English Oaks Convalescent & Rehabilitation Hospita

Inspectors wroteBased on interviews and record reviews, the facility failed to timely assess and notify the physician for one of three sampled residents (Resident 3's) change in condition of an undesirable weight change, when Resident 3 gained 10 lbs. (pounds) from 219 lbs. on 6/17/26 to 229 lbs. on 6/23/26, and staff did not complete a change in condition assessment and notified the physician until 6/29/26. This deficient practice resulted in delayed nursing assessment, identification and treatment of fluid overload, placing Resident 1 at risk for worsening edema, respiratory compromise, further clinical decline, and hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate medical records for two of three sampled residents (Resident 1 and Resident 2) when:1. Resident 1's medication administration record (MAR) for the intravenous (IV, a way of giving a drug or other substance through a needle or tube inserted into a vein) drug Cefepime (an antibiotic, medicine used to treat bacterial infections) was left blank for Resident 1's 11 AM scheduled dose on 6/20/26, and blank for the 7 PM scheduled dose on 6/25/26.2. Resident 1's medication side effect monitoring for IV drug Cefepime was not documented in the electronic health record (EHR) on 6/18/26, and 7/2/26; and,3. Resident 2's MAR were left blank for the scheduled IV Cefepime dose on 6/9/26 at 10 PM, 6/10/26, and 6/15/26 at 6 AM, 6/19/26 at 10 PM, 6/21/26, 6/22/26 and 6/27/26 at 6 AM, and 6/30/26 at 2PM. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP - infection prevention measures requiring staff to wear gown and gloves during high-contact resident care activities [care requiring frequent hands-on contact with the resident]) for one of three sampled residents (Resident 4), when the Rehabilitation Aide (RA) 1 transferred Resident 4 from the bed to a wheelchair without wearing a gown. This deficient practice had the potential to increase the risk for transmission of multidrug-resistant organisms (MDRO - bacteria that are resistant to multiple antibiotics) and cross-contamination (the spread of germs from one person or object to another) to Resident 4, staff, and other residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse to the state survey agency for one of three sampled residents (Resident 1) when, Responsible Party (RP) 1 indicated to the Director of Nursing (DON) that Resident 1 might have been handled roughly by staff and RP 1 suspected physical abuse after both of Resident 1's arms were found to have bruises on them on 4/20/26. This failure resulted in a delay of the state survey agency investigating an allegation of abuse, which had the potential to put Resident 1's, and other residents in the facility, health and safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an allegation of sexual abuse involving one of five sampled residents (Resident 1) was reported to the California Department of Public Health (CDPH) within two hours after the facility had knowledge of the allegation, as required by federal regulations (Pursuant to Title 42 Code of Federal Regulations section 483.12(c)(1)). This failure delayed the CDPH's review of the alleged abuse and potentially placed Resident 1 and other residents in the facility at risk for ongoing abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out proper dress code when dietary relief (DR) 1 did not wear a beard net properly exposing facial hair. This failure had the potential to expose residents to bacterial contamination, which could result in food borne illnesses for all residents who consumed food from the kitchen. The facility census was 167.

