Oakwood Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), potential abuse and unusual occurrences for two of three sampled residents who had falls with major injuries (Resident 1 and 2) when, Resident 1 fell and broke her wrist and Resident 2 fell and broke her hip and the facility had not notified CDPH.This failure had the potential of creating an unsafe environment for residents where conceivable abuse or unusual occurrences go unreported to appropriate authorities resulting in significant physical harm and emotional suffering to residents affected without being properly investigated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff were available to meet residents' care needs when:1. Five of five sample residents (Residents 1-5) reported long delays with Certified Nursing Assistants (CNAs) answering call lights and not getting scheduled showers.2. Resident council meetings and resident grievances identified call light response delays during January-March 2026.3. Acuity (complexity and intensity rather than just resident numbers) levels for residents were not considered when scheduling CNA staff on Nursing Station 2. This resulted in missed showers, resident care needs not being met, and residents felt unsafe and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to provide food that is palatable (refers to the taste and/or flavor of the food), attractive, and nutritious for two of five sampled residents (Residents 2 and 4) who complained of food being cold. This had the potential for all residents to receive an inadequate amount of nutrition required to aid in the recovery from illness or injury or maintain a healthy body weight. A review of a facility policy titled, Menu Operational Manual Policy, revised 04/01/2014, indicated the Dietary Manager will develop menus in collaboration with the Dietitian. Menus are to be designed in consideration of resident preferences, Dietary Department resources, and seasonal availability of food. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service in a safety manner when:1. [NAME] F did not obtain and document the internal temperature of three of five chicken breast patties prior to serving to residents.2. [NAME] F did not wear gloves when assisting with the plating (putting food on the plate to be served) of a resident's lunch.3. Dietary Aide (DA) placed food in a plastic storage bag with their bare hands. These failures had the potential to result in food contamination which could cause illness for all residents who received food prepared from the facility kitchen. A review of the facility's policy titled, P-D516 Food Temperatures with the effective date of 11/14/2025 indicated, 3. Where To Record Temperature: a. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not identify or implement interventions to ensure the residents were free from accidents or hazards when:1. An unlocked crash cart (a mobile cart that contained lifesaving equipment and medication) was stored in the communal dining room (a large room where residents met to eat meals, participate in activities, or watch TV); and2. Facility nurses did not check two out of two crash carts every night to ensure that needed supplies were available and not expired. This resulted in residents and visitors having access to the contents of the crash cart and had the potential to impact resident safety or cause a delay in life sustaining care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who entered the facility without pressure injuries (PIs, bed sores) did not develop PIs, develop care plans related to the PIs, identify heel PIs, and manage PIs in one of three residents sampled for PIs (Resident 1) when:1. Facility nursing staff failed to recognize a PI on Resident 1's coccyx (the small, triangular bone at the very bottom of the spine) until it was a stage 2 PI (partial-thickness skin loss with exposed dermis [the middle layer of the skin]).2. A specialized mattress was not obtained for Resident 1 until 11 days after her coccyx PI was discovered.3. Facility nursing staff failed to recognize the development of PIs on Resident 1's heels until her family told staff that Resident 1's heels were hurting.4. [...]

Inspectors wroteBased on interview and record review the facility did not maintain complete documentation for six out of six sampled residents (Residents 1, 2, 3, 4, 5, and 6) when Licensed Nurse (LN) B did not sign the medication administration record (MAR) when administering medication. This failure had the potential for medication errors, residents to receive a double dose of medication, and a decline in resident health status.

Inspectors wroteBased on observation and interviews, the facility failed to ensure three of four shower rooms were maintained in a clean and homelike environment. These failures had the potential to expose all residents who receive shower services to conditions that are not safe, clean and comfortable. During an observation on 2/20/26 at 9:44 am, of three of four shower rooms, two Shower Rooms in Station 1, had a dark black substance along the floor-to-wall seams and within the corners of the shower stall. The discoloration was concentrated along the grout lines and caulked joints. One of the shower rooms in Station 1 had six (6) 4 inch by 4 inch wall tiles missing from the wall surface beside and beneath the shower faucet handle mounted on the wall. The exposed surface beneath the missing tiles contained a brown and black substance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure seven Nurse's Aides (NA, in training not certified by state) were state certified prior to hiring and were competent to provide direct resident care independently. This had the potential for all residents not to have their care needs met and at risk for injury and harm when seven uncertified Nurse's Aides provided direct resident care and were not deemed by the State of California to be competent to provide direct resident care. Refer to 837.

