Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thousand Oaks Post Acute, Llc during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate after five errors were found in 30 opportunities. An LVN omitted an ordered oral rinse, gave an eye vitamin at the wrong dose, and administered metoprolol without food as ordered for one resident. For another resident, an LVN gave the wrong ibuprofen dose, did not give it with food, and administered acetaminophen even though the pain score was outside the ordered PRN range. RN, DON, and CP interviews confirmed meds were to be given per the prescriber’s orders.
Food items were found improperly stored and unlabeled in multiple freezer and resident refrigerator areas. Unopened cheese and waffles in the kitchen freezers had no dates, several Pedialyte and Ensure Plus bottles in resident refrigerators were unlabeled, and employee food items, including hummus, a lunch bag, and an opened container of potato salad, were stored in a resident refrigerator despite the unit being for resident use only.
Trash Compactor Left Open: The facility failed to keep the door of one of one trash compactor closed. During observations, the compactor door was left open with trash exposed in the outdoor garbage collection area, and KS and the DS both confirmed the lid must always remain closed. The facility policy stated waste must be properly contained in dumpsters or compactors with lids covered.
Failure to preserve resident dignity during feeding and room supply placement: A resident with failure to thrive, anemia, and muscle weakness was fed by a staff member who stood over her instead of sitting at eye level, while another resident with weakness, difficulty walking, and depression found two unopened Ensure Plus bottles labeled for another resident on her bedside table. Staff and the DON acknowledged the feeding approach was not dignified, and the misplaced supplements were confirmed to be in the wrong room.
A resident with anxiety received a PRN alprazolam order that exceeded the 14-day limit for initial psychotropic use. The MAR showed multiple PRN doses were administered over the course of the order, and the DON confirmed the order was the resident’s first PRN psychotropic order and was written for 27 days, contrary to facility policy and the CP’s explanation of the 14-day limit.
Delayed Discharge MDS Completion: A resident with dementia, HTN, and muscle weakness had a discharge MDS coded as a return-anticipated discharge, but the RN Assessment Coordinator signed it well after the required timeframe. The DON confirmed the discharge MDS was completed late and stated the RAI submission timelines were not followed.
Inaccurate MDS Hearing Coding for a Resident with Hearing Difficulty. A resident’s admission MDS coded hearing as adequate even though the resident, RP, CNA, SLP, and COTA all described ongoing hearing problems, including needing questions repeated, speaking louder, and facing the resident to communicate. The SSD stated the hearing status was not coded accurately because it was based only on her assessment, and the DON stated the RAI manual was not followed.
A resident with psychotic disorder, CKD, and muscle weakness had an inaccurate PASRR Level 1 screening: the MDS showed psychotic disorder as an active diagnosis, but the PASRR marked serious mental illness as “No” and left the psychosis-related diagnosis field blank. The DON confirmed the PASRR was inaccurately completed during record review with surveyors.
Failure to develop a comprehensive care plan for hearing impairment. A resident who was hard of hearing and used hearing aids was observed asking for questions to be repeated and stating he could not hear well. CNA and SLP interviews confirmed ongoing hearing difficulty, and the MDSC, ADON, and DON all acknowledged there was no documented care plan addressing the resident's hearing impairment.
A resident with knee osteoarthritis had lidocaine 5% patches applied to both knees, but the patches were left on overnight instead of being removed after 12 hours. During a med pass, an LPN found the old patches still in place and removed them before applying new ones. The RN, DON, and consultant pharmacist stated the patches should be on for 12 hours and then off for 12 hours, and the facility policy defined medication error as not following manufacturer specifications.
Inaccurate Pain Score Documentation in MAR: An LVN administered PRN acetaminophen and ibuprofen to a resident for pain, but documented an incorrect pain score on the MAR. The LVN stated the resident’s actual pain was 5/10, yet entered a lower score for acetaminophen and a different score for ibuprofen. The DON and consultant pharmacist confirmed the documentation was not accurate and did not reflect the resident’s actual condition.
A resident with foot and buttocks wounds had active physician orders and posted signage requiring Enhanced Barrier Precautions (EBP), including gown and glove use, during high-contact care such as hygiene and brief changes. Facility policy, state AFL guidance, and CDC recommendations all supported the need for EBP for residents with wounds. Despite these requirements, an IP and a CNA were observed changing the resident’s brief without wearing gowns, and both later acknowledged they should have been using this PPE. The ADM reported being aware of the infection control issue after being informed by staff.
A resident with diabetes and multiple comorbidities did not receive prescribed Glargine (insulin) for several days due to medication unavailability and lack of staff action to obtain or clarify orders. Staff failed to notify the physician about missed doses, did not use the emergency medication kit, and administered insulin from another resident's supply. Blood glucose monitoring was not performed as ordered, and the need for monitoring was not recognized. The resident developed severe hyperglycemia and was transferred to the hospital, where they died.
