (a clear to yellow fluid that leaks out of the wound) During a review of Resident 1's Skin and Wound Evaluation (SWE), report dated 5/12/25, the report indicated in part, Resident 1's wound on his right medial malleolus area persists. During a review of Resident 1's SM forms dated 5/2/25, 5/6/25, and 5/10/25, the forms failed to indicate documentation of Resident 1's existing wound on his right medial malleolus area. During a review of Resident 2's Nursing - Comprehensive Skin Evaluation/Assessment, dated 10/13/24, the assessment indicated in part, Section B. Skin Assessment . Left Heel Pressure, Suspected Deep Tissue Injury (DTI - a type of pressure ulcer where underlying tissue damage occurs without an open wound) . Right Toe(s), Pressure, Suspected DTI . left Toe(s), Pressure, Suspected DTI . Sacrum (area at the base of the spine just above the buttock), Pressure, Stage IV (a stage of pressure ulcer with full thickness skin and tissue loss with exposed bone, tendon or muscle). During a review of Resident 2's SWE report dated 5/5/25, the report indicated in part, Resident 2's Stage IV pressure ulcer on the sacrum area persists. (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: 055861 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 05/14/2025 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)