Health inspection·June 24, 2021

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on observation, interview, and record review, the facility failed to initiate baseline care plans for one of 20 sampled residents (Resident 431), for (1) The use of an anticoagulant medication (medication that helps prevent blood clots); and (2) The presence of a left chest Automatic Implantable Cardioverter-Defibrillator device ([AICD] - a small, electronic device implanted into the chest to monitor and correct abnormal heart rhythm). These failures had the potential for Resident 431 to have complications of abnormal bleeding from the anticoagulant use, and possible unrecognized AICD device compliations. Findings: 1. During a concurrent observation and interview, on 6/21/21 at 9:15 a.m., Resident 431 was observed lying in bed and watching TV. Resident 431 stated, I've been here a few weeks. I'm a diabetic (a group of diseases that result in too much sugar in the blood) and am on insulin (a medication used to lower blood sugar level) therapy and blood thinners. During a review of Resident 431's medical record, dated 6/18/21, the record indicated Resident 431 was admitted with diagnoses including, Congestive Heart Failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), Type 2 Diabetes Mellitus, Atrial Fibrillation (quivering or irregular heartbeat that leads to blood clots, stroke, heart failure or other heart-related complications) and presence of an Automatic (Implantable) Cardiac Defibrillator, etc. During a review of Resident 431's, Medication Administration Record (MAR), the MAR dated 6/2021, indicated, Resident 431 is currently on the anticoagulant medication, Apixaban Tablet 2.5 mg, Give one tablet by mouth two times a day for AFIB (Atrial Fibrillation). During a concurrent interview and review of Resident 431's care plans on 6/24/21 at 9 a.m., with a Licensed Nurse (LN 1), LN 1 stated, Yes, (a care plan is required for anticoagulant therapy) but, it usually goes together with a cardiac (relating to the heart) care plan. LN 1 was unable to locate a care plan for anticoagulant therapy and stated, He should have one. 2. During a review of Resident 431's, History and Physical, dated 6/21/21, indicated, Chest Physical Examination: AICD in left chest. During a concurrent interview and clinical record review, on 6/23/21 at 9:05 a.m., with LN 2, Resident 431's assessment notes and care plans were reviewed, LN 2 stated, she was not aware of Resident 431's AICD device. LN 2 was unable to locate a care plan regarding Resident 431's AICD in the medical record. During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, dated 11/2019, the P&P indicated, in part, A baseline care plan is initiated and reviewed with resident or resident's representative within 48 hours. Documentation of the Care Plan process will be electronic through the 'Interdisciplinary Care Plan Review' document, as well as in paper form (i.e. Care Plan attendance form, schedule, etc.) as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555458 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 555458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care Center 1300 North C Street Oxnard, CA 93030 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the menu as planned when: 1. Sherbet was placed on the lunch meal plate for one of 20 sampled residents (Resident 280) on a Renal (diet for kidney disease) CCHO diet (controlled carbohydrate/diabetic diet), instead of diet pineapple as planned. This had the potential to not meet the resident's nutritional needs per the planned menu. 2. Whole parsley, with stems, was placed on the lunch meal plate for one of 20 sampled residents (Resident 71) and 27 non-sampled residents (Resident's 71, 37, 7, 3, 13, 53, 23, 25 , 2, 48, 70, 27, 1, 26, 69, 56, 21, 5, 35, 74, 284, 282, 433, 432, 285, 281, and 179) on a mechanical soft diet, instead of parsley flakes as planned for a garnish. This facility failure had the potential to place residents at increased risk for choking who received a mechanical soft diet order. Findings: 1. During an observation on 6/22/21 at 11:54 a.m., of the lunch trayline meal service in the kitchen, sherbet was observed on a lunch meal plate for Resident 280. Resident 280's meal tray card indicated, Diet: Renal, CCHO. During a concurrent interview and menu review on 6/22/21 at 11:54 a.m., with the Dietary Manager (DM), the DM confirmed sherbet was on the plate for Resident 280. The DM reviewed the facility's therapeutic diet spreadsheet that indicated, Diet Pineapple was the dessert item for a Renal, CCHO diet. The DM stated, it meant that pineapple flavored sherbet should be served. The DM reviewed the therapeutic diet spreadsheet with the facility's Registered Dietitian (RD 1) by telephone. The DM then confirmed the Renal, CCHO menu was not followed for Resident 280, when sherbet was on the meal plate, instead of diet pineapple. During a review of the facility's P&P titled, Menu Planning, dated 2018, the P&P indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the facility Registered Dietitian . 