A resident with a history of stroke, diabetes, dysphagia, and a gastrostomy tube was admitted without a baseline care plan addressing diabetes management, abdominal binder use, or appropriate interventions for NPO status. Staff confirmed that required care plans were missing or contained incorrect interventions, leading to the resident's transfer to the hospital for elevated blood sugar and further management.
A resident with diabetes, dysphagia, and psychiatric needs did not receive care according to professional standards. The facility failed to develop a baseline care plan for diabetes, used non-specific interventions, did not clarify medication administration routes, and did not follow physician orders for blood pressure monitoring or PRN Seroquel duration. Care plans were developed by LVNs instead of RNs, and psychiatric assessments were not incorporated into care planning. These failures led to the resident's hospitalization for severe hyperglycemia and subsequent death.
A resident with severe neurological and physical impairments was provided bed rails without documented attempts at alternatives, a complete safety assessment, or proper installation by trained staff. The decision was made based on a family request, with incomplete documentation and no evaluation of bed, mattress, or device compatibility, contrary to facility policy and FDA guidance.
Nurses failed to administer insulin as ordered, did not notify the physician or charge nurse about missed doses, and did not clarify conflicting medication administration routes for a resident with diabetes. Blood glucose monitoring orders were not correctly entered or followed, and medications were given by mouth despite enteral feeding orders. These failures led to unsafe care and hospital admission for diabetes management.
A resident's medical record lacked complete and accurate documentation, including missing records of physician communication, incorrect skilled nursing service entries, inaccurate risk assessment reporting, and repeated blood pressure values in the MAR. Nursing staff and the DON confirmed these inaccuracies, which were not in accordance with the facility's documentation policy.
A resident's Minimum Data Set (MDS) assessment was incorrectly coded to indicate an active diagnosis of benign prostatic hyperplasia (BPH), even though the resident did not have this condition. The MDS Coordinator acknowledged the error during a review, resulting in inaccurate data being reported to CMS.
A resident with a recent hip fracture and joint replacement had an x-ray showing a dislocated hip, but the nurse supervisor did not promptly notify the physician, resulting in a delay in treatment. The facility's policy required prompt reporting and escalation if the physician could not be reached, but these steps were not followed.
The facility failed to accurately code the MDS assessments for three residents, resulting in omissions of supplemental oxygen use for two residents with COPD and incorrect discharge status for another resident. Despite documentation and staff confirmation of oxygen therapy and discharge to home, the MDS assessments did not reflect the residents' actual care needs and status during the assessment periods.
A resident was admitted with a negative Level I PASRR, but after admission developed new mental health diagnoses and was prescribed antipsychotic and antianxiety medications. Despite these changes, facility staff did not resubmit the PASRR as required by policy, and interviews confirmed that the process for reassessment was not followed when the resident's condition and medication regimen changed.
A CNA removed her bra behind a curtain in a resident's room and stored it in the resident's closet, while the resident—who was cognitively intact and had multiple medical conditions—was present. The resident reported the incident as abuse and harassment. The CNA admitted to the act, and facility policy review confirmed this behavior violated standards for resident dignity and professional conduct.
A resident with moderate cognitive impairment and dependency for toileting was not treated with respect and dignity when a CNA repeatedly instructed them to wait for a brief change. The resident activated the call light twice, but the responding CNA did not provide the necessary assistance, citing the absence of the assigned CNA. The facility's policy on dignity and respect was not upheld, as all CNAs are responsible for answering call lights and providing care.
A resident with a colostomy in an LTC facility received improper care when an unlicensed CNA removed, emptied, and replaced the colostomy bag, contrary to facility policy that only allows licensed nurses to perform such tasks. The resident, who had a BIMS score indicating intact cognition, expressed concerns about the reuse of the colostomy bag. Interviews confirmed the CNA acted beyond their scope, as instructed by a licensed nurse to only empty the bag.
A facility failed to follow hand hygiene protocols during colostomy care for a resident. An LPN was observed changing gloves without washing hands between glove changes while providing care. The LPN acknowledged not washing hands, stating it made her hands sticky. The facility's policy required handwashing between glove changes.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility had a medication error rate of 16.67% after five medication errors were identified during 30 medication administration opportunities for two residents. During a medication pass observation, an LVN prepared medications for one resident but did not give the ordered chlorhexidine oral solution, gave only one tablet of Ocular Vitamins instead of the ordered two tablets, and administered metoprolol tartrate without offering food as ordered. The resident’s record showed metoprolol tartrate 25 mg was ordered twice daily for hypertension and to be given with food, Ocular Vitamins were ordered as two tablets daily, and chlorhexidine gluconate 0.12% solution was ordered twice daily for oral care. During another medication pass observation, an LVN prepared medications for a second resident and gave two tablets of ibuprofen 200 mg and two tablets of acetaminophen 325 mg. The resident’s record showed ibuprofen 200 mg was ordered every 4 hours as needed for breakthrough pain and to be given with food, and acetaminophen 325 mg was ordered as two tablets every 4 hours as needed for mild pain rated 1-3/10. The LVN stated she gave two tablets of ibuprofen instead of one, did not give it with food, and gave acetaminophen even though the resident’s pain score was 5/10, which was outside the ordered range. Interviews with the RN, DON, and consultant pharmacist confirmed that medications were to be administered according to the prescriber’s orders, including dose, indication, and parameters, and that medications ordered with food were to be given with a meal or snack. The facility’s medication error policy defined omission, dose, and unauthorized medication errors, and its medication administration policies stated medications and treatments were to be administered as prescribed.
