Ojai Health & Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided resident care and services in accordance with professional standards of nursing practice when physician medication order and instructions were not followed for one of three residents (Resident 1). This failure had the potential to result in unsafe nursing care practices which could compromise the health and safety of Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders for restorative nursing assignments (RNA - targeted care tasks assigned to nursing staff to help patients maintain or improve their physical, mental, and functional independence) were consistently provided to four of four sampled residents (Resident 1, 2, 3, and 4). This failure has the potential for residents to experience functional decline. The facility policy and procedure (P&P) titled: Activities of Daily Living (ADL), Supporting, dated March 2018, indicates in part, .Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.b. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to adequately maintain a homelike environment when:1. Four out of six residents (Resident 1, Resident 3, Resident 5, Resident 6) stated their rooms were too hot.2. One air conditioning unit (unit 2) was in disrepair.3. The Physical Therapy gym was 84 (degrees) Fahrenheit (F - unit of measurement for temperature). These facility failures had the potential to negatively impact residents. During an interview on 7/15/26 at 10:21 a.m., in Resident 3's room, Resident 3 stated this room is too hot, but if windows are opened it lets all the hot air in, so I keep it closed. During a concurrent observation and interview on 7/15/26 at 10:30 a.m., in Resident 5's room, the room was noticeably warmer than the hallway. A thermometer in Resident 5's room read 26 C (Celsius - unit of measurement for temperature). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent (a communication process where a healthcare provider educates a patient about the risks, benefits, and alternatives of a proposed treatment or procedure and patient acknowledges to have treatment or procedure done) was obtained when the dose increased for administration of psychotropic medication use for one of two residents (Resident 34). This failure resulted with the responsible party (RP) not having autonomy in medical decision-making before the resident received the medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive person-centered plan of care for scabies rash like skin condition was formulated for one of two (2) sampled residents (Resident 17). This failure had the potential to hinder continuity of care and not to address all aspects of residents' condition and required responses without the comprehensive information of the care plan.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure compliance with the required 3.5 direct care hours per patient day (DHPPD), resulting in insufficient staffing on 11 of 26 weekend days. This facility failure has the potential to result to unmet care and needs to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow it's policy and procedures (P&P) for disposition (process for destroying unused medications) and reconciling (system of recordkeeping that ensures an accurate inventory of medications) of controlled medications (medications with a high potential for abuse and addiction) when:Two opened vials of Lorazepam (controlled medication used to treat anxiety) stored in medication cart 1 were not destroyed appropriately. One count sheet for Morphine (controlled medication used for pain) was incorrect for one out of 17 sampled residents (Resident 6). This failure had the potential to result in drug diversion (the illegal distribution or abuse of controlled prescription drugs) of controlled medications.1. During a concurrent observation and interview on 6/10/26 at 2:26 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when:Expired medications were stored in medication cart 1. Resident 34's prescription medication was stored in the medication supply room with unopened over the counter medications. Two vials of Furosemide (medication used for fluid retention) stored in medication cart 2 were unlabeled. These facility failures had the potential to result in administering expired and ineffective medications to residents and had potential for medication administration errors.1. During a concurrent observation and interview on 6/10/26 at 2:44 p.m., with Director of Staff Development (DSD), two opened foil packets of DuoNeb (medication used to treat breathing issues) were observed stored in medication cart 1. One foil packet was dated 5/19/26 and one foil packet was undated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a kitchen staff member was wearing a beard covering in the kitchen during meal preparation. This failure had the potential to result in Foodborne illness (commonly known as known as food poisoning, refers to any sickness caused by eating or drinking foods or beverages contaminated with harmful bacteria, viruses, parasites, or toxic chemicals). During a concurrent observation and interview on 6/8/26 at 12:01 PM with the Registered Dietician (RD) and the Dietary Supervisor (DS), in the kitchen, a Dietary Aid (DA1) was observed placing items on a shelf near the area where hot foods were being prepared for lunch service with a full facial beard that was not covered by a beard restraint (a hair net that covers facial hair). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record of one of 17 sampled residents (resident 11), contained documentation of oxygen given as needed (PRN). This failure had the potential to result in an incomplete medical record as well as the ability to evaluate Resident 11's respiratory (breathing) status and effectiveness of treatment. During a review of the admission Record (AR), admission date 12/11/17, the AR indicated Resident 11 was a [AGE] year-old female with diagnosis including atherosclerotic heart disease (hardening and narrowing of blood vessels), hypertension (high blood pressure), dementia (decline in mental ability severe enough to interfere in daily life), and palliative care (medical care for anyone living with a serious illness focused on providing relief from symptoms). [...]

