Oakdale Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were securely stored when: 1. Registered Nurse (RN) 3, Licensed Vocational Nurse (LVN) 2, LVN 4, and RN 2 left the facility's medication cart unlocked when they walked away from during medication pass. This failure had the potential to place facility at risk for unauthorized access to medication cart and possible drug diversion. 2. Expired over the counter (OTC) medications were stored in medication cart and medication storage room; and eye drops was stored in medication cart beyond use date. This failure had the potential for residents to received expired medications that were no longer effective. 3. Discontinued oral medications, eye drops, inhalation, and injectables medications were stored in drawers of medication storage room. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure dietetic staff had the appropriate skill sets to carry out the functions of food and nutrition services when: 1. The full-time Dietary Manger (DM) did not have the appropriate qualifications to meet the state requirements of the Health and Safety Code 1265.4 when Registered Dietitian (RD) 2 was only working onsite at the facility one day per week: and 2. RD 1 did not follow current standards of practice for nutrition-focused physical exams when she was a full-time consultant who worked remotely in another state and completed nutrition assessments for the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, and served safely in accordance with professional standards of food service safety for 91 out of 91 residents eating at the facility when: 1. An individually wrapped tuna sandwich was expired in the nourishment refrigerator. This failure had the potential to result in the serving of an expired tuna sandwich to 35 out of 35 residents eating regular textured diets at the facility which had the potential to lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). 2. A bottle of wine was not labeled and dated in the resident refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 5, Resident 15, Resident 56, Resident 76) were treated with respect and dignity when: 1. Resident 15's foley catheter bag (a collection bag that attaches to a foley catheter, a type of indwelling catheter [a catheter left in place for a period of time], to collect urine drained from the bladder) had urine visible from the hallway and was not covered with a foley catheter decency bag. This failure resulted in violating Resident 15's right to privacy. 2. Resident 5, Resident 56, and Resident 76 were lined up in the hallway outside of the dining hall and not allowed to enter and eat until other residents were done eating. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise a care plan (a detailed approach to care customized to an individual resident's needs) to reflect assessment and interventions for one of nine sampled residents (Resident 64) when Resident 64's care plans was not reviewed and revised by the Interdisciplinary team (IDT-group professional and direct care staff that development a plan of care for a resident) after re-admission [DATE]). This failure resulted in Resident 64 being served the incorrect diet for her meals and had the potential to place Resident 64 at risk for unintended weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for four of 18 sampled residents (Resident 4, Resident 23, Resident 33, and Resident 88) and follow the policy and procedure when: 1. Certified Nursing Assistant (CNA) 5 and CNA 6 did not file and a reported allegation of abuse to [NAME] President or Long Term Care Designee and notify the appropriate agencies for Resident 23. This failure resulted in Resident 23's allegation to go uninvestigated and had the potential for Resident 23's safety concerns to not be met. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure nursing staff possess the competencies and skill sets necessary to provide restorative nursing services for one of nine sampled residents(Resident 81) when Resident 81 received a restorative nursing service from Certified Nursing Assistant not a certified Restorative Nurse Assistant (RNA-a healthcare worker that assists with rehabilitative care to individuals recovering from illnesses or injuries). This failure had the potential to place Resident 81 at risk for further injury during restorative services.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and sanitary environment for four of 24 sampled residents (Residents 62, 65, 80 and 88) when: 1. Resident 88 had a urinal (a container, often a bottle, used for collecting urine, typically for someone who is unable to get out of bed to use a regular toilet), filled with urine, on his bedside table (serve as a surface for food trays and can hold personal items such as phones, laptops, or books) next to drinking cups, protein shakes and medication in a medicine cup. This failure placed Resident 88 at risk for cross-contamination (the unintentional transfer of harmful substances from one person, object, or place to another) which could result in infections and illness. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive assessments were conducted for one of nine sampled residents (Resident 64) when Resident 64's Nutritional Risk Assessment was not completed on readmission and quarterly in accordance with Minimum Data Set (MDS- a federally mandated resident assessment tool); and Resident 64's Nutritional Risk Assessments and MDS did not include a direct observation and communication with Resident 64. These failure resulted in Resident 64 not receiving an appropriate diet and put Resident 64 at risk of not having her dietary needs met.