Food Storage and Labeling Deficiencies
Penalty
Summary
Food was not properly labeled in two facility freezers and in two resident refrigerators. During a kitchen observation, one unopened and unlabeled plastic pack of individually wrapped sliced cheese was found in Freezer 2, and three unopened and unlabeled plastic bags of waffles were found in Freezer 3. The Dietary Supervisor confirmed the cheese and waffles did not have expiration dates and needed to be labeled before being placed in the freezer. The facility policy stated that all food shall be appropriately dated to ensure proper rotation by expiration dates, including received dates and expiration dates on unopened food. In the East Wing resident refrigerator, five unopened and unlabeled 500 ml Pedialyte bottles were observed, and the Dietary Supervisor stated all food in that refrigerator must be labeled. In another resident refrigerator, one unopened and unlabeled Ensure Plus bottle was found, and RN 2 confirmed it must be labeled when placed there. In the West Wing resident refrigerator, one unopened and unlabeled hummus item and one unlabeled lunch bag with food inside were observed, and the Dietary Supervisor stated employee food items should not be placed in the residents' refrigerator. RN 1 also found one opened container of potato salad with an employee's name in the residents' refrigerator and stated the refrigerator was for residents only and any food placed by staff must be tossed out.
Trash Compactor Left Open
Penalty
Summary
The facility failed to keep the door of one of one trash compactor closed. During a concurrent observation tour and interview on 7/6/26 at 8:30 AM in the outdoor garbage collection area, the trash compactor door was left open and trash was exposed. Kitchen Staff confirmed the trash compactor lid must be closed all the time. During an additional observation tour and interview on 7/8/26 at 8:35 AM in the outdoor garbage collection area, the trash compactor door was again left open, leaving trash at the bottom exposed. The Dietary Supervisor stated all kitchen trash went to the compactor and confirmed the trash compactor door must always remain closed. A review of the facility policy titled, Dispose of Garbage and Refuse, revised 1/2025, indicated that garbage and refuse containers are maintained in good condition and waste is properly contained in dumpsters or compactors with lids covered.
Failure to Preserve Resident Dignity During Feeding and Room Supply Placement
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity and respect for two residents. One resident, who had been readmitted with diagnoses including adult failure to thrive, anemia, and muscle weakness and was documented as having the capacity to understand and make decisions, was observed lying in bed while a staff member stood over her and fed her with the resident's neck hyperextended. The staff member remained standing throughout the meal and continued feeding until the resident finished lunch. During interviews, the staff member, RN 2, and the DON all acknowledged that staff were expected to sit and feed residents at eye level and that standing over a resident while assisting with meals was not acceptable and did not provide dignity and respect. A second resident, who had diagnoses including generalized muscle weakness, difficulty walking, and depression and was also documented as having the capacity to understand and make decisions, had two unopened bottles of Ensure Plus on the bedside table that were labeled with another resident's name. During the observation, the resident stated she was upset and confirmed the supplements did not belong to her. CNA 1 confirmed the bottles were labeled for another resident and were wrongly placed in the room, and RN 1 stated they were not supposed to be there. The facility's resident rights and dignity policies stated residents must be treated with kindness, dignity, and respect and cared for in a manner that promotes quality of life, dignity, respect, and individuality.
Unnecessary PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary psychotropic medication use when the resident received a PRN alprazolam order for longer than the allowed 14-day period. Resident 8 had diagnoses including Other Specified Anxiety Disorders and was initially admitted to the facility and later re-admitted. The resident had a physician order dated 5/21/25 for alprazolam 0.25 mg, to be given by mouth every 8 hours as needed for restlessness, and the order was discontinued on 6/17/25. The MAR showed the resident received three PRN doses in May 2025 and nine PRN doses in June 2025. During interviews, the Consultant Pharmacist and the DON stated that initial PRN psychotropic medication orders were limited to 14 days and could be re-evaluated after that period. The DON confirmed the alprazolam order was the first PRN order for the resident and was written for 27 days. The facility policy titled Dignity and Respect Psychoactive Medications also stated PRN psychotropic drug orders shall be limited to 14 days. The report also noted alprazolam adverse reactions include drowsiness, fatigue, tiredness, and confusional state.