Inspectors wroteThe facility failed to ensure safe pharmaceutical services with medication disposal, waste, and the accountability of delivered medications based on standards of practice for a resident census of 167 when: 1. Pharmaceutical waste (discontinued or no longer needed drugs) including prescription and over the counter (drugs sold directly to consumers without needing a prescription) medications were not rendered unusable when disposed in the pharmaceutical waste bin (also known as a drug waste bucket) and were accessible with hand retrieval from the waste bin; and, 2. Medication delivery slips and manifests from the pharmacy provider were not consistently signed and dated by licensed staff upon receipt from delivery courier for accuracy and accountability of prescription medication received. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff treated three of 33 sampled residents with dignity and respect when,1. The infection preventionist (IP) referred to Resident 193 as a feeder (a derogatory term sometimes used by nursing staff when a resident needs total staff assistance with feeding) which labelled Resident 193 by her care needs rather than as an individual.2. Staff posted signage in Resident 22's room identifying the resident as a 1:1 feeder (one staff member assists one resident at a time with feeding) which publicly disclosed Resident 22's care needs and placed the resident at risk for diminished dignity.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff protected the residents' personal privacy and confidentiality for one out of 33 sampled residents (Resident 4) and one unsampled resident (Resident 19) when:1. The Respiratory Therapist (RT) performed tracheostomy care (care provided to keep a breathing tube and the opening in the neck clean and functioning to help a person breathe safely) for Resident 4 without closing the resident's room door, exposing the resident to other staff, residents, and/or visitors during a personal medical procedure; and,2. Resident 19's confidential electronic medical record (EMR, a confidential electronic medical record that details the residents' health, treatment, demographic information, and payment source) was left opened on a laptop computer in a common hallway of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services necessary as per professional standards of practice for one of 33 sampled residents (Resident 3) when Resident 3's physician orders for constipation were not followed in a timely manner. This failure placed Resident 3 at risk for constipation-related complications such abdominal pain, nausea, vomiting, hemorrhoids (painful swollen veins in the rectum), fecal impaction (hard stool blocking the colon requiring medical removal).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for one of 33 sampled residents (Resident 2) when:1. Resident 2 did not receive oxygen therapy as prescribed by the physician; and 2. Nursing staff did not follow the identified oxygen therapy interventions as outlined in Resident 2's care plans (a document that contains the resident's problems, goals, and interventions). These deficient practices had the potential to place Resident 2 at risk for health decline and respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) had their initial comprehensive visit completed by a Physician for a resident under a Medicare Part A stay when, Resident 3's initial assessment (admission assessment) was conducted by a Nurse Practitioner (NP). This failure had the potential to result in unidentified medical conditions being untreated for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (intentional act of causing injury or trauma to another person through bodily contact) for one of four sampled residents (Resident 1) when on 9/8/25, Resident 2 who was known by the facility staff to have abusive behavior, approached Resident 1 and hit her on the hand and attempted to kick Resident 1. This failure resulted in a bruised right hand on Resident 1. In addition, this failure left Resident 1 feeling upset, uncomfortable, and unsafe.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to implement two persons assist when mechanical lift (a medical device used to safely lift and move a resident) was used to transfer (moving from one place to another) Resident 1. These deficient practices led to Resident 1 sustaining a fall that resulted in intramuscular hematoma (collection of blood within a muscle) to the right pectoralis (chest muscle) and a broken right leg. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction, (a condition where blood flow to the brain is interrupted, also known as a stroke) and aphasia (speech or language problems as a result of a stroke). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision for one of four sampled residents (Resident 1) when resident 1 was found in the parking lot of the apartment complex next to the facility at approximately 10:00 p.m., on 6/17/25. This failure resulted in two skin tears to Resident 1's right knee and had the potential of serious injury and harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was accurately assessed for the use of a partial denture (fully removable dental inserts that replaced seven missing top teeth) and use of hearing aids. These failures resulted in staff not being aware when Resident 1 ' s partial denture and hearing aids were missing and the lack of consistent use could have contributed to Resident 1 ' s confusion and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a care plan (a document that identified Resident 1 ' s problems, goals, and interventions) in place that addressed Resident 1 ' s use of a partial denture (fully removable dental inserts that replaced seven missing top teeth) and hearing aids. These failures resulted in a lack of knowledge by nursing staff of Resident 1 ' s use of a partial denture and hearing aids, lack of care of the partial denture and hearing aids, and could have contributed to Resident 1 ' s confusion and 15-pound weight loss while at the facility.

