Health inspection·October 9, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to follow a care planned intervention to monitor the intake and output of one of two sampled residents (Resident 1). Residents Affected - Few This failure had the potential for Resident 1 to experince negative outcomes. Findings: During a review of Resident 1's Care Plan undated, indicated in part, Resident 1 had a urinary tract infection on 6/22/24, with an intervention for staff to Monitor intake and output. During a concurrent record review and interview, on 10/9/24, at 4:21 p.m., with the Director of Nursing (DON 1) and Medical Records Director (MRD 1), Resident 1's Care Plan was reviewed. The DON 1 and the MRD 1 verbalized they were unable to provide documentation indicating Resident 1's care planned intervention to monitor intake and output was carried out by staff. During a review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 2001, indicated in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further indicated in part The comprehensive, person-centered care plan .describes the services that are to be furnished. Page 1 of 2 555794 555794 10/09/2024 Sherwood Oaks Post Acute 250 Fairview Road Thousand Oaks, CA 91361

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to follow physician orders for catheter care, for one of two sampled residents (Resident 1). Residents Affected - Few This failure had the potential for Resident 1 to experience negative outcomes including an increased risk for developing urinary tract infection(s). Findings: During a concurrent interview and record review, on 10/9/24, starting at 4:30 p.m., with the Director of Nursing (DON 1) and the Medical Records Director (MRD 1), Resident 1's Treatment Administration Record (TAR), was reviewed. Resident 1's TAR indicated in part Resident 1 had a physician order of Indwelling catheter: Monitor for change in urine character .every shift for f/c (foley catheter) management. The physician order was active from 5/30/24 to 8/23/24. Resident 1's TAR indicated missing/blank entries on 6/8/24, 6/17/24, 7/2/24, 7/5/24, 7/7/24, 7/19/24, 7/21/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/8/24, 8/12/24, 8/13/24. The DON 1 and MRD 1 confirmed the missing entries. During a concurrent interview and record review, on 10/9/24, starting at 4:30 p.m., with the DON 1 and the MRD 1, Resident 1's TAR was reviewed. Resident 1's TAR indicated in part Resident 1 had a physician order to Monitor proper placement, no kinking or compression that could obstruct urine flow to a gravity bag during catheter care Q (every) shift every shift for f/c management. The physician order was active from 5/30/24 to 8/23/24. Resident 1's TAR indicated missing/blank entries on 6/8/24, 6/17/24, 7/2/24, 7/5/24, 7/7/24, 7/19/24, 7/21/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/8/24, 8/12/24, 8/13/24. The DON 1 and MRD 1 confirmed the missing entries. 555794 Page 2 of 2