Delayed Discharge MDS Completion
Penalty
Summary
The facility failed to ensure timely completion of the discharge MDS assessment for one of three sampled residents, Resident 71. Resident 71’s admission record showed diagnoses including dementia, hypertension, and muscle weakness. A physician telephone order dated 2/16/26 indicated the resident may transfer to the hospital for further evaluation. The discharge MDS assessment for Resident 71 had an ARD of 2/16/26, and Section A0310F was coded as 11 for a discharge assessment with return anticipated. The assessment record showed that Section Z0500B, the RN Assessment Coordinator signature date, was 4/8/26. During a concurrent interview and record review, the DON reviewed the resident’s MDS assessments and stated the discharge MDS assessment with an ARD of 2/16/26 was completed on 4/8/26. The DON stated the discharge MDS assessment should have been completed within 14 days of the discharge date and that the RAI submission timelines were not followed. The facility’s MDS Lead (RN) job description stated the role was responsible for managing the timely completion of accurate assessments and monitoring completion of MDS assessments within regulatory timeframes.
Inaccurate MDS Hearing Coding for Resident with Hearing Difficulty
Penalty
Summary
The facility failed to ensure that Resident 33’s hearing status was accurately coded in the comprehensive admission MDS assessment. The admission MDS with an ARD of 6/5/26 coded Section B0200 (Hearing) as 0, indicating hearing was adequate, even though multiple observations and interviews showed the resident had hearing difficulty and often needed others to repeat themselves or speak louder. During an initial tour, Resident 33 was awake and verbally responsive but asked for questions to be repeated and stated he had bad hearing. His RP stated he had been hard of hearing for years and had been using hearing aids. Facility staff later observed that they needed to lean closer and repeat themselves when speaking with him, and CNA 2 stated the resident could verbalize his needs but was hard of hearing and required repeated communication. Additional interviews with the SLP and COTA confirmed hearing difficulty during therapy interactions, including the need to speak louder, repeat verbal cues, speak clearly, and face the resident. The MDSC stated Section B was completed by Social Services and that the look-back period was 6/1-5/26. The SSD reviewed the assessment and stated the resident’s hearing status was not coded accurately because she only based it on her assessment, and the DON stated the RAI manual was not followed in this case.
Inaccurate PASRR Screening for Resident with Psychotic Disorder
Penalty
Summary
The facility failed to ensure the PASRR was accurately completed for one of three sampled residents reviewed for PASRR, Resident 62. The resident’s admission record dated 7/8/26 showed admission to the facility with diagnoses including psychotic disorder, chronic kidney disease, and muscle weakness. The comprehensive admission MDS with ARD 4/24/26 indicated psychotic disorder was present in Section I, Active Diagnoses. The PASRR Level 1 Screening dated 5/11/26 marked “No” for diagnosed serious mental illness and left blank the diagnosis selection for schizophrenia, schizoaffective disorder, or symptoms of psychosis. During a concurrent interview and record review on 7/8/26, the DON reviewed the admission record, MDS, and PASRR and stated the PASRR was inaccurately filled out. The facility policy stated residents with mental disorder or intellectual disability are to be screened prior to admission, and the MDS Lead RN job description stated the role includes managing timely completion of accurate assessments.
Failure to Develop a Comprehensive Care Plan for Hearing Impairment
Penalty
Summary
The facility failed to develop a comprehensive care plan for hearing impairment for one of 24 sampled residents, Resident 33. On observation, Resident 33 was awake and verbally responsive while lying in bed, but asked for questions to be repeated and stated he had bad hearing. His responsible party stated he had been hard of hearing for years and had been using hearing aids. CNA 2 later stated Resident 33 could verbalize his needs but was hard of hearing, and that she had to repeat herself because he could not hear her. The SLP stated that one of the challenges when working with Resident 33 was his hearing difficulties and that he asked her to speak louder because he could not hear her. The MDS Coordinator reviewed the electronic health record and stated there was no documented evidence of a comprehensive care plan for the resident's hearing impairment. The ADON acknowledged that Resident 33 had no care plan for hearing impairment, and the DON stated that a hearing impairment care plan should have been developed. The facility policy stated that each resident has a person-centered comprehensive care plan developed, reviewed, and revised by the interdisciplinary team, and that it must be completed no more than 21 days after admission.
Lidocaine Patches Left On Beyond Ordered Wear Time
Penalty
Summary
The facility failed to ensure appropriate use of lidocaine 5% patches for one resident with knee osteoarthritis. During a medication pass observation, a nurse was observed removing a blanket to expose the resident’s knees and finding lidocaine patches on both knees that were labeled 7/5 and initialed. The nurse removed the old patches before applying new ones. The resident had a physician’s order for Lidoderm 5% patch to be applied to each knee in the morning, one patch to each knee, and the Medication Administration Record showed the patches had been applied during the morning medication pass on 7/5/26. During interview and record review, the nurse stated the patches applied in the morning on 7/5/26 were left on overnight before the 7/6/26 medication pass and that the orders did not include instructions to remove the patch at night. The RN, DON, and consultant pharmacist all stated lidocaine patches were to be worn for 12 hours and then removed, with the RN stating a patch applied at 9:00 AM should be removed at 9:00 PM the same day. The consultant pharmacist confirmed that leaving the patch on longer than 12 hours was not the approved manufacturer dosing, and the facility policy defined medication error as administration not in accordance with manufacturer specifications.