Inspectors wroteBased on interview, and record review, the facility failed to provide restorative (RNA- nursing intervention to increase or maintain resident's mobility and prevent further decline in mobility) treatment and services for one of three sampled residents (Resident 2) when Resident 2 did not receive her ordered RNA therapy for the week of 9/23/24. This failure had the potential to result in a decline in physical functioning for Resident 2, resulting in a negative impact on Resident 2's health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1) Three serving scoops were dirty with green and brown crusted substances, and were stored with clean serving utensils in a cook's undercounter drawer; 2) Eleven cases of thawed, soft mighty healthshakes were stored in the walk-in refrigerator and two cases of them were received on 8/29/24; 3) A pipe from the dish machine did not have an air gap; and, 4) Two ice machines were not cleaned and maintained according to manufacturer's instructions. These deficient practices exposed 145 of 155 facility residents who consume food from the kitchen to potentially harmful substances which could have led to widespread foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from significant medication errors when 1 of 38 sampled resident's (Resident 137) Midodrine (medication used to raise blood pressure and prevent it from going too low) was not administered per physician orders. This deficient practice had the potential for Resident 137 to suffer serious consequences from blood pressure being too high if the medication was given and was not needed, or symptoms such as dizziness from not receiving the medication when it was needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. A dishwasher (DSW) did not know how to correctly test the dish machine sanitizer or the safe temperatures and sanitizer levels for the 3-compartment sink. 2. A Diet Aide (DA) did not wash his hands after disposing the trash outside two times, and use proper food safety and sanitation practices to prevent cross-contamination. 3. Two DA's did not correctly demonstrate how to calibrate a thermometer. These failures had the potential to expose residents to bacterial contamination, which could result in food borne illnesses for all residents who consumed food from the kitchen. The facility census was 155. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident meals were served at a palatable temperature and flavor according to facility policy. This deficient practice had the potential to result in insufficient food intake, which could impair nutrition status for 145 out of 155 residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dish machine was in safe operating condition according to standards of practice and facility policy when the dish machine sanitizer exceeded safe sanitizing levels for dishes. This failure had the potential to place 145 out of 155 residents who receive food from the kitchen at risk of developing food related illnesses, or adverse effects from exposure to sanitizing chemicals.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of specialized mental health services for 1 of 38 sampled residents (Resident 1), when the facility failed to respond to the state designated authority for further PASRR (Pre-admission Screening and Resident Review-a tool used to ensure residents with certain mental illnesses receive care needed in the most appropriate setting) Level II needs. This deficient practice had the potential for Resident 1 to not receive additional care and services related to a mental disorder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident centered care plan for 2 of 38 sampled residents (Resident 76 and Resident 104) when, 1. Resident 76 required oxygen therapy via a nasal cannula (NC- tubing which delivers oxygen into your nose) but often removed the tubing, and his care plan did not include interventions which would ensure his oxygen level remained above 90%; and, 2. Resident 104's intravenous (IV, refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) therapy care plan was not specific to her midline catheter (a long, thin, flexible tube which is inserted into a large vein in the upper arm). These failures placed Resident 76 at risk of adverse effects of not enough oxygen, and placed Resident 104 at risk for harm related to inadequate care of her midline IV.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to professional standards of practice for 1 of 38 sampled residents (Resident 104) when a licensed nurse (LN) inserted a peripheral IV (intravenous device placed in a vein of the hand or arm and used to deliver fluids or medication) without a physician order. This failure had the potential to place Resident 104 at risk for complications related to inadequate maintenance of the peripheral IV.