Health inspection·April 21, 2023

F 0583 Keep residents' personal and medical records private and confidential. 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 ensure the privacy of protected health information (PHI-is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed while providing a health care service such as diagnosis or treatment.) for twenty two of sixty three residents residing in the facility. Residents Affected - Some This facility failure resulted in twenty two residents protected health information potenitally being compromised. Findings: During an observation on 04/18/23 at 1:10 p.m., a four wheeled rolling cart outside of room [ROOM NUMBER] was observed unattended with a laptop computer on it. The computer screen was open. The screen displayed the PHI of twenty-two residents including their name, diagnosis, room number, account number, physician name, isolation precautions (isolation precautions are used to reduce transmission of microorganisms in healthcare and residential settings. These measures are designed to protect patients/residents, staff, and visitors from contact with infectious agents), and resuscitation status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop). During an interview and concurrent record review on 04/21/23 at 9:30 a.m., with a certified nurse assistant (CNA1), the facility's policy and procedure titled HIPAA Minimum Necessary dated 5/26/2020 was reviewed. The HIPAA Minimum Necessary indicated, [Name of Facility]'s workforce will make reasonable efforts to limit protected health information (PHI) to the minimum necessary. CNA1 confirmed staff are supposed to close their computers and not leave them open when they are not using them. A review of the facility's policy and procedure (P&P) titled, HIPAA Minimum Necessary, dated 5/26/2020, the P&P indicated, Purpose. Provide guidance to [Name of facility] regarding the requirement to adhere to minimum necessary standards when releasing, accessing, or using PHI. Policy: when using or disclosing individually identifiable health information (or when requesting individually identifiable health information from other health care providers, health plans and healthcare clearinghouses), [Name of Facility] and members of [Name of Facility]'s workforce will make reasonable efforts to limit protected health information (PHI) to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 2 of 9 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 056200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Memorial Continuing Care Center 1306 Maricopa Highway 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 Based on interview and record review, the facility failed to ensure a follow up/new Preadmission Screening and Resident review (PASRR-mental disability assessment) for Level 1 was done for 1 of 18 residents (Resident 30). Residents Affected - Few This failure had the potential to result in Resident not being adequately assessed to receive recommended care and treatment. Findings: Review of Resident 30's Clinical Record indicated, resident was admitted to the facility with history diagnoses that included acquired absence of right leg below knee, adverse effect of unspecified narcotics, chronic diastolic (congestive) heart failure(when the heart does not relax and fill with blood normally). During a review of Resident 30's clinical documents titled, Preadmission Screening and Resident Review(PASRR-mental disability assessment), dated 09/08/22, the PASRR indicated, Positive (resident with mental disorder condition). Further record review of document titled, Department of Health Care Services (DHCS) letter, dated 9/16/22 for Resident 30 indicated, a PASRR Level II was incomplete and had documented, Unable to complete Level II evaluation .The individual was isolated as a health safety precaution .The case is now closed. To reopen, please submit a new Level I screening. A Review of Resident 30's clinical records showed no new level I PASRR was done after the 9/16/22 recommendation by DHCS. During an interview with a Registered Nurse (RN 1) on 04/20/23 at 10:48 a.m., RN 1 confirmed the Level II PASRR was not done. During an interview with the Director of Nursing (DON) on 4/21/23 at 10:15 a.m, the DON indicated the facility did not have a policy and procedure for PASRR screeening for residents in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 3 of 9 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 056200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Memorial Continuing Care Center 1306 Maricopa Highway 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to initiate a Care Plan (a part of the nursing process which outlines the plan of action that will be implemented during a patient's medical care) for two of 18 sampled residents (Resident 59 and Resident 163) when: 1. Care plans for two antidepressants medications were not initiated for Resident 163 and, 2. A care plan for psychotropics was not initiated for resident 59. These facility failures have the potential to prevent residents from recieving individualized care and services. Findings: During a review of the facility P&P titled, Nursing Documentation-including Admission, Shift, Plan of Care, and Discharge, dated 02/25/2020, the P&P indicated, Collection of data will be systematic, continuous and include assessments and reassessments by various professional disciplines. Problem statements or Nursing Diagnosis, Patient Outcomes (Goals) and Nursing interventions are developed by this documentation and incorporated into the Plan of Care. A review of the facility policy and procedure (P&P) titled, Psychotropic Drug Therapy and Restraint Management, dated 3/28/2017, the P&P indicated, Purpose. To establish a policy and standards, for the provision of safe psychotropic drug and restraints management within the Continuing Care Center (CCC), as required by law; including but not limited to the following: to guide the interdisciplinary team (IDT) in reviewing and attempting alternative interventions and /or behavioral management strategies prior to the use of psychoactive medication. 