Inaccurate Pain Score Documentation in MAR
Penalty
Summary
The facility failed to ensure medical records were kept in accordance with professional standards for one resident when pain scores were incorrectly documented in the medical record. During a medication pass observation, an LVN administered acetaminophen 650 mg and ibuprofen 400 mg to the resident for pain. The resident had physician orders for acetaminophen 325 mg, 2 tablets by mouth every 4 hours as needed for mild pain 1-3/10, and ibuprofen 200 mg by mouth every 4 hours as needed for breakthrough pain. During interview, the LVN stated the resident’s actual pain score during the afternoon medication pass was 5/10, but she entered a pain score between 1 and 3 on the MAR for acetaminophen and documented a pain score of 4 for ibuprofen. The DON stated it was not acceptable to document a pain score of 2 when the resident’s actual pain score was 5 and said a nurse was supposed to call the doctor for pain outside the medication orders. The consultant pharmacist stated it was not appropriate to document an incorrect pain score and that inaccurate information could affect the evaluation of the resident’s pain management therapy. Facility policies reviewed stated that resident conditions must be accurately documented and that PRN medication documentation must include the complaints or symptoms for which the medication was given.
Failure to Use Required Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) for a resident with wounds. Physician orders dated 3/5/26 directed that the resident be on EBP due to foot and right buttocks wounds, and the facility’s policy on EBP, dated January 2025, required staff to implement EBP, including gown and glove use, for residents with wounds during high-contact care activities such as providing hygiene and changing briefs. The California Department of Public Health AFL 24-15 and CDC guidance also indicated that EBP, including targeted gown and glove use, should be implemented for residents with wounds regardless of MDRO colonization status. The resident’s Order Summary Report confirmed an active order for EBP due to the identified wounds. During an observation on 3/4/26 at 3 p.m., a sign posted outside the resident’s room indicated that EBP were required. Despite this signage and the active orders, the Infection Preventionist (IP) and a CNA were observed inside the room changing the resident’s brief without wearing the required PPE gowns. In a subsequent interview, both the IP and the CNA acknowledged they should have been wearing gowns and were not. In a separate interview, the Administrator stated he was aware of the infection control issue because staff had informed him about it.
Failure to Administer Insulin and Monitor Blood Glucose Leads to Resident Harm
Penalty
Summary
A 65-year-old resident with multiple complex medical conditions, including diabetes mellitus, cerebral infarction, hypertension, hemiplegia, chronic myelogenous leukemia, anemia, drug-induced polyneuropathy, atrial fibrillation, dysphagia, and a gastrostomy tube, was admitted to the facility. The resident had a physician's order for Glargine (insulin) to be administered every 12 hours for diabetes management. However, Glargine was not administered for three consecutive days at several scheduled times. Documentation indicated that the medication was not given due to new admission and unavailability, but there was no evidence that the physician or pharmacist was notified about the missed doses. Additionally, the facility failed to use the emergency medication kit to obtain the insulin, and staff did not seek assistance when unsure how to proceed. The facility also failed to ensure proper medication administration practices. When the resident's prescribed Glargine was not available, a nurse administered insulin from another resident's supply, which was not properly labeled for the intended resident. This action was contrary to facility policy, which prohibits borrowing medications between residents. Furthermore, the order for finger stick blood sugar (FSBS) monitoring was not clarified with the physician, and the correct monitoring frequency was not established. As a result, no blood glucose monitoring was performed during the resident's stay, and the need for such monitoring was not recognized by the nursing staff. Due to these failures, the resident experienced a critically high blood glucose level (593 mg/dL), which was identified through abnormal lab results. The physician was notified only after this result, and the resident was subsequently transferred to an acute care hospital for evaluation and treatment of uncontrolled diabetes. The resident ultimately died following the transfer. The facility's policies and procedures for medication administration, medication procurement, and diabetes management were not followed, and staff interviews revealed a lack of knowledge and experience in handling new admissions, medication errors, and diabetes care.