Inspectors wroteBased on interview and record review the Governing Body (GB) failed to provide oversight for the Administrator to ensure seven Nurse's Aides (NA, in training not certified by state) were state certified and had the competencies required prior to providing care to residents independently. This had the potential to put all residents at risk of injury and harm and to not receive quality of care when seven NAs were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to F728.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1 was rushed by Certified Nursing Assistant (CNA) F and spoken to with a demeaning tone and attitude. This failure resulted in Resident 1 feeling angry, helpless and emotionally stressed and had the potential to result in embarrassment and neglect which could result in negative clinical outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was free from physical and verbal abuse when Resident 2 yelled profanity and was swinging at Resident 3 in the hallway. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, anger, and the potential for negative clinical outcomes.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the environment was free from hazards when they did not follow their laundry policies and procedures (P&P) and did not provide Laundry Tech (LT) A with required competencies (training and education). This had the potential to contribute to smoldering (burn slowly with smoke but no flames) laundry that was discovered in a laundry bag.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff consistently implemented the physical mobility care plan for one of three sampled residents (Resident 1) when Resident 1's care plan indicated that she would be transferred using a Hoyer lift (a mechanical lifting device), and staff were not consistently using the Hoyer lift and transferring her with two people lifting her up by her arms. This had the potential for Resident 1 to sustain injuries from staff not using the Hoyer lift and negatively impact her ability to attain or maintain her highest practicable level of emotional and physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed prevent an avoidable fall with injuries when staff had not correctly used a Hoyer lift (a mechanical device with a sling that has straps which are to be securely attached to the device used to lift and carry a resident to a desired location. This lift requires two staff for a safe transfer, one to operate the lift and one to guide the resident), for one of five sampled residents (Resident 1) when:1a. Staff had not ensured the straps on the Hoyer lift were secure and the sling straps came off and dropped Resident 1 onto the floor.1b. While one staff operated the Hoyer lift, the second staff had not stood by and guided Resident 1 during the transfer.1c. Staff placed Resident 1 in a Hoyer sling that had damaged straps which were rigid and stiff and should not have been used.1d. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a care plan (a written plan that outlined how the facility and staff would meet the resident needs) for four out of five sampled residents (Residents 2, 3, 4, and 5) when there was no care plan present that described the use of a mechanical lift (medical device on wheels that was used to transfer residents who could not bear their own weight). This had the potential for residents not to obtain or maintain their highest practical physical, mental, and psychosocial well-being and lead to potential accidents from not being transferred properly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Resident Safety and Maintenance Service policies and procedures (P&P) when:1. Facility staff knew the mechanical lift (device on wheels used to transfer residents that could not walk) was broken, did not report it, and used it to transfer four out of five sampled residents (Residents 2, 3, 4, and 5); and2. The Maintenance Department failed to ensure the broken mechanical lift was removed from use, reported as broken, and did not consistently perform monthly routine maintenance of all mechanical lifts that were utilized in the facility. This had the potential to cause an accident and injuries from using broken equipment to lift and transfer all residents who required the use of a mechanical lift and negatively impact their physical and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat two of three residents (Resident 15 and Resident 17) with respect and dignity when:1. The facility failed to ensure that Resident 17 was provided with appropriate clothing. This failure resulted in Resident 17 experiencing social isolation when unable to participate in facility activities and feeling embarrassed and undignified when required to attend outside appointments wearing only a hospital gown.2. Certified Nursing Assistant (CNA ) J did not provide Resident 15 with privacy and dignity when the privacy curtain was not pulled closed when Resident 15 was receiving personal care in their room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident council grievances were acted upon and promptly addressed for 12 confidentially interviewed residents when the residents stated there was an ongoing delay in answering call lights and getting care on the night shift. Refer to F726. This failure resulted in residents experiencing frustration with long wait times for needed care and had the potential to put residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of five direct care nursing staff had necessary competencies and skills sets to meet the care and services when: 1. CNA J and F had not worn an N-95 mask (recommended when caring for residents with Covid) when providing care to Resident 28, who had Covid. Refer to F880. 2. CNA J did not ensure privacy for Resident 15 during care. Refer to F550. These failures resulted in resident care needs not to be met, residents' right to privacy violated, and had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their infection control prevention program was implemented to prevent the spread of Covid (a serious virus that causes fever, tiredness, cough, breathing difficulties, loss of smell and taste) when Certified Nursing Assistants (CNAs) were observed wearing surgical masks to care for one resident with Covid (not as effective as an N-95 in preventing the spread of the Covid virus), as their policy directed. (Resident 28) This had the potential to spread the Covid virus to other residents, visitors and staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents sampled for discharge (Resident 61) had the required transfer and discharge documentation in their chart when Resident 61 was transferred to a General Acute Care Hospital (GACH) and: Resident 61 was not provided with a Notice of Transfer or Discharge. Resident 61 was not provided with a notice of a bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization). The Ombudsman's office (a government appointed person who actively supports the rights of residents) was not provided with Resident 61's Notice of Transfer or Discharge form. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper managing of a gastrostomy tube (G-tube, a tube inserted into the stomach through the abdominal wall to deliver liquid nutrition, fluids, and medication) for one of two residents sampled for G-tube management (Resident 45), when the Treatment Nurse (TN) placed Resident 45 in a flat position while the enteral feeding (liquid nutrition and fluids provided through a tube inserted into the stomach) pump was still on. This failure had the potential for the liquid nutrition to back up into Resident 45's esophagus (a tube from the throat to the stomach) and cause aspiration (where liquid nutrition enters the lungs) and can lead to a deadly lung infection called aspiration pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store, dispose, and document for the medication that had been discontinued in one of two observed medication rooms (Medication room [ROOM NUMBER]). This had the potential for discontinued medications to be available for resident use and/or diversion (taking without permission), by staff which could negatively impact the residents' health status. A review of facility policy titled, Medication Destruction for Non-Controlled Medications dated 2006, indicated unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed. Medication destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law. [...]

