Oxnard Manor Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to verify a physician's order to hold blood pressure medications or to include fluid restrictions in the diet order in one of two sampled dialysis residents, resident 1 (R1). These failures resulted in R1's inability to have a complete dialysis procedure (a process to remove extra fluid and clean the blood through an artificial filter in the machine, from toxic product of food metabolism to maintain health and sustain life) due to having too low of blood pressure or have extra fluid removal with a potential for R1 to have excess fluid in her body that can result in complications. During a review of R1's admission record, the record indicated R1 was admitted in the facility on 3/26/26 with diagnoses that included end stage renal disease (chronic kidney failure) and on dialysis. [...]

Inspectors wroteBased on record review, interview, and facility policy and procedure, the facility staff failed to obtain and clarify Oxygen administration orders from the physician for one of three sampled resident (Resident 1) when supplemental oxygen was administered without a physician order. This failure creates a risk for the mismanagement of respiratory distress and potential oxygen toxicity (lung damage that happens from breathing in too much extra (supplemental) oxygen). [...]

Inspectors wroteBased on interview, record review, and facility Policy and Procedure (P/P) the facility failed to accurately assess for a change in condition (CIC) for one of three sampled residents ( Resident 1) when a ssessment relevant to the change in condition to determine what nursing interventions are appropriate with the overall condition utilizing a physical assessment was done. This failure created a situation whereby the resident treatment and care were not recieved in accordance to medical needs. [...]

Inspectors wroteBased on interview, record review, and Policy and Procedure (P/P)facility failed to ensure a resident receiving Hemodialysis ( (HD-procedure done by a trained professional to remove waste and excess fluids from the body when the kidneys stop working properly) received care and services consistent with professional standards of practice for one of three sampled residents (Resident 1)when:1. Pre and post dialysis evaluation was not completed2. A total inspection of an arteriovenous (AV) shunt (fistula, is a surgically created direct connection between an artery and a vein, typically in the arm, for long-term hemodialysis access) site area for color, warmth, redness, edema, and drainage was not done and documented. This failure resulted in Resident 1 developing a severe infection that required interventions. According to the American Nurses Association (ANA). (2021). Standards of practice. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses (LNs) were competent in providing quality of care for one of three sampled residents (Resident 1) when a comprehensive assessment and individualized care plan was not completed related to Resident 1's change of condition (new onset of infection). This failure had resulted in Resident 1's signs and symptoms of infection not monitored by staff and had the potential to develop complications. [...]