Failure to Develop Baseline Care Plan for Complex Medical Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for a resident with multiple complex medical needs. Specifically, there was no BCP created for diabetes management, despite physician orders for regular blood sugar monitoring and insulin administration. Additionally, the BCP did not address the use of an abdominal binder, which was being used to prevent the resident from pulling on a gastrostomy tube. The absence of these care plans was confirmed during interviews and record reviews with facility staff, who acknowledged that the required BCPs were missing. Furthermore, the BCP interventions for the resident's NPO (nothing by mouth) status were not appropriate. The care plan included instructions to monitor meal intake and to offer warm beverages, which were not suitable for a resident who was NPO and receiving nutrition via a G-tube. Staff interviews confirmed that these interventions were incorrect and should have been individualized to the resident's needs. As a result of these deficiencies, the resident was transferred to the hospital for elevated blood sugar and required admission for fluids and diabetes control.
Failure to Provide Care According to Professional Standards Results in Resident Harm
Penalty
Summary
The facility failed to provide care according to accepted professional nursing standards for a resident with multiple complex medical needs, including diabetes, dysphagia, and psychiatric concerns. Upon admission, the facility did not develop a baseline care plan for diabetes management, despite the resident's diagnosis and risk for abnormal blood sugar levels. Both the Licensed Nurse and the Director of Nursing confirmed during interviews and record reviews that a baseline care plan for diabetes was missing. Additionally, care plans that were developed contained non-specific interventions, such as monitoring meal intake and offering warm beverages, even though the resident was NPO (nothing by mouth) and receiving nutrition via G-tube. These interventions were not tailored to the resident's actual needs, and staff acknowledged that they should have been updated to reflect the resident's status. There were also failures in medication management and adherence to physician orders. The facility did not clarify conflicting orders regarding the route of medication administration, resulting in medications being given by mouth instead of via feeding tube, contrary to the resident's NPO status and physician orders. Blood pressure monitoring orders related to Seroquel administration were not followed as directed; staff documented identical lying and sitting blood pressures without actually performing the required assessments or notifying the physician of their inability to obtain accurate readings. Furthermore, a PRN Seroquel order was continued for an excessive duration without an end date, and there were conflicting indications for its use in the clinical documentation. The psychiatric assessment and its results were not incorporated into the care plan, and staff were unclear about who was responsible for reviewing and communicating consultant notes to the physician. The report also identified that Licensed Vocational Nurses (LVNs) were performing tasks outside their scope of practice, such as developing and revising care plans, which is the responsibility of Registered Nurses (RNs) and physicians. Multiple care plans for the resident were initiated and revised by LVNs, contrary to regulatory requirements. As a result of these failures, the resident experienced abnormally high blood sugar, required transfer to an acute care hospital, and ultimately died.
Failure to Assess, Document, and Safely Install Bed Rails
Penalty
Summary
The facility failed to ensure that appropriate alternatives to bed rails were identified and attempted before installing bed rails for a resident with significant neurological and physical impairments. Documentation showed that no less restrictive measures or alternatives were tried, despite facility policy requiring such steps. The decision to use bed rails was based on a family request, and staff complied without conducting a thorough evaluation or identifying a medical symptom that necessitated the use of bed rails. The resident was dependent on staff for all bed mobility and transfers, was non-verbal, unable to follow commands, and not oriented, which placed them at higher risk for entrapment and injury according to FDA guidance. The assessment process for bed rail use was incomplete and lacked critical information. Key assessment forms had unanswered questions regarding the resident's bed mobility, balance, trunk control, and the specific reason for device use. The interdisciplinary team documentation indicated that the bed rail was considered solely due to a patient or family request, without evidence of a comprehensive risk-benefit analysis or informed consent process as required by facility policy. Additionally, there was no documented assessment of the compatibility between the bed, mattress, and bed rail prior to installation. Installation of the bed rails was performed by a licensed nurse who was not trained for this task, rather than by the maintenance department as per facility protocol. The maintenance director confirmed that no request for bed rail installation was made, and the nurse admitted to installing the rails after hours to accommodate the family's wishes. The bed was not measured or assessed for safety prior to installation, further deviating from established procedures and increasing the risk of resident harm.