Inspectors wroteBased on observation, interview, and facility policy and procedure review, the facility failed to ensure visitors and staff who handled food brought from the outside were educated on safe food handling practices. This failure had the potential for unsafe food handling which could lead to foodborne illness in the 53 residents receiving an oral diet who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their Fall Management Program policy and procedure (P&P) for one out of three residents sampled for falls (Resident 1). Specifically, the facility staff initiated the required post-fall documentation on 5/19/25, two days after Resident 1 fell, instead of initiating a Post-Fall Huddle (includes updating the care plan, interviewing witnesses and documentation in the medical record), within 15-20 minutes after Resident 1's fall on 5/17/25. This failure caused a delay in the facility-initiated fall investigation to be completed, had the potential to cause a delay in care, and placed Resident 1 at an increased risk for more falls.

Inspectors wroteBased on interview and record review, the facility failed to comply with state and local public health authority requirements for reporting an outbreak when a total of 11 residents and 3 staff had been reported with signs and symptoms of respiratory illness, such as cough, running nose, sore throat, shortness of breath (SOB- a sensation of running out of the air) from 3/30/25 to 4/8/25. The facility did not report the occurrence to California Department of Public Health (CDPH) until 4/8/25. This failure had the potential to result in a widespread infection in the facility that could compromise the health of the residents, visitors, and staff.

Inspectors wroteBased on interview and record review, the facility failed to protect one of four sampled residents (Resident 2) from verbal abuse when Resident 1 made derogatory comments and yelled profanities directed at Resident 2 while in the hallway. This failure had the potential to negatively affect the psychosocial and mental health for Resident 2 and other residents within hearing range.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation for one of four sampled residents (Resident 2), to the California Department of Public Health (CDPH), Ombudsman (Resident advocate organization), and local law enforcement, within two-hours after Resident 1 made derogatory comments and yelled profanities directed at Resident 2 while in the hallway. This had the potential for Resident 2, and other residents, to be vulnerable and unprotected from mistreatment, and negatively impact their emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) had a care plan developed to address Resident 1's use of Methamphetamine (illegal drug in the form of [NAME] Meth and is highly addictive and causes feelings of euphoria and increased alertness and energy and can cause violence, paranoia, anxiety, rapid heart rate, irregular heartbeat, stroke, or even death). This deficient practice had the potential to result in a decline in Resident 1's health status related to the lack of interventions and monitoring for signs and symptoms of substance abuse which could result in a potential overdose.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 1) who had a known Substance Abuse Disorder (SUD, an individual who uses and/or abuses illegal drugs and/or alcohol), was provided with the necessary monitoring and supervision to prevent avoidable accidents and hazards when: 1. Resident 1 frequently went out of the facility on pass and was not evaluated or assessed for signs of drug use and/or overdose upon his return to the facility. 2. Nursing staff had not received training or education on how to manage potential emergencies that could arise for residents with a SUD. (Refer to F741) 3. The facility failed to develop a SUD plan of care for Resident 1 with goals and interventions to mitigate potential accidents, hazards, and drug overdose. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff were trained and competent to care for one of one sampled resident (Resident 1) who had a Substance Use Disorder (SUD, an individual who uses and/or abuses illegal drugs and alcohol) when Resident 1 had many numerous physical and verbal altercations with other residents and staff over the past year, and staff indicated they did not know how to deal with these behaviors of someone with a SUD and indicated they had not received training on it. This failure has the potential for Resident 1 not to receive care and services to safely manage his SUD and result in a decline in his physical, emotional and psychosocial well-being and put other residents' health, safety and welfare at risk.