Inspectors wroteBased on interview, record review, and facility Policy and Procedures (P/P) the facility failed to ensure that one of three sampled residents (Resident 1) received timely and appropriate medical care under the supervision of a licensed physician when laboratory results were communicated to the attending physician timely. This failure has the potential to delay/miss treatment and care for the residentDuring review of Resident 1's admission Record (AR), dated 10/15/25, the AR indicated Resident 1 was initially admitted to the facility on [DATE], and then re-admitted on [DATE] with diagnoses that include hepatic encephalopathy (a decline in brain function occurring when a damaged liver cannot properly filter toxins), alcoholic cirrhosis of the liver without ascites (an advanced stage of alcohol-related liver disease where healthy liver tissue is replaced by scar tissue; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had an accurate medical record when a diagnosis of decompensated liver cirrhosis with ascites (an advanced stage of liver scarring where the liver can no longer function properly, leading to significant complications, most notably the accumulation of fluid in the abdomen [ascites] causing abdominal distension, discomfort, and potential breathing issues) was not listed as a diagnosis on the admission record. This failure had the potential for Resident 1 not to receive adequate care and have unmet medical needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one out of five sampled residents (Resident 6) skin integrity for pressure ulcers (PU - injury to skin and tissue resulting from prolonged pressure). This failure resulted in inaccurate assessment documentation and had the potential for Resident 6's identified care needs to go unmet. During review of the facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 6/27/24, the P&P indicated in part, 1. Assessments a. A Licensed Nurse will complete a skin evaluation when there is a change in skin integrity. b. A Licensed Nurse will complete the skin evaluation weekly.2. Skin Integrity Treatments c. The physician and responsible party will be notified when there is a change in the condition of the pressure injury or skin integrity condition.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of practice for one of five sampled residents (Resident 52) when the oxygen order was not implemented as ordered by the physician. This failure had the potential to place Resident 52 at risk for difficulty breathing. Review of [NAME] and [NAME], Tenth Edition, Elsevier, Fundamentals of Nursing, page 609 in the section titled, Medication Administration, indicated, If there is any question about a medication order because it is incomplete, illegible, vague, or not understood, contact the health care provider before administering the medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of eleven sampled residents (Resident 10 and Resident 52) received the necessary treatment and monitoring for pressure ulcers (PU - damage to the area of the skin caused by pressure) when: 1. A PU was not measured or documented in Resident 10's medical record after the resident was re-admitted to the facility.2a. A wound consultation and physician treatment orders were not requested for the care of bilateral stage 2 PU's (shallow, open ulcers, with partial-thickness skin loss, and a red/pink base or intact/ruptured blisters) on the right and left buttocks of Resident 52.2b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 108), reviewed for arbitration (a contract in which two or more parties agree to resolve disputes through a private arbitration process instead of pursuing litigation in court) agreement, understood the documents signed during admission to the facility. This failure resulted in Resident 108 signing a facility agreement without a full understanding of resident rights and options. During a review of the facility's admission Record this indicated, Resident 108 was admitted to the facility on [DATE] with diagnoses that included infection following a procedure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the electrical outlet was in good repair and was safe for use in one of the resident's rooms (room [ROOM NUMBER]), when the socket was left opened without a protective plate. This failure had the potential to affect resident safety and increase the risk of injury. During the observation on 7/8/25 inside room [ROOM NUMBER], the wall electrical outlet outside of the bathroom in room [ROOM NUMBER] did not have a cover plate exposing some electrical wiring inside the socket. The maintenance logbook did not have the requisition for the repair of the open electrical outlet. During the interview on 7/8/25 at 3:00 p.m. with the maintenance supervisor (MS), MS stated that the matter was not brought to his attention neither it was entered in the maintenance logbook by any staff, so no repair was done on the issue. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff accurately documented why a medication dose was not given, or that the physician was notified of the missed dose for one of two sampled residents (Resident 1) per their policy and procedure. This failure resulted in an incomplete medical record and had the potential for inaccurrate and delayed medical interventions for Resident 1.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders and adhere to its medication administration policy and procedures for one of two sampled residents (Resident 1) when: 1. Staff did not seek physician clarification for a potential frequency change for a Lactulose (a medication which can be used to reduce the amount of ammonia in the blood of residents with liver disease) order when Resident 1 did not have four bowel movements in a day. 2. Staff did not notify Resident 1's physician of their continued inability to obtain an ordered medication of Rifaximin (An antibiotic that is used to treat and prevent complications in patients with cirrhosis). 3. Staff did not check Resident 1's blood pressure or heartrate prior to the administration of Propranolol (a medication used to treat high blood pressure). [...]