Inspectors wroteBased on record review and interview, the facility failed to adhere to its own policy and procedure (P&P) on handling soiled linen when two (2) out of 17 sampled residents (Resident 17 & 50) were placed on contact isolation precautions from 5/11/26 to 5/18/26 due to a skin rash resembling scabies observed in Resident 17. Despite this precaution, the facility failed to implement the proper protocol regarding the management and storage of contaminated linen as outlined in their infection control guidelines. This failure placed both the staff and residents' health and safety at risk by storing multiple plastic bags of contaminated linen inside the residents' room for seven (7) consecutive days thereby exposing both staff and residents to possible spread of infections in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to notify the California Department of Public Health (CDPH) of an unusual occurrence involving a resident who was found to have a fracture of the outer ankle bone of the left leg. Requiring transfer to the emergency room for further evaluation and treatment. The facility's failure to notify CDPH had the potential to delay regulatory oversight of a significant injury and to inhibit external evaluation of resident safety practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff followed physician ordered parameters when administering as needed pain medication for 2 of 3 sampled residents (Resident 1 and 2). This facility failure had the potential to cause the resident ineffective pain relief and decreased quality of life. During a review of Resident 1's admission Record (AD), the AD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (the death of brain tissue as a result of reduced or blocked blood flow), hemiplegia and hemiparesis (complete paralysis and weakness) affecting right dominant side, generalized muscle weakness, and depression (persistent sadness, loss of interest in activities, and low energy). [...]

Inspectors wroteBased on interview and record review, facility failed to ensure Resident 1's drug regimen was free from unnecessary medications when Resident 1's physician order for lidocaine patch (a topical medication that delivers local anesthetic directly to the skin to provide temporary relief for localized muscle, joint, or nerve pain) exceeded manufacturer's instructions. This failure had the potential for Resident 1 to receive more than the recommended dose per manufacturer's recommendations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) for pain was updated to reflect the resident's current care needs and interventions for one of three sampled residents (Resident 1). This failure had the potential to result in inadequate pain management and could negatively impact Resident 1's psychosocial wellbeing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 2) to ensure the resident maintained the highest physical well-being; when there were no Physician's Orders that addressed hospice care (program that gives special care to people who are near the end of life), the use and care of a urinary catheter (a flexible tube that collects urine form the bladder and collected in a drainage bag), and use, care, discontinuation, and monitoring for a Peripherally Inserted Central Catheter (PICC- a long, thin tube that's inserted through a vein in the arm). This failure had the potential to result in Resident 2 not receiving necessary care and services consistent with their health status. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure compliance with the required 3.5 direct care hours per patient day, resulting in insufficient staffing on 2 of 28 days reviewed. This failure had the potential to result in unmet care needs, inadequate supervision, delayed response to changes in condition, and avoidable adverse outcomes for residents. A review of the facility's Direct Care Hours Per Patient Day (DHPPD) staffing logs for the month of 2/1/26 - 2/28/26 , showed the facility reported the following direct care hours: 2/2/26 - 3.40 hours 2/8/26 - 3.46 hoursThe records confirmed that 2 of 28 days reviewed, the facility failed to meet the staffing minimum of 3.5 DHPPD.During an interview on 4/2/26 at 11:40 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 was identified as at risk for elopement, left facility without knowledge of staff, and was found a block from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to comply with the state requirement of unusual occurrence by not reporting to the Department (State Agency) for one of two sampled residents (Resident 1). When a Resident with a history of dementia left the care facility without knowledge to staff, fell and was transported to emergency department. This deficient practice resulted in a delayed investigation by the Department.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure four employees working as Certified Nursing Assistants (CNAs 1, 2, 3, and 4) had valid and up-to-date CNA certifications. 2. Ensure two employee personnel files (CNAs 1and 3) were complete and up to date. These failures resulted in unlicensed CNAs providing direct care to residents without proper certification and placed residents' safety at risk.1. During an interview on [DATE] at 10:05 a.m. with the Director of Staff Development (DSD), DSD stated the CNA is responsible for maintaining up to date certification and I double check with the files. DSD further stated we had to check three or four months ago and knew the CNAs who were about to expire and reminded them to get it done and that they can't be on the schedule, it's paper tracking and we keep a schedule of who is due. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents while smoking for one of four sampled residents (Resident 2). This failure had the potential for residents to suffer significant injuries. During an observation on 5/30/25 at 8:35 a.m. while walking up to the front entrance of the facility, Resident 2 was observed lying in the street after sustaining a fall from his wheelchair after going off the curb of the sidewalk while alone in the front of the facility to smoke a cigarette. The surveyor walked into the facility to look for staff to get assistance but was unable to locate any staff members. The surveyor walked down the hall to the nurse's station and alerted Charge Nurse (CN) of Resident 2 lying in the street next to his wheelchair. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure staff observations of resident skin issues and/or conditions were consistently and accurately documented in the skin monitoring form for two of two sampled residents (Residents 1 and 2). These failures had the potential to result in inaccuracies of information which could affect the delivery of care and services for these residents affecting health and safety.

