Thousand Oaks Post Acute, LLC

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 16.67% when five medication errors occurred out of 30 opportunities during the medication administration observation for two of ten residents (Residents 86 and 23). These failures in medication administration resulted in medications not being given according to the physician's orders and had the potential for Residents 86 and 23 to experience inadequate management of conditions or side effects such as upset stomach and nausea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately store food for food service safety when:1. Food was not properly labeled in two of four facility freezers (Freezer 2 and Freezer 3).2. Food was not properly labeled in two of two resident refrigerators (West Wing Refrigerator and East Wing Refrigerator).3. Employee food items were being stored inside one of two resident refrigerators (West Wing Refrigerator). These failures had the potential for expired foods to be served to the residents, which could cause illness and for residents to be exposed to foodborne disease through contamination of resident food items.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the door of one of one trash compactor closed. This failure had the potential to attract pests to the exposed trash, which could then spread disease to residents and staff in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promoted residents' dignity and respect for two of 24 sampled residents (Resident 121 and 108) when:1. A Facility Staff (FS) fed Resident 121 while standing and not at eye level.2. Two unopened bottles of Ensure Plus labeled with another resident's name were found on the table of Resident 108. These failures violated residents 121 and 108's right to be treated with respect and dignity and had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 8) was free from unnecessary psychotropic medications (medications that affect brain activities associated with mental processes and behavior) when Resident 8 received an as needed (PRN) psychotropic medication for more than 14 days. This failure resulted in Resident 8 receiving an as needed psychotropic medication for an extended time period and had a risk of medication side effects, such as drowsiness and confusion.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of the Discharge Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment for one of three sampled residents (Resident 71) reviewed for Resident Assessments. This failure had the potential to result in inadequate monitoring of Residents 71's progress and decline and a lack of resident specific information to CMS for payment and quality measure monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's hearing status in the comprehensive admission MDS (MDS- a federally mandated resident assessment tool) assessment was accurately coded per Resident Assessment Instrument (RAI- comprehensive assessment and care planning process used by nursing home) guidelines for one of 24 sampled residents (Resident 33). This failure had the potential for Resident 33 not to receive the necessary care, treatment, and services to attain his highest practicable level of functioning.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long term care) was accurately completed for one of three sampled residents (Resident 62) reviewed for PASRR.This failure had the potential for Residents 62 not to receive the most appropriate care and services for his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for hearing impairment for one of 24 sampled residents (Resident 33). This failure had the potential to delay Resident 33's care, treatment, and services to maintain or improve his hearing abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate use of lidocaine patches (medication to treat pain), when the nursing staff failed to remove lidocaine patches after 12 hours per manufacturer recommendations for one out of ten residents (Resident 86) during the medication administration observation. This failure had the potential for Resident 86 to receive an excessive dose of lidocaine which could result in side effects, including swelling and skin irritation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards of practice for one of ten residents (Resident 23) observed during the medication administration observation, when Resident 23's pain scores were incorrectly documented in the medical record. This failure resulted in inaccurate documentation of Resident 23's pain which could cause inaccurate clinical assessment of pain management medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), was cared for by staff (IP and CNA2) using enhanced barrier precautions (gloves and gown). This failure had the potential to result in the spread of harmful germs from contaminated uniforms to residents during the delivery of care. During a review of Resident 1's physician orders dated 3/5/26, the orders indicated Resident 1 to have Enhance Barrier Precautions due to: foot and right buttocks wounds every shit for infection control and prevention. During a review of the facilities P&P titled, Enhanced Barrier Precautions, dated January 2025, the P&P indicated, EBP are indicated for residents with any of the following: Wounds, even if the resident is not known to be infected or colonized with a Multi-Drug-Resistant Organism (MDRO). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided quality care when the facility failed to: Administer Glargine (insulin used for regulating blood sugar) for 3 days, on 8/21 at 9 p.m., 8/22 at 9 a.m. and 9 p.m., and 8/23 at 9 a.m. 2. Notify/Communicate to the charge nurse and physician the missed doses of Glargine. 3. Acquire insulin to meet Resident 1's needs. 4. Administer Glargine from a properly labeled medication container. 5. Clarify the order for finger stick blood sugar (FSBS- a method of monitoring blood sugar levels) with the physician. 6. Failed to monitor blood glucose (BG- blood sugar). 7. Realize the need for monitoring blood sugar. As a result of these failures, Resident 1 was transferred to an acute care hospital due to abnormally high blood sugar (593) for evaluation and treatment and ultimately died. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1): 1. Had a baseline care plan (BCP- initial instructions for care right after admission) developed for diabetes management. 2. Had BCP developed for abdominal binder (a wide, elastic compression belt worn around the abdomen) use. 3. Had BCP interventions (specific actions to be taken) that were applicable to Resident 1 regarding NPO (nothing by mouth) status. These failures resulted in Resident 1 being transferred to the hospital for elevated blood sugar and had the potential for choking or aspiration (food or liquids entering the lungs). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided care according to accepted professional nursing standards (actions that ensure safe nursing practice) when the facility failed to: Develop a baseline care plan (BCP- initial instructions for care right after admission developed by using the nursing process) for diabetes management. 2. Develop care plans (CP- a detailed outline of health needs, goals, and preferences that guides care to ensure consistent and appropriate care) with resident specific interventions. 3. Clarify conflicting orders for the way to (route) administer medication. 4. Follow physician order for monitoring blood pressure (BP). 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1):1. Had appropriate alternatives to bed rails identified and tried.2. Was adequately assessed for bed rail use. 3. Had their bed and mattress assessed for bed rails (metal bars attached to the bed) prior to the bed rail installation. 4. Had the appropriately trained staff install the bedrails. These failures had the potential to result in an increased risk of entrapment (caught, trapped, entangled, or strangled in the space in or about the bed rail). [...]

