Health inspection·April 17, 2024

F 0641 wounds, Level of Harm - Minimal harm or potential for actual harm g. Section M1200 gets surgical wound care treatments, application of nonsurgical dressings, and application of dressings to feet. Residents Affected - Few During a review of Resident 1's Progress Note (PN): - Dated 2/2/24 at 4:04 p.m., Patient requires one person assist with transfer, personal hygiene, adl's and bed mobility. Patient uses wheelchair for locomotion. - Dated 2/3/24 at 9:12 p.m., Requires one person extensive assist with transfer, personal hygiene, adl's and bed mobility. - Dated 2/4/24 at 10:07 a.m., the PN indicated, Pt requires one person ext assist w/ transfer, personal hygiene, ADL's and bed mobility pt uses wheelchair for locomotion. - Dated 2/5/24 at 2:12 p.m., the PN indicated, Resident needs 1person extensive assist w/ bed mobility transfer toileting and ADL's . Uses wheelchair for locomotion. During a review of Resident 1's MDS, dated 2/6/24, the MDS indicated: a. Section A2300 the assessment observation end date was 2/6/24, b. Section GG0115 no impairment in functional ROM of lower extremities that interfered with daily functions or placed the resident at risk of injury, c. Section GG0120 walker and wheelchair were not normally used, d. Section GG0170 required helper to provide verbal cues and/or touching/steadying and/or contact guard assistance to complete walking 10 feet, walking 50 feet with two turns and walking 150 feet. Required helper to provide set up or clean up prior to or following moving fromsitting to standing, transferring from chair/bed to chair, transferring to a toilet, and transferring to tub/shower. Does not use a wheelchair or scooter, e. Section I8000 has left and right foot drop During a concurrent interview and record review on 3/27/24 at 4:20 p.m., with the Assistant Director of Nursing (ADON) and the Director of Rehabilitation (DOR), Resident 1's: - PPN dated 10/31/23, - MDS, dated [DATE], - PN's dated 2/2/24 at 4:04 p.m., 2/3/24 at 9:12 p.m., 2/4/24 at 10:07 a.m., and 2/5/24 at 2:12 p.m., and - MDS, dated [DATE] were reviewed. ADON stated Resident 1 had major surgery just prior to admission and if section J2000 and J2100 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555458 If continuation sheet Page 2 of 4 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 04/17/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were answered correctly, then J2300-5000 would have identified the surgery. ADON also stated Resident 1 did use a wheelchair and had right foot drop, not left foot drop. ADON further stated the NN and PN don't match the MDS. DOR stated their assessment of Resident 1 was limited to their time during therapy. During a review of Resident 2's AR, dated 2/29/24, the AR indicated, Resident 2 was a [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. During a review of Resident 2's PPN, dated 1/30/24 at 12:35 p.m., the PPN indicated, Resident 2 was admitted 3/2024 after falling off his scooter and fracturing his right hip. Resident 2 had a history of an amputation (surgically cutting off) of his right leg through tibia (larger shin bone) and fibula (smaller shin bone) and had a history of amputation of his left great toe. Resident 2 continued to be wheelchair bound with weakness of both lower extremities. During a review of Resident 2's MDS, dated 12/20/23, the MDS indicated, a. Section A2300 the observation end date was 12/20/23 b. Section GG0115 no impairment in functional ROM of lower extremities that interfered with daily functions or placed the resident at risk of injury, c. Section GG0120 wheelchair was not normally used, and d. Section GG170 uses a wheelchair. During a concurrent interview and record review on 3/27/24 at 4:20 p.m., with the ADON and the DOR, Resident 2's PPN dated 1/30/24 and MDS dated [DATE] were reviewed. ADON and DOR stated, the MDS sections don't match, have conflicting information, and don't match the information on the PPN. DOR further stated their assessment of Resident 2 was limited to their time during therapy. During a review of the Centers for Medicare & Medicaid (CMS) Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (User's Manual), dated October 2023, the User's Manual indicated, GG0115 . Steps for Assessment 1. Review the medical record for references to functional range-of-motion limitation during the 7-day observation period. 2. Talk with staff members who work with the resident as well as family/significant others about any impairment in functional ROM . GG0120 . Steps for Assessment 1. Review the medical record for references to locomotion during the 7-day observation period. 2. Talk with staff members who work with the resident as well as family/significant others about devices the resident used for mobility during the observation period . GG0170 . Steps for Assessment 1. Assess the resident's mobility performance based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident's medical record during the assessment period . If the resident's functional status varies, record the resident's usual ability to perform each activity. Do not record the resident's best performance and do not record the resident's worst performance, but rather record the resident's usual performance . I8000 . There may be specific documentation in the medical record by a physician . J2100 . Major Surgery Refers to a procedure that meets the following criteria: 1. The resident was an inpatient in an acute care hospital for at least 1 day in the 100 days prior to admission to the skilled nursing facility (SNF), and 2. The surgery carried some degree of risk to the resident's life or the potential for severe disability . J2000 . Steps for Assessment . 2. Review the resident's medical record to determine whether the resident had major surgery during the inpatient hospital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555458 If continuation sheet Page 3 of 4 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 04/17/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm stay that immediately preceded the resident's Part A admission . J2300-5000 . Code surgeries that are documented to have occurred in the last 30 days, and during the inpatient stay that immediately preceded the resident's Part A admission, that have a direct relationship to the resident's primary SNF diagnosis. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555458 If continuation sheet Page 4 of 4