Whitney Oaks Care Center

Inspectors wroteBased on interview and record review the facility failed to follow reporting and response requirements after an allegation of financial abuse was reported for one of three sampled residents (Resident 1) when:Report of investigation was not received by the State agency (California Department of Public Health-CDPH) within the 5-day as required by the regulations andResident 1's psychosocial (mental, social interactions and emotional well-being) status was not assessed following allegations of financial abuse. These failures resulted in CDPH being unaware of the outcome of the facility's abuse investigation and potential risk for psychosocial harm to Resident 1.1. A review of the facility report dated 7/1/26, indicated, the facility reported to CDPH an allegation of financial abuse with Resident 1 as the victim, and an outside agent as the alleged perpetrator. [...]

Inspectors wroteBased on interviews and records reviews the facility failed to ensure a prompt resolution was provided for one out of three sampled residents (Resident 1), when Resident 1's Family Member (FM) filed a grievance for Resident 1's lost prescription glasses. This failure resulted in Resident 1's inability to see clearly.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that physician ordered wound care was provided as prescribed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 missed wound care for one day.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of three sample residents (Resident 1) when Resident 2 and Resident 1 had a physical altercation. This failure resulted in Resident 1 sustaining a fall with an abrasion to forehead and broken nails.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident rights were respected and honored for one of three sampled residents (Resident 1) when Licensed Nurse (LN) 1 did not initiate interventions to allow Resident 1 to go safely out on pass with a family member. This failure had resulted in Resident 1 not able to go out and have dinner on thanksgiving weekend with her family, and had the potential to negatively impact residents' psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one of five sampled residents (Resident 1's) right to send and receive mail was protected when it withheld Resident 1's mail for a period of seven months. This failure had the potential to cause emotional distress such as social isolation, missed important matters, and distrust in care for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of five sampled residents (Resident 1) when Resident 1 was not administered glipizide (a medication used to control high blood sugar levels in adults with type 2 diabetes) as prescribed by the physician. This failure had the potential to cause Resident 1 to experience uncontrolled blood sugar levels, which could result in complications such as vision impairment and/or nerve issues related to poor blood sugar control.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of care for one of five sampled residents (Resident 1), when Resident 1's pain was not assessed and managed, and Resident 1's Responsibility Party (RP) did not receive communication regarding Resident 1's change in condition from the physician. These failures resulted in a delay in determining that Resident 1's cause of pain was due to a fracture of the right leg. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident abuse prevention training was sufficient for one out of three sampled facility staff (Certified Nurse Assistant [CNA] 4). This failure had the potential for an ineffective resident abuse prevention program of the facility making facility residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation by Resident 1 of verbal abuse to The Department within the regulatory timeframe. This failure had the potential to put Resident 1 at risk of abuse if not investigated by The Department. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in November 2024 with multiple diagnoses including polyneuropathy (nervous system disorder that impacts nerve function in multiple areas of the body), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), schizoaffective disorder (mental health condition that is a combination of symptoms of schizophrenia and mood disorder), moderate protein-calorie malnutrition (a deficiency of both calories and protein causing nutritional deficiencies), and cannabis use and stimulant abuse. [...]