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH) suspicion of abuse for one resident (Resident 1). This failure had the potential to delay investigation and affect physical and psychosocial well-being of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedure when a Certified Nurse Assistant (CNA 1) reported an alleged incident of sexual abuse for one of three sampled residents (Resident 1) to a nurse, who did not report the allegation to the administration. This failure resulted in a delay in the investigation of the alleged sexual abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was an informed consent for the use of bed rails for one of five sampled residents (Resident 4). This failure had the potential to result in Resident 4 or representative not to be given the information needed to make an informed decision.

Inspectors wroteBased on interview and record review, the facility failed to provide information about the right to formulate an advanced directive (a legal document that states a person's wishes for medical care if they are unable to communicate them) for four of four sampled residents (Residents 4, 18, 20, and 42). In addition, the facility failed to establish, maintain, and implement written policies and procedures regarding the residents right to formulate an advanced directive. These failures had the potential for the residents' decisions regarding their health care and treatment not being honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. The toilet grab bar in room [ROOM NUMBER] was present. 2. room [ROOM NUMBER]'s room temperature was within ideal temperature range, as per facility policy. These failures had the potential to compromise resident safety and comfort.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - screening for individuals with a mental disorder and individuals with intellectual disability) Level II Evaluation (a person-centered evaluation that is completed for anyone identified as positive for Level I screening or as having or suspected of having serious mental illness, intellectual disability, developmental disability or related condition) was completed for one of four sampled residents (Resident 51). This failure had the potential to result in the resident not receiving appropriate care and services.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan of one of four sampled residents (Resident 46) was revised to address the significant decline of the Brief Interview for Mental Status (BIMS - a 15-point cognitive screening measure that evaluates memory and orientation impairments in older adults; 0-7 points suggests severe cognitive impairment, 8-12 points suggests moderate cognitive impairment, 13-15 points suggests cognition is intact) scores of the resident. This failure had the potential to result in appropriate care and services not being provided to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was protected from misappropriation of property when a package received was open with missing items. This failure resulted in violating Resident 1's rights to receive unopened, intact packages, and right to privacy.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of three sampled residents (Resident 1), when a pain medication was not available within 24 hours from order date. This failure had the potential for Resident 1 to have untreated pain and hinder recovery.

Inspectors wroteBased on observation and interview the facility failed to maintain a temperature range of 71-81 degrees Fahrenheit in the facility when temperatures throughout the facility measured between 64.9 and 65.2-degrees Fahrenheit, and one resident (Resident 1) was found with a plugged in space heater in their shared room. These facility failures violated all 72 resident's rights to have comfortable and safe temperatures within the facility and posed a risk for fire with a space heater in a resident ' s shared room.

