Health inspection·August 16, 2023

F 0641 Highly impaired - absence of useful hearing. Level of Harm - Minimal harm or potential for actual harm A review of the fscility policy and procedure for MDS assessment titled . Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual (RAI Manual instructions for completing MDS), Version 1.17.1, dated October 2019, the RAI Manual indicated, Residents Affected - Few > B0200 Ability to hear (with hearing aid or hearing appliances if normally used). Code hearing: 0 Adequate (no difficulty in normal conversation, social interaction, listening to TV). > Code 1 Minimal difficulty - difficulty in some environments (e.g. (example) when person speaks softly, or setting is noisy). > Code 2 Moderate difficulty - speaker has to increase volume and speaks distinctly. > Code 3 Highly impaired - absence of useful hearing. 2. During a review of Resident 1's MDS, Assessment Reference Date (ARD) (The date that signifies the end of the look back period for asseesment ), dated 6/15/23, the N (section for Opioid) was coded 0.Meaning Resident 1 did not recieve any Opioid medication for the observation period. During a review of Resident 1's Medication Administration Record (MAR), dated 6/23/23, the MAR indicated, Resident 1 received an opioid medication during the 7-day look back period, from 6/9/23 to 6/15/23. During a concurrent record review and interview with the MDSC, on 8/16, at 11:25 a.m., dated 6/15, The MDSC acknowledged, the information was inaccurate and acknowledged Resident 1 received an opioid medication for 7 days and the assessment should have been coded 7 instead of 0. During a review of the RAI Manual, Version 1.17.1, dated October 2019, the RAI Manual indicated, N040H Opioid: Record the number of days an opioid medication was received by the resident at any given time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days. 3. During a review of Resident 1 ' s MDS section M, dated 6/30/23, the MDS section M indicated, M0100 code 1 (Resident 1 has a pressure ulcer/injury, a scar over bony prominence or a non-removable dressing/device.) M0210 code 1 (Resident 1 have one or more unhealed pressure ulcers/injuries.) M0300 Current number of unhealed Pressure Ulcers/Injuries at Each Stage, number of Stage 2 pressure ulcers = 1; Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry = 1. During a concurrent record review and interview with the MDSC, on 8/16/23, at 11:30 a.m., the MDS section M was reviewed. The MDS section M indicated, Resident 1 had one or more unhealed pressure ulcers/injuries, and had 1 stage 2 that were present upon admission/entry or reentry. MDSC explained that Resident 1's skin was assessed on the day of discharge. And the pressure ulcer on the coccyx (tail bone) area had already healed however, Resident 1 had an ongoing stage 1 to the right buttock. MDSC confirmed, the codes for MDS section M was incorrect. The correct code for stage 2 should have been 0 instead of 1. MDSC claimed, she should have clarified the record with the nurse and documented the findings when Resident 1 was assessed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 2 of 5 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 08/16/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the RAI Manual, Version 1.17.1, dated October 2019, the RAI Manual section M indicated, If a resident had a pressure injury that healed during the look-back period of the current assessment, do not code the ulcer/injury on the assessment. During a review of the facility ' s policy and procedure (P&P) titled, Nursing documentation -Including Admission, Shift Plan of Care, and Discharge, dated 2/20, the P&P indicated, Document daily and PRN Changes: Skin Risk Assessment is done daily and updated if actual skin impairment occurs. Document system changes or treatment (that is (i.e.) wound measure and care .) Event ID: Facility ID: 056200 If continuation sheet Page 3 of 5 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 08/16/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 one of three sampled residents (Resident 1), had Residents Affected - Few a doctor' s treatment order for an ongoing right ankle stage 2 (a shallow opening on the skin with red or pink wound bed) pressure injury with accurate documentation of Resident 1's skin condition upon discharge. This failure had the potential to delay treatment and cause Resident 1 to not recieve accurate care. Findings: During a review of Resident 1' s History & Physical (H&P) on 7/11/23 at 3:12 p.m, dated 6/8/23 indicated,Resident 1 was a [AGE] year-old male who was hospitalized due to dysarthria (difficult or unclear speech) and dysphagia (difficulty swallowing), and with diagnosis of deaf and blind in one eye. During a review of Resident 1's Braden Skin Summary Risk Score (tool to assess risk of skin complications) dated 6/8/23, the