Inspectors wrote2a. During a review of Resident 20's admission record, indicated that she was originally admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses which included cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), dysphagia (difficulty swallowing) following cerebral infarction, aphasia (a disorder that makes it difficult to speak) following cerebral infarction, and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). Resident 20 was not her own health care decision maker. During a review of Resident 20's MDS, dated [DATE], the MDS indicated that a Brief Interview for Mental Status (BIMS) shouldn't be conducted, because Resident 20 was rarely/never understood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers twice a week and nail care as indicated on the residents Activities of Daily Living (ADL's refers to dressing, bathing, grooming, toileting and hygiene) record, for 3 of 18 residents who were sampled for ADL care. (Residents 5, 7, and 41) when: 1. Resident 5 missed two of his Saturday showers which were important to him, because he e attended Spiritual Meetings on Sundays. This had the potential to negatively impact Resident 5's emotional well-being. 2. Resident 7 had unwanted body odor. This had the potential for Resident 7 to experience embarassment and skin irritation. 3. Resident 41 had long fingernails with jagged sharp edges and thick dark brown substances under each nail. This had the potential to cause infection and skin tears from long sharp nails.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe use and accountability of narcotic controlled medications (prescription narcotic drugs of abuse), when: Resident 61's Norco (Hydrocodone-APAP; an opioid/narcotic pain medication) was removed from Controlled Drug Record (CDR, an accountability sheet that tracked narcotic removal with nurses initial, date, and time), without the corresponding administration documentation in Resident 61's MAR (Medication Administration Record- a legal document that listed the drugs given to Resident 61). This failure could contribute to unsafe drug handling, poor pain control, and risk of drug diversion (drug loss).

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure safe use of psychotropic medications (medication that alters mood, behavior and cognition (thinking, learning and understanding)), on one out of five residents (Resident 42) reviewed for unnecessary drug use with census of 75 when: Resident 42's PRN (as needed) use of phenobarbital (an anti-seizure medication also used to treat mood and behavior problems), was not evaluated and assessed by the facility and medical doctor for duration of use based on facility's policy. These failures could contribute to unsafe use of psychotropic medications that could have placed resident at risk for adverse consequences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 75. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 31 opportunities which resulted in a facility wide medication error rate of 9.68% in 2 out of 9 residents (Resident 19 and Resident 71) observed for medication administration as follow: 1. The facility failed to ensure Resident 19 received food with the potassium (an essential electrolyte needed by all tissues in the body) administration. 2. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure safe medication storage practices in the medication room (a locked room used to store medications and supplies) and two out of 5 medication or treatment carts (a mobile cart stored medication and supplies for immediate use) based on manufacturer specifications with census of 75 when: 1. Medication Cart 3 at Station 2 stored an unopened and unused eye drop called latanoprost (or Xalatan- used to treat eye disease) that required refrigeration based on manufacturer specification. An undated glucometer (a device that measure blood sugar) test strips bottle (testing supply inserted in the glucometer to measure blood sugar) based on manufacturer specification. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food service safety for the residents of the facility when during the initial tour food preparation equipment was not clean. These failures had the potential for risk of contaminating food with germs and causing a food born illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete for one out of 18 sampled residents (Resident 46) when Restorative Nursing Assistant (RNA, trained in providing residents with range of motion exercises [ROM, exercises that assist with movement of the arms or leg]) did not document care that was provided. This failure caused medical records to be incomplete which caused an inability to know of physician care ordered was provided or not.

Inspectors wroteBased on observation, interview, and record review, the facility did not follow their Arbitration Agreement (a binding contract that explained how a resident would resolve disputes against the facility) policy and procedure (P&P) for three of three residents (Residents 27, 42, and 48) that were sampled for arbitration when: 1. Resident 27 did not fully understand the terms and conditions of the arbitration agreement, stated it was not explained in a manner that was understood, and felt rushed during the process; and 2. Resident 42's responsible party (RP, decision maker/representative) stated, facility staff did not discuss the arbitration process or agreement with RP and was not aware RP had signed a binding arbitration agreement; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an electrical outlet cover in room [ROOM NUMBER], located near a privacy curtain (a fabric curtain that hung from the ceiling and provided privacy to the residents), was maintained when the electrical outlet cover was loose and there was an exposed gap between the electrical outlet cover and the wall. The failure to maintain an electrical outlet and it's cover could be considered a safety hazard.

Inspectors wroteBased on interview and record review, the facility failed to report a physical abuse allegation for one of two residents (Resident 1) to the California Department of Public Health (CDPH) within two-hours after Resident 1 alleged a tall, thin, male staff member, physically abused her. This had the potential for Resident 1, and other residents, to be vulnerable and unprotected from mistreatment, and negatively impact their emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was developed or revised to determine interventions for one of two sampled residents (Resident 1) when Resident 1 expressed he wanted to die. This failure had the potential for Resident 1 to experience a decline in psychosocial and physical wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered per physician ' s order when one of three residents (Resident 1) received Tacrolimus External cream (a medicated ointment for skin rash with petroleum (a skin protectant used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin) as an ingredient) in error and was allergic to it. This failure caused Resident 1 to experience burning to his back.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Nurses (LNs) documented in the electronic medical record for one of six sampled residents (Resident 1) when Resident 1 had a change of condition and was transferred to the acute hospital. These failures resulted in an inaccurate record and had the potential to affect developing an accurate resident plan of care when a change of condition was not documented in the record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' rights to be free from physical, psychological (mental), or verbal sexual abuse for two of four sampled residents (Residents 1 and 3) when: 1. Resident 2 made sexually explicit comments to Resident 3 and continued to harass her after staff and law enforcement asked him to stop. 2. Laundry Personnel 2 (LP2) touched Resident 1 on the shoulder and whispered into her ear, which made Resident 1 feel very uncomfortable. These failures caused mental suffering and feelings of distress for Resident 3 and an increase in anxiety for Resident 1.