Inspectors wroteBased on observation and interview, the facility failed to follow state laws regarding name badges for employees working in the facility actively caring for residents when 6 of 7 employees working did not have name badges. This facility failure had the potential for unauthorized people to act like employees in the facility, and also prevents residents knowing who is caring for them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow facility polices and procedures for unusual occurrence when Resident 1 was brought to the hospital for an alleged overdose of medication. This failure resulted in the facility failing to report the unusual occurrence to the California Department of Public Health.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident ' s room was free from a cracked window for one out of five sampled residents (Resident 5). This failure has the potential to be a safety risk to Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of two sampled residents (Resident 1), as evidenced by no documentation of the following physician orders: 1. COVID-19 testing on days 3 and 5 after admission. 2. Check Temperature every shift. This failure had the potential for facility missing changes in Resident 1's health condition and a delay in treatment.

Inspectors wroteBased on observation and interview, the facility failed to accurately post contact information with the name, addresses, and phone number for the State agency (California Department of Public Health [CDPH]) in an accessible and understandable manner and failed to ensure the posting included a statement that the resident may file a complaint with the State Survey Agency. These failures had the potential that residents rights to be informed of these agencies and services would not be supported.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a safe, functional, and sanitary environment for residents, staff, and the public when the maintenance department was cluttered and trash bins were overflowing. This failure had the potential to create an unsafe environment for the residents and visitors due to possible pest infestation, spread of diseases in the facility, and exposure to hazardous materials.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for 61 of 61 residents when: 1. The residents' drinking water dispenser contained several areas of a brown slimy substance in the drip tray. 2. The air gap vent on the ice machine had a brown grime substance and broken drain pipe. These failures had the potential to cause waterborne illness, from drinking contaminated water, in a vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and assistance for one of two sampled residents (Resident 1) during transportation to and from an appointment outside of the facility. This failure resulted in Resident 1 not waiting for transportation and leaving the appointment. Resident 1 subsequently fell out of their wheelchair near a road with heavy traffic and verbalized they did not know where they were or how to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate staffing to meet the resident's needs for seven of eight sampled residents (Residents 4, 9, 10, 11, 6, 7, and 8), when: 1. The facility did not meet required direct care service hours 15 days from 11/1/23 through 12/13/23. 2. Residents 4, 9, 10, and 11 were not given their prescribed medications for one or more shifts/days. 3. Residents 6, 7, and 8 tested positive for COVID and nursing was not documenting their progress and/or response to treatment for a minimum of 72 hours. This failure had the potential of physical or psychosocial harm due to missed medications or no documentation of residents' response to treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly date and store food in refrigerators. This failure had the potential for food borne illnesses for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 2) was assessed and provided with the appropriate way to self-control the overbed light. This failure had the potential for Resident 2's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 18 residents (Residents 3 and 67) Physician's order for do not resuscitate (DNR) were in the residents' medical records. This failure had the potential for residents to not receive their healthcare choices when they were no longer capable of making decisions for themselves.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Gastrostomy (GT- tube placed in the stomach for feeding, hydration or medicine) care was observed prior to medication administration and medications as prescribed by the attending physician were administered as ordered for 1 of 18 sampled residents (Resident 34) when: 1. GT placement was not checked prior to medication administration. This failure has the potential for the GT to be not be in the correct place which could result to medications and fluids administered going straight to the lungs causing pneumonia (lung infection). 2. Residual crushed medication was left in all 13 medication cups and not administered. This failure had the potential for the resident to not receive medications as ordered which could affect the resident's overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the availability of the re-filled medication per physician's order for 1 of 18 sampled residents (Resident 34). This failure resulted in Resident 34 missing two doses of the prescribed medication and placed Resident 34's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control practices (prevention of contamination with disease causing infection) when an open, unlabeled bottle of cleaning solution was found in the medication storage room. This failure had the potential to transmit infectious microorganisms (germ) and increase the risk of infection for residents and staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician received notification of, or responded to, a resident's change of condition, for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to receive inadequate care and treatment, post an unwitnessed fall with injury.