Inspection·October 23, 2019

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 37) had a splint applied to the left hand as ordered by the medical doctor (MD). Residents Affected - Few This facility failure had the potential for Resident 37 to suffer complications, such as worsened contracture (a permanent shortening of muscle, tendon, or scar tissue) producing deformity or distortion. Findings: According to [NAME] and Perry's, 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice, Nurses are obligated to follow physician order unless they believe they orders are in error or would harm clients. During an observation on 10/21/19, at 4:14 p.m., Resident 37's left hand was noted to be clenched into a fist, and no splint was in place. Resident 37's Responsible Party (RP) manually opened Resident 37's fingers and stated Resident 37's splint is supposed to be on. During a review of the clinical record for Resident 37, the Order Listing Report, dated 4/12/19, indicated in part, Splint wearing schedule: beige splint for left hand, on 2 hours/off 2 hours during waking time i.e. after breakfast on approx 9:30-12:30, off for lunch, on in p.m approx. 2:00-5:00, off during dinner . During a review of Resident's 37's, Treatment Administration Record (TAR), dated October 2019, did not contain splint application and removal documentation. A review of Resident's 37's, Care Plan Report, dated 7/26/19, indicated a focus is, Resident at risk for skin breakdown to left palm related to neurological dysfunction to left hand causing left hand contracture. One intervention states, Splint wearing schedule: beige splint for left hand, on 2 hours/off 2 hours during waking time i.e. after breakfast on approx 9:30-12:30, off for lunch, on in pm approx. 2:00-5:00 off during dinner . During an interview with the Administrator (ADM), and the Director of Nursing (DON), on 10/21/19, at 5:16 p.m., the DON stated there is no mechanism for documentation of the splint being applied or removed, and acknowledged that the splint was not in place as it should have been. The facility policy and procedure titled, Resident Mobility and Range of Motion, dated 1/1/19, indicated in part, Interventions may include therapies, the provision of necessary equipment, and/or exercises and is based on professional standards of practice . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555857 If continuation sheet Page 2 of 3 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 555857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakview Skilled Nursing 3557 Campus Drive Thousand Oaks, CA 91360 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and medical supplies were properly labeled and stored when: 1. Two vials of expired heparin (a blood thinning medication) were found in a facility emergency medication kit (E-Kit) (a kit that stores a variety of medications intended for emergency resident use). 2. Expired supplies were found in the intravenous (IV) supply cart. These failures had the potential for residents to receive medications which may be ineffective or altered, and for residents to to have potential complications from use. Findings: 1. During an observation and concurrent interview with a licensed nurse (LN1), on [DATE], at 10:20 a.m., two expired vials of heparin were found in a facility E-Kit with a labeled expiration date of [DATE]. LN1 confirmed the two vials of heparin were expired and acknowledged she would contact pharmacy to get them replaced. 2. During an observation on [DATE], at 10:40 a.m., in the IV supply cart the following items were found: a. Four expired povidone-iodine prep pads (an antiseptic used to clean the skin to prevent infection) were found. Three povidone-iodine prep pads were labeled with an expiration date of 9/19 and one povidone-iodine prep pad was labeled with an expiration date of 8/18. b. One expired chloraprep applicator (an antiseptic used to clean the skin to prevent infection) was labeled with an expiration date of 3/14. c. Six expired chloraprep swab sticks were expired. Four chloraprep swab sticks were labeled with an expiration date of 5/16. Two chloraprep swab sticks were labeled with an expiration date of 9/13. d. One expired alcohol swab stick (an antiseptic used to clean the skin to prevent infection) was found with an expiration date of 5/11. During an interview on [DATE], at 10:56 a.m., LN1 confirmed the supplies were expired and stated We will dispose of these. The facility policy and procedure titled, Disposal/Destruction of Expired or Discontinued Medication, dated 5/10, indicated in part, Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555857 If continuation sheet Page 3 of 3