Health inspection·April 27, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to accurately document the health condition related to medical condition for two of five sampled residents (Resident 9 and Resident 196), using the Minimum Data Set ((MDS - a tool used to assess and plan care of residents in a nursing facility) when: Residents Affected - Few 1. For Resident 9 - had a missing diagnosis for anxiety. 2. For Resident 196 - had a missing diagnosis for depression. This facility failure resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS). Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI), dated 10/2019, the P&P indicated, Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. 1. During a review of Resident 9's Face Sheet (FS), dated 4/23, the FS indicated, Resident 9 had a diagnosis of Unspecified Anxiety Disorder. During a review of the Physician's Order (PO), dated 4/19/23, the PO indicated, Resident 9 is to be given Lorazepam concentrates 2 milligrams/milliliter (mg/ml), 0.1 ml orally (by mouth) every six hours as needed for Anxiety manifested by restlessness and/or shortness of breath. During a review of the Physician Order and Informed Consent Verification Form (POICVF), dated 4/23, the POICVF indicated, the informed consent for the Lorazepam for diagnosis of Anxiety was obtained from Resident 9's responsible party. During a review of Resident 9's Care Plan (CP) - (a plan developed by the facility to identify resident's needs care and needs), dated 2/23, the CP indicated, Resident 9 uses anti-anxiety medication related to anxiety disorder. During a concurrent interview and record review, on 4/27/23, at 10:30 a.m., with the Director of Nursing (DON), Resident 9's most recent MDS section I, dated 2/17/23 was reviewed. The MDS indicated, a missing diagnosis for Anxiety. The DON stated, I already knew my deficiency. I missed the diagnosis for Anxiety. The DON further stated, I should have coded it. (continued on next page) 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: 555857 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 04/27/2023 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)