Health inspection·August 12, 2025

F 0578 admission. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555857 If continuation sheet Page 2 of 4 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 08/12/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure infection control practices were implemented when: 1. Rehabilitation staff entered a Contact Isolation (infection control measures used to prevent spread of infections through direct (touching resident) or indirect (residents environment)) room without personal protective equipment (PPE - protective clothing such as gowns, gloves, face shields or other equipment) for one of three sampled Residents (Resident 2). 2. Proper identifier for enhanced barrier precautions (EBP - an infection control intervention used to reduce transmission of MDROs (multidrug-resistant organisms that includes use of PPE during high-contact resident care) was not placed on Residents door alerting staff to use PPE, for one of three sampled residents (Resident 3). These deficient practices had the potential to cause cross contamination and the spreading of MDRO's among residents. 1. During a review of the facility's policy and procedure P&P titled, Enhanced Standard Precautions (ESP), undated, the P&P indicated, Policy Statement: . to reduce and/or prevent the transmission of pathogens, including Multi-Drug-Resistant Organisms (MDRO) and viruses. D. Contact Precautions: . gowns and gloves are required for all resident contact. Contact Precautions must be implemented for a resident known or suspected to be infected or colonized with micro-organisms contained within such things as excessive uncontained wound drainage, fecal incontinence or other body fluids that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Signs used to Alert staff of Contact Precautions: d) Signs: Color coded signs will be used to alert staff of the implementation of isolation precautions, while protecting the privacy of the resident. Orange is the color code for Contact Precautions. During an observation on 07/30/25 at 12:20 p.m., in the hallway outside room [ROOM NUMBER], observed PPE (personal protective equipment - protective clothing such as gowns, gloves, face shields or other equipment) and an orange contact isolation precautions sign on the door that occupied two residents. Observed a staff member at the bedside of Resident 2 not wearing PPE, gown or gloves. Witnessed this staff member leave the Residents room without using hand sanitizer or washing hands, enter the nurses station and proceed back to room [ROOM NUMBER] and enter with PPE or hand sanitizer. During an interview on 07/30/25 at 12:20 p.m. with Director of Rehab (DOR), DOR stated she did not know Resident 2 was on isolation precautions and assumed the isolation was for another resident in the room. The DOR stated Resident 2 was newly admitted to the facility and does not know Resident 2's isolation stating, did not check prior to seeing Resident 2. DOR acknowledged she saw the contact isolation sign on the door but states didn't know if PPE is to be worn when entering the room. During an interview on 07/30/25 at 12:25 p.m., with Licensed Nurse (LN) 1, LN1 stated Resident 2 was on contact isolation precautions for an active MDRO infection being treated with antibiotics and confirmed the DOR should should have worn PPE, including gown and gloves when entering the room. During an interview on 07/30/25 at 1:10 p.m. with Nursing Supervisor (NS), NS confirmed that Resident 2 was on contact isolation precautions for MDRO stated that staff should be wearing gowns when entering the room. The NS agreed that DOR should have worn PPE, including gown and gloves. 2 . During a review of the facility's policy and procedure (P&P) titled, Enhanced Standard Precautions (ESP), undated, the P&P indicated, . Signs: Color-coded signs will be used to alert staff of the implementation of isolation precautions, while protecting the privacy of the resident. During an interview on 07/30/25 at 12:25 p.m. with LN1, LN1 stated that residents on EBP, require staff to wear PPE during patient care and that an EBP sign should be posted outside the resident's room. During an observation on 07/30/25 at 12:45 p.m., in room [ROOM NUMBER], Resident 3 was observed in bed, with a Foley bag on the lower side of the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555857 If continuation sheet Page 3 of 4 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 08/12/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete bed. Resident 3 room did not have isolation (EBP) sign posted on the door to alert staff.During an interview on 07/30/25 at 1:10 p.m. with NS, the NS confirmed that a Resident has an indwelling device such as a Foley catheter (tube placed and left in the bladder to drain urine into a bag), they would be placed on EBP (enhanced barrier precautions - an infection control intervention used to reduce transmission of MDROs that includes use of PPE during high-contact resident care) and a sign would be placed on Residents door alerting staff to use PPE. The NS acknowledges there was no EBP sign on Resident 3's door, and stated the signage should have been posted upon admission. Event ID: Facility ID: 555857 If continuation sheet Page 4 of 4