Braden Skin Summary Risk Score indicated, a score of 11 (score of 14 or less indicates at risk status for pressure ulcer development.). During a review of Resident 1's admission Nursing Progress Notes (NPN), dated 6/8/23, the NPN showed, Resident 1 was admitted with a right buttocks stage 1 pressure injury (a reddened skin that does not turn white when pressed), right ankle stage 2 pressure injury and a left buttock blanchable redness (skin turned white when pressed with fingertips). During a further review of Resident 1's NPN dated 6/19/23 indicated, Resident 1 had a new coccyx (tail bone) stage 2 pressure injury. Further review of the NPN showed, Resident 1 had a new stage 2 pressure injury to the peristomal (around the opening) skin under the gastrostomy (artificial feeding tube) stopper on 6/21/23. During a review of Resident 1's Care Activity, dated 6/21/23 and 6/24/23 indicated, the coccyx stage 2 pressure injury had been resolved. However, a further review of the Care Activity dated 6/29/23, indicated, Resident 1 still had a right buttocks stage 1 pressure injury and right ankle stage 2 pressure injury. A review of Resident 1's discharge NPN dated 6/30/23 also indicated, Resident 1 still had a stage 2 pressure injury on the coccyx and right buttocks. During an interview with the Registered Nurse Supervisor (RNS) on 8/10/23, at 2:50 p.m., the RNS verbalized a skin assessment was done on the day of discharge and an ongoing stage 2 pressure ulcer on Resident 1's coccyx and stage 1 to the right buttock was now stage 2 upon assessment. During a concurrent record review with RNS of Resident 1's admission Orders, dated 6/8/23, there were no treatment order obtained from the physcian for the right ankle stage 2 found. During an interview with the RNS on 8/10/23, at 2:50 p.m.,RNS ocnfirmed there was no treatment order for right ankle stage 2 pressure ulcer since Resident 1's admission obtained. RNS further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 4 of 5 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 08/16/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acknowledged there should have been a wound care treatment order obtained from the physician to avoid delay of Resident 1's treatment. During a concurrent record review and interview with the MDS Coordinator (MDSC - the person attesting accuracy of the data in MDS), on 8/16/23, at 11:30 a.m., the MDS section M was reviewed. The MDS section M indicated, Resident 1 had one or more unhealed pressure ulcers/injuries, and had 1 stage 2 that were present upon admission/entry or reentry. MDSC stated, Resident 1 ' s skin was assessed on the day of discharge, the pressure ulcer on the coccyx area had already healed and an ongoing stage 1 on the right buttock. MDSC admitted seeing the nursing documentation for multiple pressure injuries during the look back period but did not clarify the record with the nurse and did not document the findings when Resident 1 was assessed. During a record review and interview with the Director of Nursing (DON), on 8/10/23, at 10:57 a.m., the Care Trends Integumentary (skin) was reviewed. The Care Trends Integumentary indicated, pressure ulcer on the coccyx was healed on 6/21/23. Resident 1's monitoring for pressure Injury in the coccyx continued from 6/22/23 to 6/23/23 then the documentation stopped. The DON acknowledged via e mail, Definitely, it appears there are gaps with the documentation. During a review of the facility ' s policy and procedure (P&P) titled, Nursing documentation -Including Admission, Shift Plan of Care, and Discharge, dated 2/20, the P&P indicated, Document daily and PRN Changes: Skin Risk Assessment is done daily and updated if actual skin impairment occurs. Document system changes or treatment (that is (i.e.) wound measure and care .) During a review of the facility ' s policy and procedure (P&P) titled, Skin Assessment: Including Skin Risk, Impaired Skin Integrity, Wound Documentation & Nursing Interventions, dated 2/22, the P&P indicated, It is the policy of Community Memorial Health System (CMHS) that all in-patients have a complete skin assessment, including skin risk, performed and documented within four hours of admission. Patients who are at risk for skin integrity impairment and those with actual skin breakdown will be identified by these assessments .Document skin assessment on Skin Assessment section of Continuing Care Center (CCC) Physical Assessment Group in Meditect (electronic program). Wounds will be assessed and documented on admission and initial identification during stay, weekly and PRN change in condition. The physician should be notified of any wounds identified on admission and throughout hospital stay. CCC - Wounds receiving care and treatment will be documented weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056200 If continuation sheet Page 5 of 5