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide weekly showers to 1 of 38 sampled residents (Resident 48) as requested by Resident 48. This failure resulted in Resident 48 not receiving preferred bathing services (showers) and had the potential to result in decreased comfort and hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of care were met for 1 of 38 sampled residents (Resident 37) when licensed staff were unable to contact Resident 37's orthopedist (doctor who treats disorders of bones, joints, muscles and tendons) for an order after she returned from an appointment wearing a sling (device worn to support and immobilize a limb) on her right arm and her primary medical doctor (MD) 2 was not notified. This failure led to Resident 37's sling being removed and had the potential for worsening of her condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement measures to minimize accidents when: 1. One of fourteen resident's (Resident 122) wander guard to prevent elopement (a device used to alert staff if a resident leaves without their knowledge) was not being monitored; and, 2. One of three residents who smoked (Resident 296) was not assessed for the ability to smoke safely in a timely manner. These failures placed Resident 122 at an increased risk of physical harm due to his behavior of wandering in and outside the facility; and had the potential to result in Resident 296 not using her smoking device safely and could expose other residents to aerosols from an electronic cigarette device.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe medication use for one of five residents (Resident 110) on antipsychotic medication, when Resident 110's antipsychotic drug, called Haldol (a drug used to treat a variety of mental and neurological disorders) was not monitored for its effectiveness. These failures placed Resident 110 at risk for inadequate symptom relief and/or adverse effects from the use of an anti-psychotic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in three of nine medication carts (Med Cart, a locked mobile cart used to store medications and supplies) when, 1. An expired multi-dose prescription medication was stored and available for use. 2. An undated multidose prescription medication was stored and available for use. 3. An expired single-dose prescription medication was stored and available for use. These failed practices could contribute to unsafe medication storage and administration of outdated and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food brought in from the outside for 1 of 38 sampled residents (Resident 85), was stored and reheated according to regulatory standards and facility policy. This failure affected the temperature and palatability of Resident 85's meal, and had the potential to alter nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for 2 of 38 sampled residents (Resident 56 and Resident 246) when: 1. The licensed nurse (LN) did not change gloves or perform hand hygiene during wound care for Resident 56; and, 2. Resident 246's urinal was not labeled with name or room number. These failures placed Resident 56 at increased risk of healthcare associated infections, and increased the risk Resident 246's urinal could be used by another resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record accurately reflected a fall incident for one of four residents (Resident 3) when, a. Licensed staff failed to document whether Resident 3's fall mat (placed on the floor at bedside to prevent injury in the event of a fall) was present on 9/8/23, when Resident 3 fell out of bed; and b. The interdisciplinary team (IDT-members include professionals from varied disciplines to provide collaboration) recommended use of a fall mat (to prevent injury in the event of a fall) for Resident 3, but Resident 3's care plan and other records indicated this intervention was in place. This failure had the potential to cause miscommunication of information and confusion among healthcare providers regarding Resident 3's fall, which could contribute to the development of inadequate fall prevention measures for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate pain management for one of seven sampled Residents (Resident 1) when Resident 1's pain medication was not ordered in a timely manner. This failure led to Resident 1 experiencing unnecessary pain which had the potential to affect her physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received care to prevent pressure ulcers, when Resident 2 was not repositioned every two hours. This failure had the potential to result in Resident 2 developing pressure ulcers related to prolonged time spent on his back.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention program when: 1. Licensed nurse (LN) 4 failed to perform hand hygiene consistently while performing wound care for Resident 5. 2. Certified nursing assistant (CNA) 5 did not don (put on) the appropriate personal protective equipment (PPE) when providing care for residents on Enhanced Standard Precautions (an approach of targeted gown and glove use during high-contact resident care activities, designed to reduce transmission of drug resistant organisms). These failures had the potential to result in infection in residents receiving care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective pain management for one of five sampled residents (Resident 5), when Resident 5 complained of pain and was not assessed or given pain medication for approximately 2 hours. This failure resulted in Resident 5 waiting an extended time for pain medication and had the potential for Resident 5 to experience emotional distress from inadequate pain relief.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were implemented during medication administration for one of four sampled residents (Resident 4) when gastrostomy (G-Tube-a tube directly into the stomach for nutrition, hydration, and medications) tube medications were crushed together and administered at once. This failure had the potential to result in a clogged gastrostomy tube and unknown effects of medications interacting with each other.