Inspectors wroteBased on interview, and record review, the facility's Administrator (ADM) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when: 1. ADM did not ensure the abuse policy was implemented to protect residents' rights to be free from physical, psychological (mental), or verbal sexual abuse, and allegations of abuse were identified/reported. Refer to F600 and F609. 2. ADM did not report an unusual occurrence of a facility lockdown. 3. ADM did not ensure the building equipment was operating and the environment was safe. Refer to F689 and F908. This put all residents at risk for ongoing abuse and accidents and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment in safe operating condition when: 1. An air conditioning unit leaked for three days from the ceiling in room [ROOM NUMBER]A (Resident 5's bedroom). This failure resulted in Resident 5 stating she felt frustrated and worried and had the potential for avoidable life-threatening hazards such as ceiling collapse from water damage, electrocution, and infection from mold and bacterial growth. 2. Facility staff silenced a malfunctioning fire system alarm for five hours. Failure to maintain the fire system had the potential to place all 89 residents, staff, and visitors at risk of injury or death in the event of a fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse within 24 hours for one of four residents (Resident 1). This failure had the potential for ongoing staff-to-resident abuse for all 89 residents within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident environments remained free from avoidable accidents and hazards when Resident 5 lived in her bedroom for three days with a ceiling leak from a malfunctioning rooftop air conditioning unit. This failure resulted in a negative psychosocial (relating social conditions to mental health) outcome when Resident 5 stated she felt frustrated and worried, and put her a risk for accidents and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained free from potential accident hazards when: 1. One Fire Door (FD) A (a door that is fire proof and helps contain smoke), which led to the outside of the facility was damaged and could not be completely closed or locked for the past year and a half. The door led to the facility backyard where there was a steep creek. 2. A staff locker room door (LD) B, that residents had access to, was not kept locked and contained rusty unlocked lockers, stainless steel chemical cleaner, personal protective equipment (eye goggles, face shield and face masks), staff belongings, food items, a broken air conditioner, TV monitors [televisions], cardboard boxes, an industrial-sized container of a chemical rust remover. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, evaluate, and intervene in a timely manner in order to prevent an avoidable pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence, where bones are close to the surface of the skin), for 1 of 3 residents who were sampled for pressure ulcers (Resident 63). This resulted in Resident 63 developing an infected Stage 4 (full thickness skin loss with damage and exposure of muscle, bone, fat and/or tendon), pressure ulcer on his right heel and subsequent right leg amputation (cut off by surgical operation), below the knee which caused the resident anxiety, depression, and uncontrolled pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety when: 1. Expired food items were present in refrigerator/freezers and dry storage areas; 2. Food was not properly stored, labeled and dated; 3. Kitchen and food service equipment were not in sanitary condition; 4. The kitchen environment was not in sanitary condition; 5. An eyewash station was present in the handwashing station. These failures created a potential risk for exposure to food- and waterborne illnesses in a medically vulnerable population of 78 residents who received food prepared in the kitchen.

Inspectors wroteBased on interview, and record review, the facility's Administrator (ADM) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when: 1. The ADM failed to ensure the resident environment was safe, clean, and free from accident hazards. This resulted in an immediate jeopardy for failure to provide a system to ensure the safety of the resident and prevent the outsiders from entering the facility. These failures had the potential to put all the residents at risk for accident and hazards. Refer to F 689. 2. The ADM failed to ensure that the facility have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services. Refer to F 725, and F 726. 3. [...]