1. During an interview on 04/18/23 at 11:06 a.m., Resident 163 indicated on initial pool that she is taking medications for her anxiety (A sense of uneasiness, distress, or dread you feel before a significant event). During a record review on 4/19/23 at 11:47 a.m., Resident 163's record indicated, Resident 163 is taking Lexapro (a medication used to treat depression) 20 mg by mouth daily and Cymbalta (a medications used to treat depression, anxiety, panic attacks, and social anxiety disordernt) 30 mg by mouth (PO) every day (QD). During a review of Resident 163's Care Plans (CP) on 4/19/23 at 12:02 p.m., the record revealed there were no care plans initiated for the use of Lexapro and Cymbalta (antidepressant) medications. During a concurrent interview and record review with the Registered Nurse (RN 2) on 4/20/23 at 1:58 PM, RN 2 confirmed there were no Care Plans initiated for the use of both antidepressant medications. During an interview with the Director of Nursing (DON) on 4/21/23 at 9:57 a.m., the DON acknowledged there were no Care Plans initaited for Lexapro or Cymbalta for Resident 163. During a concurrent interview and observations of resident rooms on 4/18/23 at 12:49 p.m., Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 4 of 9 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 056200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Memorial Continuing Care Center 1306 Maricopa Highway 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 59 was observed to be awake in bed and verbally responsive. Resident became tearful at times during interview and stated he misses real food, misses home, had been in hospital for 5 months and then transferred to this facility where he has been for about a month. During a review of the Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) for Resident 59, dated 1/30/23, in section I (Diagnosis), the MDS indicated Resident 59 had a diagnosis that included, Adjustment disorder with Depression (stress-related condition where you feel overwhelmed and have a hard time adjusting to a stressful event or change.) During a review of the Patient Active Orders (POA) for Resident 59, dated 4/21/23, the POA indicated Doxepin (a tricyclic antidepressant medication used to treat major depressive disorder) 10 mg (milligrams). During a review of the [Name of Facility]Psychotropic Drug Informed Consent (IC) for Resident 59, dated 1/30/23, the IC indicated, Psychotherapeutic drug (s): Sinequan (Doxepin) Diagnosis: Depression m/b (manifested by) Sadness. During a concurrent interview and record review on 4/21/23 at 11:56 a.m. with the Director of Nursing (DON), the Care Plan for Resident 59 dated 1/30/23, the P&P titled Psychotropic Drug Therapy and Restraint Management, dated 3/28/2017, and the P&P titled, Nursing Documentation-including Admission, Shift, Plan of Care, and Discharge, dated 02/25/2020 were reviewed. The DON confirmed the facility did not have a care plan in place for the use of the psychotropic drug (Doxepin) for Resident 59. The DON further indicated the facility should have implemented a plan of care for the use of the Doxepin for Resident 59. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 5 of 9 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 056200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Memorial Continuing Care Center 1306 Maricopa Highway 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 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review of facility policy and procedures, the facility failed to update and revise a fall care plan for one of 18 sampled residents (Resident 169) after a fall incidence. Residents Affected - Few This facility failure had the potential for new interventions and new fall precations to not be implemented which could potentially prevent Resident 169 form future falls. Findings: During an interview on 4/18/23 at 11:10 a.m, resident 169 on initial pool, indicated she had fallen in the facility recently. During record review on 4/20/23 at 9:05 a.m., Resident 169's record indicated, resident 169 had an unwitnessed fall on 4/15/23 at 6:45 AM, and that Resident 169 was taken to the emergency department and returned back to the facility the same day. During a record review of Resident 169's Care Plan (formal process that correctly identifies existing needs and recognizes a client's potential needs or risks which help guides nurses) on 4/20/23 at 9:24 a.m., a fall care plan was noted to have been initiated on 4/6/23. There were no revisions or updates to the fall care plan interventions that were documented after the resident's fall incidence on 4/15/23. During a concurrent interview and record review with the Nurse Informatics (NI) super user on 4/20/23 at 11AM, the NI agreed there were no revised or updated fall Care Plans noted for Resident 169. During an interview with Director of Nursing (DON) on 4/21/23 at 10 a.m., the DON acknowledged the fall Care Plan was not revised or updated after Resident 169's fall incidence on 4/15/23. The DON further indicated the fall Care Plan for resident 169 should have been updated. During a review of the facility policy and procedure (P&P) titled, CCC Resident Fall Prevention, dated 3/20/2021, the P&P indicated, Document the incident .b. initiate or update the Fall care plan .d, Review and revise the care plan as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 6 of 9 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 056200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Memorial Continuing Care Center 1306 Maricopa Highway 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to ensure restorative nursing services (RNA) were provided to two of eighteen sampled residents (Resident 57, Resident 59). Residents Affected - Few This facility failure resulted in Resident 57 and Resident 59 not receiving required services to ensure they maintain, improve, or restore muscle strength, balance, range of motion, and functional mobility. Findings: During a review of the facility policy and procedure (P&P) titled, Nursing Documentation-including Admission, Shift, Plan of Care, and Discharge dated 02/25/2020, the P&P indicated, Collection of data will be systematic, continuous and include assessments and reassessments by various professional disciplines. Problem statements or Nursing Diagnosis, Patient Outcomes (Goals) and Nursing interventions are developed by this documentation and incorporated into the Plan of Care. During an observation and interview on 04/18/23, at 12:49 p.m., in residents' room, Resident 59 was alert and lying in bed. Resident became tearful at times during interview and stated he misses real food, misses home, had been in hospital for 5 months and then transferred to this facility where he has been for about a month. Resident 59 had n abdominal wound covered in a clear dressing with a wound drainage to a bag. Resident also noted to have a PICC (a type of long catheter that is inserted through a peripheral vein, often in the arm, used when intravenous treatment is required over a long period.) to upper left and a foley catheter (a tube placed in the body to drain and collect urine from the bladder.) During a review of the Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) dated 1/30/23 for Resident 59, in section I (Diagnosis), the MDS indicated Resident 59 had diagnosis including muscle weakness (lack of muscle strength), morbid obesity (being more than 100 pounds over ideal body weight (IBW) and vascular disorder of intestine (a serious condition that can cause pain and make it difficult for your intestines to work properly. In severe cases, loss of blood flow to the intestines can damage intestinal tissue and possibly lead to death.) under section G (Functional mobility- is a person's physiological ability to move independently and safely in a variety of environments to accomplish functional activities or tasks and to participate in the activities of daily living, at home, work and in the community.) the MDS indicated Resident 59 required staff assistance with all mobility tasks. During a review of the physician orders dated 4/21/23 for Resident 59, the physicians orders indicated, Ambulate as tolerated with nursing assistance. During a review off Resident 59's PT (physical therapy) Inpatient Daily Progress Note dated 04/05/23, the PT note indicated, Discharge Summary: patient will benefit from continued ambulation daily by nursing/RNA (RNA-restorative nurse assistant-provides rehabilitation care to help people regain or improve their physical, mental, and emotional health). During an interview and concurrent record review on 04/20/23 at 11:28 a.m. with a community memorial hospital information technology assistant (CMH IT), the electronic medical record (EMR) for Resident 59 was reviewed. The CMH IT confirmed there were no RNA notes or evaluation anywhere in Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 7 of 9 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 056200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Memorial Continuing Care Center 1306 Maricopa Highway 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 0688 59's EMR. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 04/21/23 at 9:25 a.m. with the director of nursing (DON), the PT (physical therapy) Inpatient Daily Progress Note dated 04/05/23 for Resident 59, and the facility P&P titled, Nursing Documentation-including Admission, Shift, Plan of Care, and Discharge dated 02/25/2020 were reviewed. The DON confirmed the facility does not have RNA services at this time. The DON stated, Yes, we have not had them, but we are going to start- I have an RNA book right here. The DON confirmed the facility is not implementing RNA services per the PT recommendation and per the facility's P&P. Residents Affected - Few During a concurrent observation and interview on 04/21/23 at 9:30 a.m. in Resident 59's room with a certified nurse assistant (CNA1), Resident 59 stated, It's not that i don't want to walk- i just needs someone to get me up. CNA1 confirmed Resident 59 should be receiving RNA services per the physician orders dated 4/21/23, and per the PT Inpatient Daily Progress Note dated 04/05/23. CNA1 confirmed Resident 59 had not recieved any RNA services as ordered.During a review Resident 57's clinical record, the clinical record indicated diagnosis including, difficulty in walking, muscle weakness, and unspecified fall. During a review of the care plan for Resident 57, dated 11/15/22, the care plan indicated, Encourage resident to do self care activity, document functional ability, provide positive reinforcement during activity, bed mobility training, transfer training using walker, education to meet functional goal. RNA 3 times a week for 15 mins. During an interview and record review, with the DON, on 04/20/23, at 1:46 p.m., the DON stated the facility used to have 2 RNAs but during the pandamic they became CNAs. The DON confirmed the facility does not currently have an RNA program and residents who have care plans indicating RNA services are not being implemented or provided on a consistent basis. Review of the flow sheet dated 1/18/23 thru 2/17/23 indicated, RNA services were only performed on the dates of 1/18/23; 2/8/23; and 2/17/23. The DON stated, If RNA activity is not documented on the flow sheet then it wasn't done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 8 of 9 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 056200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Memorial Continuing Care Center 1306 Maricopa Highway 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow appropriate dress code for food and nutrition services personnel in the kitchen failed to serve food in accordance with professional standards for food service safety. This failure has the potential for cross contamination of food (transfer of harmful bacteria to food when they are not handled properly). Findings: During an observation and interview, with the [NAME] (Job title for the person responsible for preparing ingredients at an establishment that serves food) and Food and Nutrition Services Director (FNS) on 04/18/23 at 10:15 a.m., [NAME] was observed not wearing a beard restraint when he entered the kitchen. The FNS confirmed CK1 was not wearing a beard restraint. A review of Policies and Procedures (P&P) titled, Uniform Dress Code in FNS dated 11/26/19, indicated, E. Facial hair must be covered as per local and state regulations. A. Long Term Care: [NAME] restraints must be worn. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 9 of 9