Inspectors wroteBased on record review and interview, the facility failed to capture/be aware of, a resident diagnosis of cataracts (a clouding of the lens of the eye) for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to experience negative outcomes in care.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and discard perishable food items, from the resident refrigerator, per policy and procedure. This facility failure had the potential for residents to experience negative outcomes, including foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to implement fall care planned interventions for one of two sampled Residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the Registered Dietitian (RD) failed to ensure her skill set related to nutrition assessments was current when standards of practice were not implemented as follows: 1. The RD utilized a method to assess the nutritional needs for elderly residents classified as obese that had the potential to promote weight loss, and was not in accordance with professional standards of practice, without obtaining and/or discussing Resident 53's and/or responsible party (RP) weight goal or preference and potential risks of weight loss for informed decision making for one of one sampled residents (Resident 53). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the planned menu for therapeutic diets (part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet or to provide mechanically altered food) when: 1. Resident 9, Resident 40 and Resident 26 received salad when prescribed a mechanical soft diet (to make it easier to chew and swallow foods, reducing the risk of choking) that was not on the mechanical soft diet menu. The Dietary Supervisor (DS) 1 confirmed the error had the potential to affect the following resident's prescribed a mechanical soft diet: Resident's 378, 54, 233, 4, 67, 21, 53, 14, 52, 42, 70, 129, 41, 127, 60, 49, 24, 349, 10, 27, 28, 30). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment in one resident room and two shower rooms. This failure had the potential to negatively impact residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person focused care plan for 2 of 5 sampled residents when: 1. Resident 65's preference for warm drinking water was not identified in the resident's careplan. This failure resulted in the resident storing warm water via water [NAME] at the bedside by self , with no facility assessment if ok with medications and other dietary intake /food/meal. 2. Resident 40's interdisciplinary team (IDT) nutrition care plan (detailed plans of care created by representatives from several medical disciplines or specialties) did not contain clear and resident specific measurable objectives with the input of the resident and/or responsible party (RP) on their goals and desired outcomes related to Resident 40's weight and 2b. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident 's ( Resident 127) electronic medical record (eMAR - a digital version of a resident's medication administration) was accurately signed or accurate documentations were entered when a medication was administered or not administered as ordered by the physician . This failure has the potential for resident not to received the medications as ordered essential for quality of life and well being .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 65) who was hard of hearing, was assessed and assisted in obtaining a hearing device while admitted in the facility to facilitate adequate communication. This failure has the potential for the resident's needs to be not attended and understood by staff .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure post dialysis assessment and ongoing communication between the facility was completed after 1 of 4 sampled residents (Resident 127), returned from dialysis and failing to communicate with the contracted dialysis company when Resident 127 was sent from the dialysis clinic to the hospital. This failure had the potential to result in undetected complication(s) of dialysis and compromise the safety and well being of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pureed recipe for spaghetti with meat sauce was followed when the consistency was not a smooth, pudding or soft mashed potato consistency as directed in the recipe. Dietary Supervisor (DS) 1 verified there were eight residents (Resident 31, 11, 8, 6, 62, 72, 56, 3) with a puree diet order that had the potential to receive an inappropriate texture. This failure had the potential to result in choking and aspiration (food or liquid is breathed into the lungs, instead of being swallowed) in residents who experience difficulty swallowing. There was a total of 75 residents receiving meals from the main kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary practices when a dietary aide failed perform hand washing after touching dirty dishes and before handling clean dishes. This failure had the potential to result in cross contamination and foodborne illness to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medical record for one of 18 sampled residents (Resident 12) was updated to reflect the changes in a Physician Orders for Life-Sustaining Treatment (POLST). This failure had the potential to result in a life saving measure or preference of the resident, to be not carried out as ordered by the physician.

Inspectors wroteBased on record review and interview, the facility failed to provide an arbitration agreement (a legal contract that requires the parties in a dispute to resolve it through arbitration, rather than a lawsuit) to one resident (Resident 1), in a form and manner the resident or resident representative understood. This failure had the potential to violate Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was adequate supervision for one of two sampled residents (Resident 1). This failure resulted to Resident 1 leaving the facility without staff knowledge and had the potential for an accident while away and without supervision.

Inspectors wroteBased on record review and interview, the facility failed to implement care planned interventions and physician orders, for one of two sampled Residents (Resident 2). This facility failure had the potential to lead to negative outcomes for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) was discharged to an appropriate level of care when the resident was discharged to an independent living facility (ILF-a place where residents need no assistance with activities of daily living such as mobility, dressing, eating, toileting, and medication management), instead of a board and care home (homes that provide room, board and 24-hour staffing assistance and care for the seniors with things like dressing, bathing and medication management) or an assisted living facility (ALF -a variety of facilities that provide both housing and personal care). In addition, the facility did not verify the receiving ILF was licensed and fully capable of providing care and supervision to Resident 1. This failure put Resident 1 at risk for harm and not having her basic needs met at the ILF.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a discharge summary (a review of a residents stay) for one of 2 residents (Resident 1). This failure had the potential for the receiving facility to not have accurate medical information regarding Resident 1's status and her required needs.

