Oakwood Gardens Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to fulfill a record request for one of one residents (Resident 4), when they had record of a request from 11/5/25 and still had not sent the records as of 12/15/25. This failure put the resident at risk of not receiving his records in a timely manner. During a review of Resident 4's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 10/1/25, the admission record indicated, Resident 4 was admitted to the facility on [DATE] with a diagnosis which included Rhabdomyolysis ( a rare muscle injury where your muscles break down. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received an accurate fall risk assessment when on admission the licensed vocational nurse supervisor (LVNS) did not accurately account for history of falls at home and hip fracture, mobility deficits in calculating the risk for falls for Resident 1. These failures resulted in assigning a moderate risk rather than a high risk for falls with the potential not to implement an individualized care plan to prevent falls and could have contributed to his fall on 11/15/25.

Inspectors wroteBased on interview, and record review the facility failed to ensure compliance with its policies and procedures regarding resident appointment coordination and verification for one of three sampled residents (Resident 1), when Resident 1 was mistakenly prepared and transported to a medical appointment that was not scheduled for her. This failure resulted in unnecessary physical and emotional distress to Resident 1 and potentially exposed to inappropriate treatment or risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 12 sampled residents (Resident 6) when Resident 6 ' s low air loss (LAL - a special mattress used to prevent skin injuries, often occurring in individuals who are bedbound) mattress setting was not used according to the manufacturer ' s recommendation. This failure had the potential to result in Resident 6 to develop pressure ulcer (injury to the skin and underlying tissues by prolonged pressure on the skin) and placed Resident 6 at an increased risk for falls and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when one of six sampled residents' (Resident 5) oxygen concentrator (a device that concentrates the oxygen from the ambient air) was being used without a filter. This failure placed Resident 5 at an increased risk to develop respiratory and healthcare-associated infections.

Inspectors wroteBased on interview and record review, the facility failed to report two unwitnessed falls with injury to the California Department of Public Health (CDPH- State survey agency) within the required time frame for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 was found on the floor in his room, and Resident 2 was found on the bathroom floor in his room. Resident 1 and Resident 2 required transportation to the emergency Department (ED) for higher level of care. This failure resulted in Resident 1 and Resident 2 falls not investigated timely within the required time frame and had the potential to result in Resident 1's and Resident 2's safety needs not being met.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have a medication error rate of less than 5%. There were 2 medication errors out of 26 medication opportunities which resulted in a medication error rate of 7.69% affecting 1 (Resident #26) of 6 residents observed during medication administration.

Inspectors wroteBased on observation, interview, record review, facility document, and facility policy review, the facility failed to ensure 4 (adjoined rooms [ROOM NUMBERS], 27 and 29, 34 and 36, and 38 and 39) of 33 bedrooms accommodated no more than four residents. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings.

Inspectors wroteBased on interview and record review, the facility failed to implement their admissions policy and procedure for one of three sampled residents (Resident 1) when the facility admitted Resident 1 from the general acute care hospital (GACH) for intravenous (IV-within a vein) antibiotics (medication that fight bacterial [small organism which can cause disease] infections) therapy and the facility did not have registered nurse (RN) on duty to administer the IV antibiotic medication. This failure resulted in Resident 1 not receiving his prescribed IV antibiotic medication and Resident 1 had to be transported back to the GACH just 3 hours after being admitted to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with current accepted professional standards of practice when: 1. Resident 34's Lorazepam (a medication used to treat anxiety disorders, trouble sleeping, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy-induced nausea and vomiting) was discontinued on 2/11/13 and the medication was not separated from active medications and was stored in medication cart. 2. Resident 5's Lorazepam with directions that did not match current physician Lorazepam orders and the medication cards of Lorazepam did not have change of direction stickers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in accordance with the professional standards for food safety service and safety for 73 residents when: 1. The ice machine curtain had calcium build up. 2. The walk-in refrigerator food storage shelving contained a black fuzzy, brown, and white substance, the floor had decomposed food, the wall had black substance, and the door had brown and black grime. 3. The fan located above the dishwashing station was covered with brown debris, and was blowing directly on the cleaned dish area. 4. The can opener based in the kitchen was not kept in a sanitary condition and had black and brown grime build up. 5. The baseboard located under the ice machine had a hole, debris and trash. 6. The floor under the dish machine and dry storage room contained trash, debris, and food crumbs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician Informed Consent (a process in which residents are given important information of the possible risk and benefits of the use of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) for two of five sampled residents (Resident 34, and Resident 69) was obtain when: 1. Resident 34 was administered lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) without an Informed Consent. 2. Resident 69 was administered mirtazapine (a medication used to treat depression [mood disorder characterized by feelings of sadness and loss of interest]) on 12/6/22 to 12/31/22 and Informed Consent was not obtained prior to medication administration. [...]