Inspectors wrote2. During a concurrent interview and record review on 3/20/25 at 5:07 p.m. with License Vocation Nurse (LVN) 1, Resident 76's Treatment Administration Record (TAR- essential for documenting medication administration details) dated 2/22/2025 was reviewed. The TAR indicated, [box] Order Summary: Treatment-outer left foot DTI (DTI- a serious type of pressure injury, involves damage to underlying soft tissues, potentially leading to a purple or maroon discoloration of the skin) -Paint with [brand name of antiseptic] Solution every day and night shift for Pressure Injury . LVN 1 stated there were no care plan for Resident 76's DTI treatment order. LVN 1 stated a care plan should have been develop the same time the treatment order was done. LVN 1 stated a care plan was important to make sure the DTI was acknowledged. [...]

Inspectors wroteBased on observation interview and record review the facility failed to ensure one of six sampled resident (Resident 42) grooming was maintained when red patches of dried flaky skin were on top of his scalp and on the front of his shirt and pant. This failure resulted in Resident 42 having dried flaky skin on his skirt and pants which made him feel upset and embarrassed and had this had the potential to cause skin infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1), when Resident 1 with the known behavior of wandering into other Resident rooms was left unattended on 4/10/24. This failure resulted in Resident 1 entering Resident 2's room where Resident 1 bit the hand of Resident 2.

Inspectors wroteBased on record reviews, review of the facility policy, and interviews, the facility failed to ensure there was documented evidence to indicate advance directives were discussed during the admission process for 3 (Residents #11, #31, and #89) of 5 sampled residents reviewed for advance directives.

Inspectors wroteBased on interviews and document review, the facility failed to ensure the activity program was directed by a qualified professional. This deficient practice affected all 99 residents who currently resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing to residents when the dining room was left with insufficient staff to meet the needs of the residents requiring assistance for two of three meals on Saturday, March 23, 2019. This failure resulted in residents not having care and socialization needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and handle food safely when: 1. There were red bell peppers with a black organic substance and past their storage guidelines. 2. There was black and yellow substance inside the ice machine. 3. Trayline (meal service) food temperatures were taken in an unsanitary way. These failures resulted in unsafe food storage and handling that could lead to contamination and potentially negative outcome to all residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a policy regarding the use and storage of foods brought to residents by family and visitors from outside of the facility when there were unlabeled and incorrectly labeled resident food items in the resident refrigerator. This failure had the potential of giving unlabeled or incorrectly labeled food items to the wrong resident which could result in negative outcome to the residents.

Inspectors wroteBased on interview and record review, the facility failed to use staff development resources effectively and efficiently to ensure the Certified Nursing Assistants (CNAs) employed by the facility receive annual training when 57 of 59 Certified Nursing Assistants (CNAs) did not complete one or more of the annual five required dementia training in-services. This failure had the potential for the residents to be cared for by CNA's inadequately trained.