Inspectors wroteBased on interview and record review, the facility failed to implement the plan of care for one of two sampled resident's (Resident 1) related to Resident 1's dietary restrictions due to dental needs. This failure had the potential for Resident 1 to experience pain and choking with no assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, and homelike environment for residents when: 1. [NAME] Patio exit door could not be shut, as posted, Keep closed at all times. 2. [NAME] medication storage room was dirty and in disrepair. 3. Three medication carts were visibly soiled. 4. Resident 4's wall was damaged with a large area of missing plaster, and Resident 4's bed frame was covered with a sticky substance. 5. Resident 63 and Resident 39's room had scratches, peeling paint, and holes in the walls. 6. Windows in the kitchen and dining room had no screens on the windows and a broken window was observed in the dining room. 7. Resident 8's wall was damaged. 8. Outside trash dumpster lid was not closed, and trash was scattered on the ground. 9. Resident 26's room had a large area of drywall scraped away with peeling paint. 10. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Three medications were contained in labeled bottles in two of two sampled medication carts (east nurses' station cart - C1 and west nurses' station cart- C2). 2. A medication was labeled for individual use in one of two sampled medication carts -C2. 3. A medication was labeled with an open date in one of two sampled medication carts - C1. This failure had the potential for residents to receive expired, ineffective, and contaminated medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the cook followed the therapeutic puree diet menu as planned on 12/14/21 for residents on puree diet. These failure had the potential for resident's on puree food not to get the calculated nutirional amount their bodies need from each meal.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe food handling and storage when lids on containers of dry foods (flour, sugar, parboiled rice, and spices) were left open. This failure had the potential to decrease food quality, cause food contamination and foodborne illnesses due to unsafe food handling practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) and other infectious diseases in accordance with Centers for Disease Control (CDC) and the facility's policies and procedures when: 1. Staff did not wear proper (PPE) personal protective equipment before entering a resident's room on transmission - based precautions. 2. Staff were cleaning PPE, a reusable gown with disinfectant wipes that did not contain bleach. These facility failures had the potential to spread COVID-19 and/or other infectious diseases to staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to investigate, document, and update missing eyeglasses in a resident's medical record (MR) on timely manner for one of 24 sampled residents (Resident 11). This failure resulted in the lack of follow -up by the facility's Social Services Director (SSD) in obtaining replacement eyeglasses for Resident 11 which can potentially affect the resident's overall visual fucntion.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care) was accurate for one of 24 sampled residents (Resident 59) when Resident 59's special treatments, procedures, and programs under section O, for dialysis, was left blank. This failure had the potential to result in Resident 59's identified care needs to go unmet and for the resident's medical record to be inaccurate.

Inspectors wroteBased on interview and record review the facility failed to follow and implement the comprehensive care plan for one of 24 sampled residents, (Resident 59), with weight loss when the facility failed to: 1. Weigh Resident 59 weekly. 2. Monitor Resident 59's meal intake daily. 3. Provide RNA (restorative nursing assistants provide range of motion exercises that are vital for health and well-being of residents) with dining every breakfast and lunch as care planned. These failures placed Resident 59 more at risk for continued weight loss.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin (a medication to lower blood sugar [BS] levels) as ordered by the physician for one of nine sampled residents (Resident 36). This failure had the potential for Resident 36 to develop unstable BS, which could have led to a high or low BS level affecting the resident's already compromised condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents electrical care equipment was maintained in a safe operating condition for one of 24 sampled residents (Resident 25) when the phone jack wires inside the resident's room was open and exposed . This failure had the potential to result in electrical injury to the resident.