Inspectors wroteBASED ON THE IDR REVIEW, RESIDENTS' 43, 52, AND 7'S FINDINGS WERE DELETED, THEREFORE, LOWERING THE SCOPE/SEVERITY TO E. Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for two of nine sampled residents ( Resident 9 & Resident 17) when: 1. Resident 9's anticoagulant medication (medication used to prevent blood clots in the legs) was inaccurately coded on the MDS section N (medications). 2. Resident 17's new pressure ulcer and current antibiotic were not coded in the MDS. These failures had the potential for Resident 9, and Resident 17's necessary care and services not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for 3 of 4 sampled residents (Resident 9, Resident 79 and Resident 40) when: 1. Resident 9 did not have a care plan addressing the use of anticoagulant medication. This failure had the potential for Resident 9 to experience severe bruising and bleeding which could lead to serious medical condition and hospitalization. 2. The facility did not implement interventions and a plan of care to treat Resident 79's significant edema (when excess fluid collects in the body) to his bilateral (both right and left) upper extremities (arms). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of medication errors in excess of five percent when the facility's medication error rate was 9.52 percent. There were 42 opportunities for errors and 4 medication errors occurred with four of eight sampled residents (Resident 5, Resident 13, Resident 38 and Resident 41). This failure resulted in medication errors for Resident 5, Resident 13, Resident 38 and Resident 41 which placed residents at risk of experiencing adverse side effects without adequate monitoring.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure the Registered Dietician effectively monitored the food and nutrition services in accordance with the Registered Dietician job description when the Registered Dietician failed to monitor food services operations to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Ice machine curtain had calcium build up. 2. The walk-in refrigerator food storage shelving contained a black fuzzy, brown, and white substance, the floor had decomposed food, the wall had black substance, and the door had brown and black grime. 3. The fan located above the dishwashing station was covered with brown debris and was blowing directly on the cleaned dish area 4. The can opener based in the kitchen was not kept in a sanitary condition and had black and brown grim build up. 5. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of eight sampled residents (Resident 83) was provided a shower three times a week in accordance with the facility practice and the scheduled number of showers for Resident 83. This failure had the potential to result in a negative impact to the resident's quality of life and self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a comprehensive and effective systematic approach was implemented to monitor and maintain acceptable parameters of nutritional status for one of 76 sampled residents as evidenced when: 1. The facility failed to ensure Resident 74 with severe unplanned weight loss was identify in a timely manner and recommend nutritional interventions. This failure resulted in Resident 74 experienced severe unplanned weight loss 21 pound (lb.) 16.2 percent (%) within five months from 7/1/2022, until 12/3/2022. 2. The Registered Dietician failed to reevaluate Resident 74's comprehensive nutrition assessment per facility policy. This failure had the potential risk to place Resident 74 for impaired nutrition status or compromised nutritional status. (Cross reference F801).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of unnecessary drugs for two of five sampled residents (Resident 5 and Resident 41) when: 1. Facility failed to remove lidocaine patch (used for relief of neuropathic nerve pain [occurs when a health condition damages the nerves that carry sensation to the brain]) to left knee within 12 hours as specified by manufacturer guidelines for Resident 5. 2. Facility failed to monitor, and order Thyroid Stimulating Hormone (TSH- a hormone produced by the pituitary gland [a gland in the brain]. It prompts the thyroid gland to make and release thyroid hormones into the blood) labs (a blood test which measures TSH) annually as clinically indicated for levothyroxine (used to treat thyroid hormone deficiency) for Resident 41. [...]

Inspectors wroteBASED ON IDR REVIEW F756 WAS MOVED TO F836 Based on interview and record review, the facility's Pharmacy Consultant (PC) failed to follow standards of practice to identify irregularities and make recommendations for two of five sampled residents (Resident 5 and Resident 41) when: 1. Facility failed to remove lidocaine patch (used for relief of neuropathic nerve pain [occurs when the nerves that carries sensation to the brain is damage]) to left knee of Resident 5 within 12 hours as specified by manufacturer guidelines. 2. [...]

Inspectors wroteBased on observation during the survey period of 2/13/23 through 2/17/23, the facility failed to ensure each bedroom accommodated no more than four residents in eight of 37 rooms (Rooms' 9, 11, 27, 29, 34, 36, and 38 and 39). This failure had the potential to adversely effect care provided to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items and dishware were stored in a sanitary manner when: 1. One container of coffee creamer was torn and leaking onto other food items in the walk-in refrigerator. 2. Two steam table food pans were not air dried and stored away wet. These deficient practices placed residents at risk of consuming contaminated food and having food prepared in unsanitary food pans could lead to foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide for the storage of foods brought to residents from outside sources, when the facility policy did not allow residents to store food brought in by family or visitors. This failed practice prevented residents from exercising their rights to store food in the facility that was brought in from outside sources.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident call lights were easily accessible and within reach for one of 38 sampled residents (Resident 62). This deficient pra resulted in Resident 62's embarrassment when he did not have a call light to call for help which caused him to urinate on himself and prevented Resident 62's needs from being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan for one of 16 sampled residents (Resident 186) when Resident 186 was taking anticoagulation (AC - medications that slow down clot formation and have the potential to increase bleeding) medication and a baseline care plan was not developed for the use of the anticoagulation medication. This deficient practice placed Resident 186 at risk for episodes of bleeding not being detected and monitored timely.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dialysis (the process of artificial filtering and removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions) services consistent with professional standards of practice for one of two sampled dialysis residents (Resident 188) when the SNF [Skilled Nursing Facility]/Dialysis Assessment Communication Form (SNF/DACF - form used to communicate pertinent dialysis resident assessment information between the facility nursing staff and dialysis center staff to ensure residents are in stable condition prior to and after dialysis treatment) was incomplete on three of three sampled forms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were functioning properly for one of 36 sampled rooms (Rm 39) and four of four sample residents (Resident 11, 13, 50, and 76) when the call light monitor in RM [ROOM NUMBER] was not blinking nor sounding at the nurse's station, and the Maintenance Director (MD) did not document call light equipment checks. This failed practice had the potential to result in resident call lights not being answered timely and for emergent situations to be undetected by staff which could lead to resident injuries and/or harm.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms accommodated no more than four residents each, when rooms [ROOM NUMBERS] housed a total eight residents, room [ROOM NUMBER] and 29 housed a total eight residents, room [ROOM NUMBER] and 36 housed a total eight residents, and room [ROOM NUMBER] and 39 housed a total eight residents. This failed practice had the potential for residents to not have a reasonable amount of privacy or adequate space.