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe resident monitoring and the services provided met professional standards of quality for three of 32 sampled residents, (Resident 547, Resident 56, and Resident 548) when: 1. Resident 547 and Resident 56 were not monitored for adverse effects of blood thinner medication use in the setting of high-risk status; and, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 3 of 32 sampled residents (Resident 547, Resident 131, and Resident 95) when: 1. Resident 547 had duplicate oxygen orders and did not receive oxygen at the prescribed flow rate; 2. The oxygen flow rate was not followed per physician order for Resident 131; 3. Oxygen therapy was provided without a physician order for Resident 95; and, 4. Resident 95's oxygen tubing and the oxygen humidifier bottle were not dated when changed. These failures placed Resident 547, Resident 131, and Resident 95 at risk for respiratory distress and inadequate treatment.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure safe medication storage practices in three out of three medications rooms (a locked room that stored medication) and four out of eight medications/treatment carts (a locked mobile cart that stored medication and treatment drugs) when: 1. Treatment cart in the South station (a unit within the facility) contained unlabeled medications. 2. Medication room in the South station contained large quantities of un-used or discontinued medications and the multi-dose (means the bottle or container could be used multiple times) medication containesr were opened and undated. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's rights to be treated with dignity were honored for one of 32 sampled residents (Resident 7) when staff stood at Resident 7's bedside while assisting Resident 7 to eat the lunch meal in bed. This failure had the potential to negatively impact Resident 7's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a person-centered care plan for one of thirty-five sampled residents (Resident 7) when fall risk care plan interventions (call light within reach and non-skid footwear) were not implemented for Resident 7. This failure had the potential to result in a fall with the potential for injury for Resident 7.

Inspectors wrote1c. Review of Resident 77's admission RECORD indicated Resident 77 was admitted to the facility with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During an interview on 2/16/23, at 10:10 a.m., Certified Nurse Assistant (CNA) 1 stated Resident 77 did not refuse care. CNA 1 stated sometimes Resident 77 could be resistive to a shower so then a bed-bath would be provided. CNA 1 stated if a resident refused to shower, then staff would document in the resident record that the resident refused. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and/or heal pressure injuries (areas of damaged skin caused by staying in one position for too long) for one of thirty-five sampled residents (Resident 77) when a low air loss mattress (LAL, a mattress designed to prevent and treat pressure injuries) was not implemented as indicated in Resident 77's pressure injury care plan. This failure had the potential to delay the healing of Resident 77's pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a fall prevention measure was implemented for one of 32 sampled residents (Resident 82) when Resident 82's floor/landing pads (mats) were not placed on the floor on each side next to Resident 82's bed while Resident 82 was asleep. This failure placed Resident 82 at risk for injury from a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (procedure done by a trained professional to remove wastes and excess fluids from the body when the kidneys stop working properly) received quality care and services consistent with professional standards of practice for one of two residents (Resident 543), when: 1. Resident 543's post-dialysis assessment was not completed on 2/14/23; and, 2. Resident 543's arteriovenous shunt (AV- connection between an artery and a vein used as an access site for dialysis) was not assessed for bruit (a sound heard through a stethoscope) and/or thrill (vibrations felt through palpation) since admitted to the facility. These failures increased the potential for delayed detection, reporting, and/or management of complications from the hemodialysis access sites for Resident 543.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 64) of 32 sampled residents received a psychotropic medication (drug that effects a person's mental state) for a specific psychiatric diagnosis (mental health illness) when: Resident 64 was treated with quetiapine (also known as Seroquel, a medication used to treat mental illness) to treat symptoms including hallucinations, and potential causes of behavioral symptoms, including other medications, were not addressed as a contributing factor to Resident 64's symptoms. These failures may have contributed to unsafe medication use and adverse consequences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration. The facility had a total of three errors out of 34 opportunities which resulted in a facility wide medication error rate of 8.82%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The three medication errors were identified in three residents (Resident 52, Resident 64, and Resident 81) out of 12 residents observed for medication administration observation as follows: 1. Resident 52's eye drop medication administered in the wrong eye; 2. Resident 64's medications were crushed with no doctor's order; and, 3. Resident 81's medication was not administered after food consumption as ordered. [...]