Failure to Ensure Nursing Competency in Medication Administration and Monitoring
Penalty
Summary
Nurses and nurse aides at the facility failed to demonstrate the necessary competencies to provide safe care for a resident with diabetes mellitus type 2. The licensed nurses did not administer Glargine insulin as ordered over several days, failed to notify the physician about the missed doses, and did not communicate these omissions to the charge nurse. Additionally, the nurses did not clarify conflicting medication administration orders, resulting in medications being given by mouth despite an order for enteral administration via feeding tube. The Director of Nursing confirmed that the insulin was not given for multiple days and that the physician was not notified, attributing these failures to the inexperience of the nursing staff. The facility also failed to ensure that blood glucose monitoring orders were correctly entered and followed. The order for finger stick blood sugar (FSBS) monitoring did not appear on the Medication Administration Record (MAR), and as a result, no blood sugar monitoring was performed. The Director of Nursing acknowledged that the FSBS order was entered incorrectly and that the new nurses did not recognize the need to clarify or implement the order. One nurse admitted that inexperience was the reason for not clarifying the missing FSBS order with the physician. Documentation review revealed that the resident received multiple medications by mouth, despite orders indicating the need for enteral administration due to NPO status and enteral feeding. The Director of Nursing and a licensed nurse both confirmed that medications were administered orally without clarification from the physician. The resident ultimately required hospital admission for fluids and diabetes control following these failures in care.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate, resulting in care being planned and delivered based on incorrect assessments. Specifically, a licensed nurse reported texting a physician to clarify the resident's medication administration route, but there was no documentation of this communication in the resident's medical record. Additionally, the resident's Medicare Skilled Charting did not reflect the skilled nursing services provided, such as diabetic care and enteral feeding care, as required. The Bed/Side Rail Entrapment Risk Assessment inaccurately indicated that alternatives to bed/side rails had been attempted, when in fact, no such alternatives were tried. Further review of the Medication Administration Record revealed that the same blood pressure readings were recorded for both lying and sitting positions over several days, which a nurse confirmed was inaccurate. The Director of Nursing also acknowledged that the charting was inaccurate upon review of the relevant records. The facility's own documentation policy requires that relevant findings be accurately documented in the clinical record, which was not followed in these instances.
Inaccurate Diagnosis Recorded on MDS Assessment
Penalty
Summary
The facility failed to ensure that an accurate diagnosis was recorded on the Minimum Data Set (MDS) assessment for one of two sampled residents. During an interview and record review with the MDS Coordinator, it was found that the MDS 3.0 Section I - Active Diagnoses incorrectly indicated that the resident had benign prostatic hyperplasia (BPH), despite the resident not having this diagnosis. The MDS Coordinator acknowledged that this section was incorrectly coded. Review of the facility's MDS manual confirmed that the MDS assessment is intended to provide an updated and accurate picture of the resident's current health status, and the incorrect coding resulted in the facility reporting inaccurate data to CMS.
Delay in Physician Notification of Abnormal X-ray Results
Penalty
Summary
The facility failed to promptly notify the physician of x-ray results for one of two sampled residents. The resident was admitted with a midcervical fracture of the right femur and aftercare following joint replacement surgery. On 5/19/2025, a radiology report indicated a superior dislocation of the femoral component of the hip implant. The nurse supervisor received the radiology results around 7 p.m. and communicated the findings to the physician via text message at 10:44 p.m. However, the physician did not respond or contact the facility until the following afternoon. The delay in communication resulted in a delay in treatment for the resident's dislocated hip. The facility's policy required that abnormal test results be promptly reported to the ordering provider, and if there was no response after three call attempts, the staff should escalate the report to the medical director. The director of nursing confirmed that staff should have continued attempts to contact the physician and escalated the issue to avoid delays in care.
Inaccurate MDS Coding for Oxygen Use and Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for three residents, as required by facility policy and federal regulations. For one resident with chronic obstructive pulmonary disease (COPD) and a physician's order for supplemental oxygen, the MDS did not reflect the use of oxygen therapy, despite documentation in care plans, progress notes, and vital records indicating the resident received oxygen as needed during the assessment period. The MDS Coordinator confirmed the omission, stating that only the physician order and electronic medication administration record were referenced during the assessment, and acknowledged the MDS was coded incorrectly. Another resident, who had diagnoses including speech and language deficits, dysphagia, aphasia, apraxia, dementia, seizures, and heart failure, was discharged to home with home health services. However, the discharge MDS incorrectly indicated the resident was discharged to a hospital setting. The MDS Coordinator admitted to the error, explaining that she had attended the care plan meeting and was aware the resident returned home, but the MDS was not coded accordingly. The Director of Nursing and Administrator both confirmed the importance of accurate MDS coding and attributed the error to human mistake. A third resident with a history of COPD, idiopathic interstitial pneumonia, and dependence on supplemental oxygen was also affected by inaccurate MDS coding. Although the resident's care plan, physician orders, and progress notes documented regular use of supplemental oxygen, the MDS did not indicate oxygen use during the lookback period. The MDS Coordinator and DON both confirmed, after reviewing the records, that the resident was using oxygen intermittently and that the MDS should have reflected this. Interviews with nursing staff further confirmed the resident wore supplemental oxygen continuously at their request.