Inspectors wroteBased on interview and record review, the facility failed to have competent nurses who possessed the knowledge, skills, and judgment required to provide safe care for one of two sampled residents (Resident 1), when the facility failed to ensure: Licensed nurses knew to contact the physician when they did not administer Glargine (insulin- medicine used to regulate blood glucose levels) as ordered. 2. Licensed nurses knew to communicate to the charge nurse the missed doses of Glargine. 3. Licensed nurses knew to contact the physician when the medication administration record did not include blood glucose monitoring. 4. Licensed nurses knew to clarify conflicting orders for how to (route) administer medication. For Resident 1, these facility failures resulted in unsafe nursing care and admission to the hospital for an avoidable decline.1. According to Fundamentals of Nursing ([NAME] et al; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had complete and accurate documentation in their health record. This failure resulted in the planning and delivery of care based on inaccurate resident assessments. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 389), Information in a patient's record provides a detailed account of the level of quality of care delivered. The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important nursing responsibility. During an interview on 9/25/25 at 3:45 p.m. with a licensed nurse (LN1), LN1 stated LN1 texted the physician to clarify Resident 1's route of medication administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had an accurate diagnosis recorded on their Minimum Data Set Assessment ([MDS] a tool for implementing standardized assessment and for planning care). This facility failure resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS).

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly notify the physician of the x-ray results for one of two sampled residents (Resident 1). This failure resulted in a delay in treatment for Resident 1's dislocated hip and increased the potential for Resident 1 to experience unnecessary pain or worsening of her condition.