Inspectors wroteBased on interview and record review, the facility's Governing Body (GB), legally responsible for establishing and implementing facility policies, failed to effectively manage the facility when: 1. The GB did not ensure the administrator (ADM) had capital expense approval to ensure of the safety of the residents. Refer to F 689. 2. The GB did not ensure sufficient and competent staffing was present to meet the needs of all residents. Refer to F 725, F 726. 3. The GB did not ensure adequate oversight and monitoring of the dietary department. Refer to F 812. 4. The GB failed to ensure and effective Quality Assessment and Assurance Program to identify, implement corrective actions and evaluate their effectiveness. These failures led to an Immediate Jeopardy (IJ) being declared on 5/22/2024 at 11:25 am, at F 689. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) committee when they did not identify nor correct facility issues to ensure care and services met residents needs when: 1. The facility had two unlockable doors, one -as a fire door with a broken hinge, leading to the facility's backside parking lot that nears a creek and a busy road. The facility's QAPI Program failed to monitor and take action to improve known defects in the facility's process for obtaining the vender's quote for the cost of the fire door and the capital expense approval. This resulted in an immediate jeopardy for failure to provide a system to ensure the safety of the resident and prevent the outsiders from entering the facility. Refer to F 689. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to sustain a safe and sanitary environment for 82 out of 82 residents when: 1. During an inspection of the water-borne pathogen prevention program, the Maintenance Supervisor (MAINT) was unable to consistently provide proof that water temperatures were being monitored, and, 2. Personal protective equipment (PPE) consisting of a box of surgical masks, eye goggles and a face shield designed to be used during direct patient care were found in rusted employee lockers, and PPE and medical supplies were found to be stored in a basement around an active water leak directly below the dishwasher upstairs, and, 3. Nurses were observed to apply disinfecting agents (solutions designed to kill disease-causing pathogens) for inadequate lengths of time on shared medical equipment. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident council grievances were addressed and resolved when confidential interviews indicated ongoing facility issues. This resulted in the residents to express feelings of helplessness and not being wanted.

Inspectors wroteBased on interviews, medical record review and facility policy and procedure review, the facility failed to ensure two of six resident's responsible parties (Residents 63 and 4) were notified of significant unplanned weight loss. These failures resulted in a delay of communication of Residents 63 and 4's significant weight losses to their responsible parties which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility environment was maintained safe, comfortable and homelike when: 1. Air temperatures were cold throughout the building. 2. The outside resident patio and facility grounds were not maintained. 3. Multiple screens were missing from residents rooms and dining room. This resulted in residents that were cold and had the potential for insects to enter the facility through windows without screens and violated the residents right to have a homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for two of two sampled residents (Residents 47 and 61) to ensure the residents maintained their highest physical, mental, and psychosocial well-being. This deficient practice had the potential not to meet the highest practicable psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staffing to meet the needs of residents for 16 of 18 sampled residents (Resident 435, 55, 7, 33, 27, 20, 44, and nine Residents from a confidential resident meeting) when: 1. Resident 435 was observed waiting for their call lights to be answered for 30 minutes or longer. 2. Five of Eighteen sampled residents (Resident 55, 7, 33, 27, 20) reported waiting over one hour at times for staff assistance. 3. Resident 44 reported that certain Certified Nursing Assistants (CNA's) enter Resident rooms and cancel call lights without assisting Residents. 4. During a confidential resident meeting, nine of ten residents who attended stated call lights were not answered in a timely manner, which resulted in the resident's care needs not being met. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nursing staff with necessary competencies and skill sets to meet the care and services for resident needs for 17 of 18 sampled residents (Resident 435, 55, 7, 33, 27, 20, 44, 58, and nine Residents from a confidential resident meeting) when: 1. Resident 435 was observed waiting for their call lights to be answered for 30 minutes or longer. 2. Five of Eighteen sampled residents (Resident 55, 7, 33, 27, 20) reported waiting over one hour at times for staff assistance. 3. Resident 44 reported that certain Certified Nursing Assistants (CNA's) enter Resident rooms and cancel call lights without assisting Residents. 4. During a confidential resident meeting, nine of ten residents who attended stated call lights that were not answered in a timely manner, which resulted in the resident's care needs not being met. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and serve food that maintained an appetizing flavor, texture, appearance, and at a palatable (pleasant taste) temperature when 10 of 18 sampled residents (Residents 7, 13, and 8 Residents from a confidential resident meeting) when: 1. Resident 13 was served with a puree diet, the taste was so-so, and was cold. 2. Resident 7 stated the food was overcooked and did not have the appearance of what it should be. 3. Confidential resident interviews and resident council meeting minutes review indicated food was served cold. 4. The food on the test tray were mostly bland. These failures resulted in meals to be served cold, unpleasant, and not meet the resident food preference, which had the potential for residents to decrease meal intakes and have weight loss issues.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure facility equipment was functioning when: 1. Air conditioner (AC) units to cool Rooms 11-18 were not working properly and needed replacement. 2. Toilet in room [ROOM NUMBER] was not secured to the floor. 3. Shower heads in shower rooms were leaking with low water pressure. 4. Sliding glass door track bent in dining room. 5. The door at the facility entrance would not close. 6. Leaking back flow pipe left corner of the building. 7. Floor of dietary department is leaking and flooding into basement These failures resulted in an uncomfortable warm temperatures, a fall with injury, and put all residents at risk for accidents and hazards.

Inspectors wroteBased on interview, and record review, the facility failed to ensure required corrective action was followed in the resolution of a grievance for one of 18 sampled residents (Resident 20). This failure had the potential for Resident 20 to feel her grievance was not managed properly, and therefore feel unsupported by the facility.