Inspectors wroteBased on interviews and record review, the facility failed to assess the demographic composition of its resident population and location as part of the required facility assessment when there was no water management program for the facility. This failure resulted in the facility not having a water management program which could potentially expose the residents to Legionella in an event of an outbreak.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively implement and maintain an infection prevention and control program for 11 of 59 sampled residents (Resident 46, 63, 39, 11, 238, 63, 32, 36, 43, 14 and 18) when: 1. Registered nurse (RN) 5 and RN 1 failed to perform hand hygiene prior to placing on gloves when care was delivered to residents during a physical assessment and a finger stick procedure to test blood for blood sugar levels for (Resident 46, 63, and 39). 2. Licensed vocational nurse (LVN) 4 and RN 1 used a contaminated pair of gloves in the performance of the finger stick procedure on three residents (Resident 11, 238, and 63), and touched objects in the resident room without changing the gloves LVN 4 wore to perform the finger stick procedure. 3. RN 5 used a contaminated pair of gloves in the provision of care to Resident 43. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain equipment in safe operating condition when: 1. There was ice build-up on the door frame and on a copper pipe inside the walk-in freezer. 2. There was black and yellow substance in the ice machine at the bottom part of the evaporator. These failures had the potential for the residents to use ice and food that was unsafe for consumption that could lead to negative outcome.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNAs) employed by the facility receive annual mandated training to keep competencies in the delivery of care when: 1. Three of 21 CNAs (CNA 1, 2 and 3) completed less than 12 hours of mandatory training per year. 2. 57 of 59 CNAs (CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65) did not complete the five dementia training modules offered by the facility. This failure resulted in CNA's insufficient training which placed the resident at risk to not have quality of care needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and homelike environment for residents when: loud alarms and overhead paging was frequently used in the facility and Resident 4's restroom floor was in disrepair. These failures created an environment that was not homelike for residents.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure a performance review of every nurse aide at least once every 12 months was for 17 of 21 Certified Nursing Assistants (CNAs). These failures had the potential for residents' needs to go unmet by CNAs' whose competence had not been determined through annual performance reviews.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed when incorrect portions of beef stew were served to 21 of 22 residents receiving small portion diets. This failure resulted in residents receiving incorrect servings and amount of nutrients in their meals which could potentially result to negative outcome to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 28 sampled residents (Resident 57, 71 and 83) were treated with dignity and respect when the three residents sat together for lunch and were served at different times. This practice failed to promote the right to a dignified dining experience for Resident 57, 71 and 83.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents right to privacy during care for two of two sampled residents (Resident 39 and 65) when: Resident 39 and 65 were provided with care by two Registered Nurses (RN 1 and RN 5) without privacy. This practice violated Resident 39's and 65's right to privacy during the delivery of care.

Inspectors wroteBased on observation, staff interview and record review the facility failed to ensure services provided meet professional standard of quality for 18 of 18 sampled residents (Resident 17, 25, 42, 64 ,74, 89, 90, 1, 7, 10, 20, 31, 41, 76, 74, 5, 89 and 64) when: 1. Registered nurse (RN) 5 did not follow the manufacturer's specifications on an inhaler (inhalers - a portable device for administering a drug which is to be breathed in) inhalation administration use for one of 18 sampled residents (Resident 17). This failure had the potential to place Resident 17's at risk for developing infections in her mouth. 2. RN 2 signed the medication administration record (MAR) prior to the administration of medications to one of 18 sampled residents (Resident 25). This failure had the potential to place Resident 25 at risk for medication errors. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident who were unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition for two of 28 sampled residents (Residents 83 and 71) when Residents 83 and 71 did not have assistance with their meals. This failure resulted in Residents 83 and 71 having to wait for 10 minutes to receive assistance with their meals which could have the potential to cause unplanned weight loss.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to implement an ongoing resident centered activities program to support the resident/family's choice of activities to maintaining and/or improve resident's physical, mental and psychological wellbeing for one of four sampled residents (Resident 43). This failure resulted in the activity needs of Resident 43 going unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents environment remained free of accident hazards for one of 59 sampled residents (Resident 4) when the linoleum (hard, washable floor covering) flooring by the door to Resident 4's bathroom was lifted and peeling off the floor base. This failure resulted in a hazardous environment for Resident 4 that could lead to falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional principles and ensure all drugs and biologicals were securely stored and permit only authorized personnel to have access to these medications when: 1. An insulin medication vial was not labeled with a change of direction sticker for one of 12 sampled residents (Resident 63). 2. Registered nurse (RN) 5 left an inhaler on top of the med cart unattended. 3. RN 2 left the medication cart unlocked and unattended. These failures placed all residents' health and safety at risk when drugs were inappropriately labels and drugs were left unattended and accessible to unauthorized individuals.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician ordered diet for one of 28 residents (Resident 5) in the dining room when Resident 5 was served a regular meal instead of a clear liquid. This failure resulted in Resident 5 being given the wrong diet which had the potential to compromise his scheduled medical procedure.