Inspectors wrote2. An admission Record revealed the facility admitted Resident #103 on 01/25/2025. According to the admission Record, the resident had diagnoses that included other speech and language deficits following cerebral infarction, dysphagia, aphasia, apraxia, dementia in other diseases classified elsewhere, seizures, and systolic heart failure. Resident #103's discharge MDS, with an Assessment Reference Date (ARD) of 02/04/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS also indicated the resident discharged to a short-term general hospital setting. Resident #103's Order Summary Report, revealed an order dated 02/04/2025, for the resident to discharge to home with home health on 02/04/2025. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) as required for 1 (Resident #64) of 3 residents reviewed for PASRR.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three resident's (Resident 1) right to be treated with dignity when a Certified Nursing Assistant (CNA 1) removed bra while in Resident 1's room. This facility failure had the potential to result in a loss of dignity for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was treated with respect and dignity when the Certified Nursing Assistant (CNA) 1 repeatedly told Resident 1 to wait for a brief change. This failure had the potential to negatively impact Resident 1's sense of self-worth, self-esteem, and overall quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) who had a colostomy (an opening that connects the digestive tract to the surface of the belly to allow for waste material and gas to leave the body) received care consistent with professional standards of practice when Resident 1's colostomy bag was removed, emptied, and placed back on by unlicensed staff. This failure had the potential to place Resident 1 at risk for complications such as infections or dislodgment of the colostomy bag.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand washing while providing colostomy (an opening that connects the digestive tract to the surface of the belly to allow for waste material and gas to leave the body) care with one of three sampled resident (Resident 3). This failure had the potential to cause infection to Resident 3's colostomy site.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had timely access to their medical records. This failure resulted in Resident 1's legal representative delayed access to their health history and violated the resident's right to medical record access.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) on dry food storage and kitchen sanitation, and ensure food quality and safety standards were met when: 1) stored food products found in the dry food storage room [ROOM NUMBER] were beyond the indicated use by date labels, and 2) the temperature of the sanitizing solution used to cleanse/sanitize non-food contact work surfaces and kitchen equipment was not measured. These failures had the potential to contaminate foods served to the residents, that can lead to serious food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment when residents shared closets/cabinets in rooms (18, 19, 20, and 36) for one of 20 sampled residents (Resident 54), and eight unsampled residents (Resident 58, 12, 28, 80, 302, 41, 7, and 83). This failure resulted in the residents not having a personalized, homelike atmosphere and could affect their psychological well-being

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards in clinical practice and documentation were met, when: 1) staff administered pain medication to two of 20 sampled residents (Resident 20 and Resident 97), that did not meet the medication order parameter for its indication, and 2) staff follow-up assessment and education were not done, after resident refusal of apical pulse measurement, for two of 20 sampled residents (Resident 2 and Resident 8). These failures had the potential to inappropriately identify and manage resident health issues that may lead to serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriate call light for one of 20 sampled residents (Resident 54). This failure has the potential for the resident to not receive necessary care and could result in complications and poor psychosocial outcome.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of 20 sampled residents (Resident 82) was free of physical restraints. This failure had the potential to negatively affect the resident's physical mobility and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to update a care plan for one of twenty sampled residents (Resident 85) after returning from the hospital. This failure resulted in improper monitoring of Resident 85 for bleeding episodes related to chronic anticoagulant (commonly known as blood thinners, are chemical substances that prevent or reduce chance of getting a deep vein thrombosis [DVT] - a blood clot) use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the activity assistant was trained to provide activities according to resident's preference and interests for one of twenty sampled residents (Resident 35). This failure resulted in Resident 35 not receiving activities that were person centered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 20 residents (Resident 35) was monitored for signs and symptoms of a urinary tract infection ([UTI] bladder infection). This failure had the potential for the resident to have a catheter (a tube that is inserted into the bladder, allowing urine to drain) associated urinary tract infection (CAUTI)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medication was administered as prescribed for one of six sampled residents (Resident 453). This failure had the potential for the resident to have ineffective pain management and resulted in a medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication cart and narcotic storage boxes were locked, secured, and inaccessible to unauthorized staff, residents, and visitors when one of five medication carts was left unlocked and unattended in a resident hallway. This failure had the potential for visitors, residents, and unauthorized staff to access medications and narcotics stored in the medication cart.