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. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555794 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 555794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherwood Oaks Post Acute 250 Fairview Road Thousand Oaks, CA 91361 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)