Inspectors wroteBased on interview, and record review, appropriate procedure was not followed in the execution of an out-of-facility transfer for one of four sampled residents (Resident 84). This failure could have resulted in Resident 84 and the Ombudsman (a resident advocate) not being notified and unaware of the impending transfer.

Inspectors wroteBased on interview, and record review, appropriate procedure was not followed in the execution of an out-of-facility transfer for one of four residents (Resident 84). This failure could have resulted in Resident 84 not being properly oriented to the purpose for the transfer and being unprepared, which could have resulted in uncertainty and anxiety.

Inspectors wroteBased on interview, and record review, the facility failed to ensure regular (annual, quarterly, or as needed) IDT (an IDT is an interdisciplinary team of health care providers who have knowledge of the resident and his or her needs who is involved in making decisions about the resident's care), assessment for psychotropic medication (mind altering drugs) use and behavioral data for one of five sampled residents, Resident 53. This failure resulted in Resident 53 having a schizophrenia diagnosis (a mental health disorder that affects the way a person thinks, feels, and behaves and may include hallucinations) added to the medical records, in addition to anoxic brain injury (an injury to the brain due to lack of oxygen). The addition of the schizophrenia diagnosis was not documented by a psychiatric (mental health) physician or primary care physician.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Provide the necessary care and services for dysphagia (difficulty swallowing foods or liquids) and gastrostomy feeding tube (or G-Tube, a medical device inserted into stomach surgically and used to provide liquid nourishment, fluids, and medications by bypassing oral intake) for one of two sampled residents (Resident 61), when Resident 61 was found to be lacking current Speech Therapy orders. This failure had the potential to lead to the Resident not attaining their highest level of practicable nutrition and emotional happiness. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a plan of care to assess, monitor and modify approaches to pain management for one of three sampled residents (Resident 435). This resulted in Resident 435 to experience unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe practices in handling and storage of hazardous medications (drugs that pose short- or long-term harm upon exposure to human via skin or inhalation with required special handling by National Institute for Occupational Safety and Health, or NIOSH), when a hazardous liquid medication called Depakote solution (also called Valproic acid in liquid form; used to treat mood swings or seizure disorders) was stored unsafely in medication cart and was handled without use of gloves during medication administration. These failures could contribute to unsafe medication use and exposure of hazardous medication to staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe monitoring and accurate documentation of psychotropic medications (medication used for mood disorder and mental health) use including diagnosis and use of non-drug interventions (methods used to address other personal, emotional, or physical interventions before giving drugs) in two out of five sampled residents assessed for unnecessary drug use (Resident 61 and Resident 53) when: 1. Nursing interventions for non-drug approaches was not implemented for Resident 61's PRN (as needed) psychotropic medication called lorazepam (or Ativan, a drug used to treat anxiety). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage practices when: 1. The respiratory medication called Duoneb inhalation solution (or also known as Ipratropium and Albuterol inhalation solution, two drugs in one, used for better breathing and shortness of breath) stored in facility's Medication Cart #2 at Station 1 and Medication Cart #4 at Station 2, were not dated upon opening and; 2. Medication refrigerator at Station 2's medication room was heavily frosted and insulin (a biological product to treat blood sugar disease) and vaccine (a biological product used to prevent and protect from infections) product were stored in close proximity of the frosted area. These failed practices could result in spoiled, ineffective, and unsafe medication use in the facility.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure federal regulations related to the education qualification requirements of the Certified Dietary Manager (CDM), were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refuse (garbage) was stored in a sanitary manner when: 1. the lids to two of three outdoor refuse dumpsters did not close tightly, and 2. the area surrounding the dumpsters was not maintained in a sanitary manner to prevent pest/rodent infestation. These failures had the potential to attract pests and rodents that carry diseases.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate a staff to resident abuse allegation between Certified Nursing Assistant (CNA) A and Resident 1 when no further interviews were conducted by Admin with facility residents or staff after video footage was reviewed. This had the potential for ongoing staff to resident abuse in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure steps were taken to protect one of three sampled residents' (Resident 1) personal property when Resident 1 ' s inventory list (an itemized list of the personal belongings and other items the resident brought with them to the facility), was not completed on admission or at any other time during her stay. This failure failed to honor Resident 1 ' s right to have their personal belongings protected and secured which had the potential to cause loss of personal property and affect her quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide an accurate and complete assessment for one of three sampled residents (Resident 1), when Resident 1 ' s pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure exerted over specific areas of the body) to coccyx (a small area at the base of the spinal cord) and buttocks was not identified on their admission Minimum Data Set ( MDS, a complete clinical assessment). This failure had the potential for staff to not be fully informed of Resident 1 ' s skin condition to determine the need for further assessments and interventions that could result in delays in care and decline in Resident 1 ' s medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system or process for recording the disposition for wasting (disposing of a controlled substance) narcotic patches when one of four residents was prescribed narcotic patches (Resident 1). Resident 1 was on hospice with fentanyl patches (a strong narcotic that comes in the form of a patch that is placed on the skin), ordered, and the disposition of the fentanyl patches that were removed from Resident 1's skin was not recorded by nursing staff who were unclear of the process for disposing of, and recording the disposition of, the narcotic patches. This failure had the potential to result in narcotic patches not being appropriately disposed of, due to lack of process for recording the disposition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the safety of one of three sampled residents (Resident 1), who were reviewed for falls and injuries, from a significant avoidable injury when Resident 1 had been evaluated to benefit from bed rails (rails attached to the bed to help with turning over in bed), and Resident 1 had requested bed rails that were never put on her bed. Certified Nursing Assistant (CNA) B told Resident 1 to roll over in bed so that she could change Resident 1 ' s brief (an adult protective underwear for loss of bowel and bladder control). Resident 1 told CNA B that she did not have enough room to turn over and was going to fall off of the bed, and CNA B told her to roll over anyway. [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently document the current oxygen delivery methods for two of three sampled residents (Residents 1 and 3) when: 1. Resident 1 ' s physician order for supplemental oxygen was not addressed in the resident ' s Care Plan and was inaccurately documented in the weekly nursing evaluation; 2. Resident 3 ' s oxygen delivery method was inaccurately documented in the weekly nursing evaluation. This failure had the potential to communicate inaccurate information which could have threatened the residents ' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow their Laboratory Services policy and procedure (P&P) for two out of two sampled residents (Resident 1 and Resident 2) when: 1a. The facility did not notify the physician when Resident 1 had abnormal laboratory results on 11/16/23. 1b. Laboratory services were provided to Resident 1 on 12/27/23 without a Physician ' s order. 2. The facility did not obtain Physician ordered laboratory services on two separate occasions for Resident 2. These failures had to potential to cause a decline in resident health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the policy and procedure (P&P) for residents that received dialysis (procedure to remove waste and extra fluid from the body), were followed when: 1. Pre and Post Dialysis Assessments communication forms, that included an assessment of the resident before and after dialysis were not consistently performed and documented for two out of two sampled residents (Resident 1 and 2). 2. A recommendation made by the dialysis center, to discontinue a medication was not acted upon for one out of two sampled residents (Resident 2). 3. Dialysis dressings (bandages) had not been removed from the graft site (area of access for dialysis), within the required time frame for two out of two sampled residents (Resident 1 and 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from potential accidents and hazards by blocking access to one hand-pull (manual) fire alarm, emergency exits, and handrails (assist residents with walking). This failure put all residents at risk for falls and fire hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff wore hairnets when entering the kitchen area. This failure had the potential for hair to contact and contaminate food served to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect residents from abuse when: 1. One out of four sampled residents (Resident 1) had been struck in the face by another resident (Resident 2) when Resident 2 heard Resident 1 verbally abuse female staff members. 2. Two out seven sampled residents (Resident 6 and Resident 7) endured ongoing verbal abuse from Resident 1 during resident cigarette (smoke) breaks. This failure placed residents at an increased risk for inability to attain or maintain physical, mental, and psychosocial well-being and caused feelings of anxiety (feelings of worry, nervousness or unease, symptoms could include irritability or aggression)