Failure to Resubmit PASRR After Change in Mental Health Status
Penalty
Summary
The facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) as required for a resident who developed or was identified with mental health diagnoses and was prescribed psychotropic medications after admission. The facility's policy states that a negative Level I PASRR screen permits admission unless a possible serious mental disorder or intellectual disability arises later, in which case a new screening and referral for Level II evaluation must occur. The resident in question was admitted with a negative Level I PASRR obtained from the hospital, which indicated no serious mental disorder or psychotropic medication use at the time of admission. After admission, the resident was diagnosed with psychotic disorder, dementia with behavioral disturbance, and anxiety disorder, and was prescribed antipsychotic and antianxiety medications. The resident's Minimum Data Set (MDS) assessment showed severe cognitive impairment and ongoing use of psychotropic medications. The care plan and physician orders reflected the presence of psychosis, the use of olanzapine, and monitoring for side effects and behavioral symptoms. Despite these changes in the resident's condition and treatment, the facility did not resubmit the PASRR as required by policy and regulation. Interviews with facility staff, including the Admissions Co-Director, Business Development Director, DON, and MDS Coordinator, confirmed that the PASRR process was not followed when the resident's diagnoses and medication regimen changed. Staff acknowledged that a new PASRR should have been completed when the resident was started on routine psychotropic medication and developed new mental health diagnoses. The deficiency was identified through record review and staff interviews, which revealed a lack of compliance with PASRR requirements for residents whose mental health status changes after admission.
CNA Removed Undergarment in Resident's Room, Violating Dignity Policy
Penalty
Summary
A Certified Nursing Assistant (CNA) removed her bra while in a resident's room, behind a curtain, and stored the bra in the resident's closet. The resident, who was cognitively intact and had diagnoses including muscle weakness, aphasia, type 2 diabetes mellitus, and cerebral infarction, reported the incident via email to the facility administrator, describing it as verbal, emotional, and physical abuse, and also alleged sexual harassment by the CNA. The CNA admitted to removing her bra behind the curtain, stating it was due to feeling hot, and claimed the resident could not see her during the act. The facility's investigation confirmed that the CNA violated company policy regarding professional conduct and resident dignity. Facility policies reviewed emphasized the importance of treating residents with dignity, respect, and privacy, and outlined that inappropriate behavior, including suggestive gestures or unprofessional conduct, is not tolerated. The facility's work rules require employees to maintain acceptable standards of respect and professional conduct towards residents. The incident was determined to be a violation of these policies, as the CNA's actions did not uphold the resident's right to dignity and privacy.
Failure to Provide Timely Assistance with Brief Change
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity when a Certified Nursing Assistant (CNA) repeatedly instructed the resident to wait for a brief change. The resident, who had been admitted with diagnoses including encephalopathy, arthritis, and muscle weakness, had a BIMS score indicating moderate cognitive impairment and was dependent on assistance for toileting. On the night in question, the resident activated the call light for assistance with a brief change, and a tall female staff member responded but instructed the resident to wait for the assigned CNA, turning off the call light without providing the requested assistance. The resident had to activate the call light a second time, and the same staff member again instructed the resident to wait for the assigned CNA. The resident's CNA was late for the shift, arriving approximately an hour after the shift began, and the resident's brief was not changed until 20 minutes after the CNA's arrival. Interviews with the CNA and the Director of Staff Development confirmed that all CNAs are responsible for answering call lights and providing necessary care, and the CNA who responded should have changed the resident's brief. The facility's policy on dignity and respect emphasizes assisting residents in exercising their rights and ensuring they are treated with respect, kindness, and dignity, which was not upheld in this instance.
Improper Colostomy Care by Unlicensed Staff
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a colostomy. The deficiency involved an unlicensed staff member, a Certified Nurse Assistant (CNA), who removed, emptied, and replaced a colostomy bag for a resident. This action was contrary to the facility's policy, which states that only licensed nurses are permitted to remove colostomy bags. The CNA was instructed by a licensed nurse to only empty the bag, but instead, the CNA removed and rinsed it before placing it back on the resident. The resident, who was admitted with a colostomy, artificial opening of the urinary tract, hypertension, and hyperlipidemia, expressed concerns about the reuse of the colostomy bag. The resident's cognitive status was intact, as indicated by a BIMS score of 15. Interviews with the CNA, the licensed nurse, and the Director of Nursing confirmed the inappropriate handling of the colostomy bag by the unlicensed staff, which was not in line with the facility's policy and procedure for colostomy care.
Failure to Perform Hand Hygiene During Colostomy Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during colostomy care for one of the sampled residents, identified as Resident 3. During an observation, a licensed nurse (LN 1) was seen removing a soiled colostomy bag and disposing of it, then changing gloves without washing hands in between. LN 1 continued to clean the stoma and again changed gloves without performing handwashing. In an interview, LN 1 admitted to not washing hands between glove changes, citing that it made her hands sticky and made it difficult to put on new gloves. The facility's policy and procedure for colostomy care, dated November 2017, clearly stated that handwashing should occur between glove changes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Thousand Oaks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Skilled Nursing | 0.8 mi | ★★★★★ | 7 | 0 |
| Sherwood Oaks Post Acute | 4.3 mi | ★★★★★ | 17 | 0 |
| Mary Health Of The Sick Convalescent & Nursing Hos | 4.4 mi | ★★★★★ | 9 | 0 |
| Alta Healthcare Center Of Camarillo | 6.3 mi | ★★★★★ | 0 | 0 |
| St. John's Hospital Camarillo D/p Snf | 8.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.