F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation, interview and record review, the facility failed to ensure a shower room was sanitary
and in good repair.This failure had the potential to violate Residents rights to receive care in a safe, clean
and homelike environment. During a concurrent observation and interview, on 7/31/25, beginning at 12:55
p.m., with the Maintenance Director (MTD 1), a shower room located in hallway four was inspected. In the
shower room, the shower doorframe was in a state of disrepair, the wall had broken tiles, the call light cord
was broken and had been replaced with plastic bags in lieu of replacing the cord, a bottle of lotion was
stored atop a dirty sharps container and a used razer was stored in a plastic cup atop a box of clean
gloves. The MTD 1 confirmed and verbalized the doorframe was in a state of disrepair, there were broken
tiles, the call light cord needed to be replaced, staff had stored a lotion bottle atop a dirty sharps container
and a dirty razer was stored atop a box of clean gloves. During a review of the facility's policy and
procedures titled Homelike Environment dated 2/21, indicated in part Residents are provided with a safe,
clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent
possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics
include.clean, sanitary and orderly environment.
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
07/31/2025
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)
F 0813
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to adhere to its policy and procedure
for foods brought in by family and visitors. This failure had the potential for Residents to consume spoiled
food and to experience negative outcomes.During a concurrent observation and interview, on 7/31/25, at
1:21 p.m., with the Infection Preventionist (IP 1), the resident refrigerator was inspected. Inside the resident
refrigerator was a unlabeled and undated plastic bag containing a head of lettuce which had partially turned
brown and two unlabeled and undated half eaten sandwiches in plastic containers. The IP 1 confirmed the
observations and verbalized the resident food items should have been labeled with a resident's name and
date. When asked how long these items had been in the resident refrigerator the IP 1 could not give a
definitive answer but did verbalize facility practice was to clean out the refrigerator once a week on
Friday's.During a review of the facility's policy and procedure titled Foods Brought by Family/Visitors dated
3/22, indicated in part Perishable foods are stored in re-sealable containers with tightly fitting lids in a
refrigerator. Containers are labeled with the resident's name, the item and the use by date.The nursing
and/or food service staff will discard any foods prepared for the resident that show obvious signs of
potential foodborne danger.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555794
If continuation sheet
Page 2 of 2