2. During a concurrent observation and interview on 6/22/21 at 12:01 p.m., with the DM, observation of the lunch trayline meal service in the kitchen, a cook (Cook 1) placed an intact parsley garnish, with stems, on Resident 71's lunch plate. A dietary aid (DA 2) then placed Resident 71's lunch meal plate on a meal delivery cart. Resident 71's meal tray card indicated, Diet: CCHO (controlled carbohydrate/diabetic diet) Consistency: M/S (mechanical soft). According to the planned menu, a mechanical soft diet was to be served parsley flakes as a garnish. The DM removed Resident 71's meal tray from the meal delivery cart and observed the intact parsley (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555458 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 555458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care Center 1300 North C Street Oxnard, CA 93030 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with stems on Resident 71's meal tray. The DM confirmed parsley flakes were to be served for mechanical soft diet orders, and proceeded to remove five meal trays from the same meal delivery cart for residents who had a mechanical soft diet, in order to remove the whole parsley with stems. During a review of the facility's diet manual, dated 2020, the diet manual indicated, Regular Mechanical Soft Diet; Description: The Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified in texture to a soft, chopped or ground consistency ., Allowed .parsley flakes, Avoid .Parsley sprigs . During a review of the facility's P & P titled, Menu Planning, dated 2018, the P & P indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders .Menus are written for regular and modified diets in compliance with the diet manual . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555458 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 555458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care Center 1300 North C Street Oxnard, CA 93030 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 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 observation, interview, and record review, the facility failed to accurately document in the clinical records for one of 20 sampled residents (Resident 430). Resident 430's high blood sugar level and subsequent physician telephone order were not documented in the resident's medical record. This failure had the potential for Resident 430 not to receive appropriate care and treatment interventions which could result in health complications. Findings: According to ANA's (American Nurses' Association) book titled, Principles for Nursing Documentation (Guidance for Registered Nurses), copyright 2010, the nursing book indicated, in part, Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines .Nurses document their work and outcomes for a number of reasons: the most important is for communicating within the health care team and providing information for other professionals .to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care. During a concurrent observation and interview on 6/21/21, at 9:15 a.m., with Resident 430, the resident was observed lying in bed and watching TV. Resident 430 stated, I've been here a few weeks. I'm a diabetic (a group of diseases that result in too much sugar in the blood) and am on insulin (a medication used to lower blood sugar level) therapy. During a review of Resident 430's Medication Administration Record (MAR), the MAR dated 6/21, indicated, Blood sugar check two times a day for DM (Diabetes Mellitus). NOTIFY MD (Medical Doctor) IF BS (Blood Sugar) < 70 or > 250 (less than 70 or more than 250). On 6/12/21 at 9 p.m., the MAR indicated, Resident 430 had a blood sugar level of 285. Review of Progress Notes (Nursing), dated 6/12/21 through 6/15/21, there was no documented physician notification of Resident 430's high blood sugar reading during this timeframe. During a concurrent interview and clinical record review of Resident 430's MAR, dated 6/2021, and Progress Notes on 6/24/21 at 9:05 a.m., with a licensed nurse (LN 1). LN 1 reviewed Resident 430's clinical record and was unable to locate any documentation the MD was notified of the high blood sugar level on 6/12/21 and stated, It should have been documented. During a telephone interview with LN 3 on 6/24/21, at 4:35 p.m., LN 3 confirmed she notified MD 1 of Resident 430's high blood sugar level on 6/12/21 but forgot to document MD 1 was notified. LN 3 stated she also received a physician order to continue Resident 430's current treatment but did not document the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555458 If continuation sheet Page 5 of 5