Inspectors wroteBased on observation, interview, and record review the facility failed to treat three out four sampled residents (Residents 3, 4, and 5) with dignity and respect when long call light wait times were experienced. This failure resulted in feelings of neglect and anxiety for Residents 3, 4, and 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure registry staff (staff that worked at the facility but were not employees) and housekeepers, who provided residents with cigarette (smoke) breaks, were knowledgeable of care planned (a plan that outlined a residents care) interventions (action taken, included in the residents care plan) for two out of two residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 had been in a physical altercation, had interventions to be kept separated, and were outside in the resident smoking area at the same time. This failure placed Resident 1 and Resident 2 at risk for harm and abuse.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete for one out of two sampled residents (Resident 1) when: 1. The medical record did not contain Alert Notes (a note that was written by Licensed Nurses (LN), each shift after Resident 1 was involved in a Resident-to-Resident altercation that described Resident 1's condition. 2. The medical record did not contain a Change of Condition note that indicated the physician had been notified when Resident 1 was struck in the face by another resident. 3. The LN did not document a physical assessment of Resident 1 after Resident 1 was stuck in the face by another resident. This failure had the potential for confusion regarding Resident 1's health status and for potential health decline to go unnoticed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received food that accommodated their schedule, needs, preference, and request for one of 8 sampled residents (resident 2), when Resident 2 was scheduled to be out of the facility for dialysis, was unable to consume food for lunch, and was not provided food upon return to the facility. This failure resulted in loss of nutritive sustenance with the potential to contribute to a decline in nutritional status, weight loss, and an overall decrease in health and wellbeing.