Thousand Oaks Post Acute, LLC

In the surveyor’s words

From the most serious findings on record at Thousand Oaks Post Acute, LLC, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 17, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 18, 2021

  Based 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 #1 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. […]

• No harm, potential for more than minimal, patternF759Jul 10, 2026

  Based 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.Findings:1. During a medication pass observation on 7/6/26, at 8:49 AM, outside of Resident 86's room, Licensed Vocational Nurse 1 (LVN 1) was observed preparing nine medications for Resident 86. […]

• No harm, potential for more than minimal, patternF812Jul 10, 2026

  Based 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.Findings:1. […]

• No harm, potential for more than minimal, patternF814Jul 10, 2026

  Based 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. Findings:During a concurrent observation tour and interview on 7/6/26, at 8:30 AM, with Kitchen Staff (KS), in the outdoor garbage collection area, the trash compactor door was left open and trash was exposed. KS 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, with the Dietary Supervisor (DS), in the outdoor garbage collection area, the trash compactor door was left open, leaving trash at the bottom exposed. […]