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 served safety when: 1. Several various sizes metal pans were stacked wet at the clean and ready-to-use areas; 2. Found meats were not thawed in a proper procedure in the walk-in refrigerator; 3. The blade of the can opener was not well maintained; 4. Dietary Aide (DA) 1 was not able to verbalize the proper process of manual dishwashing by the 3-comparment sink; and, 5. Resident's food was not stored at safe temperatures in the resident's food refrigerators and freezers at the nursing stations. These failures had the potential to cause foodborne illness in a highly susceptible population of 113 residents who consumed food from the facility kitchen and food from outside sources.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu was followed for the therapeutic diets during lunch on 5/21/25 when: 1. Six residents (Resident 1, 11, 70, 85, 88, and 108) with small portion diets received three ounces (oz.) of meat instead of two oz.; 2. Six residents (Resident 16, 23, 49, 81, 82, and 112) with fortified diets did not receive planned fortified food; and, 3. 57 out of 113 residents who received lunch meals did not receive garnishes with their lunch meals. These failures had the potential to result in compromising the medical and nutrition status of residents who received meals from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when: 1. The licensed nurse (LN) did not perform hand hygiene (HH, washing hands with soap and water or use of an alcohol-based sanitizer) in accordance with standards of practice during medication pass for Resident 6 and Resident 23; and, 2. Residents were not offered to clean their hands by staff prior to consuming their lunches in the dining room. These failures had the potential to result in transmission of infection to residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for Resident 61 when Licensed Nurse 3 (LN 3) did not provide privacy to body after leaving Resident 61's room, and did not communicate with Resident 61 while providing care. These failures decreased the facility's ability to provide care in a dignified and respectful manner for Resident 61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of 24 sampled residents (Resident 64). Failure to accurately assess Resident 64's Multi-Drug Resistant Organism (MDRO, an organism that is resistant to multiple antibiotics) status resulted in an inaccurate record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a medication according to professional standards of quality for one of 34 sampled residents (Resident 23) when his insulin lispro (a fast acting insulin, medication to treat diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing)) according to the physician's order. This failure had the potential to cause poor glycemic (blood sugar) control which could lead to heart disease, nerve damage, kidney disease, vision loss, and foot problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure communication needs were met for one of 34 sampled residents (Resident 51) when communication materials were not available for use by the resident. This failure had the potential to impede Resident 51 from maintaining or reaching the highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 34 sampled residents (Resident 27 and Resident 220) received services to maintain nail care, good grooming, and personal hygiene for the use of neck brace device. This failure decreased the facility's ability to promote healthy nail growth and enhanced residents' appearance, overall well-being and to prevent skin irritation and potential infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident (Resident 31) out of 34 sampled residents was provided nail care. This failure resulted in Resident 31's overgrown toenails and the potential to develop an infection or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 102) indwelling catheter (IC, a type of urinary catheter designed to remain in place for an extended period to drain urine from the bladder) tubing was free from accumulated urine sediments. This failure decreased the facility's ability to prevent obstruction of the catheter's lumen, leading to reduced urine flow or complete blockage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 220) incentive spirometer (IS, a handheld medical device used to help patients practice taking deep breath, encouraging lung expansion to prevent respiratory complications) was available and provided as ordered. This failure decreased the facility's ability to help Resident 220's exercise his lungs to expand, strengthen, inflate, and clear mucus and other secretions after surgery.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Destruction prescription medications according to facility policy and procedure (P&P); and, 2. The narcotic emergency kit (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced according to facility P&P after use. These failures had the potential for abuse or misuse of medications and for emergency medications to be unavailable when needed.

Inspectors wroteBased on observation, interview and record review, the facility's consultant pharmacist (CP) failed to identify drug-related issues on one of 34 sampled residents (Resident 170). This failure had the potential for unsafe medication use for all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened multi-dose medications and biologicals were dated with an open and discard date, expired medications were not available for resident use, and single resident over-the-counter (OTC) products were appropriately labeled . These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications or biologicals from inadequate temperature monitoring and storage.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure resident safety for three residents (Resident 56, 76, and 114) out of 34 sampled residents when the call lights were out of reach. This failure had the potential for the residents to be unable to notify staff if there was an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and sanitary environment for the residents who used the dining area and residents who ate facility prepared meals when a bird cage containing 4 birds was not kept clean and sanitary, and was placed next to the walkway of the two (2) kitchen doors where food carts carrying resident meals pass through for a census of 118 residents. This failure had the potential to result in cross-contamination of facility prepared resident meals and could spread infection and/or other bird-related diseases to residents, facility staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed for one of three sampled residents (Resident 1), when the dose of Resident 1's Seroquel (Quetiapine Fumarate, a medication used to treat mental/mood disorders) was not given per physician's order. This failure had the potential to result in Resident 1 not having the desired effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were honored for one of three sampled residents (Resident 2), when Resident 2 disliked broccoli but he was served broccoli during the lunch meal. This failure resulted in Resident 2's food preferences not being honored, and Resident 2 not receiving options for food of similar nutritive value.

Inspectors wroteBased on interviews and record review, the facility failed to protect two of three sampled residents' (Resident 1 and Resident 2) right to be free from physical abuse when they were attacked by Resident 3. This failure resulted in Resident 1 to sustain a laceration (cut) to the left side of the head, a blunt head trauma injury, and chest wall contusion (bruising). Resident 2 sustained a laceration to the back of his head and multiple skin tears.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility garbage dumpsters were not accessible to insects and vermin when the dumpster lids were not kept closed. This failure had the potential to harbor pests and other types of vermin capable of spreading disease for a census of 123.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient supply of linens were available for staff to use during residents daily care for a census of 123. This failure decreased the facility's ability to provide care and services to enhance the self-esteem and self-worth of the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop baseline care plans for three out of 29 sampled residents (Resident 364, 366, and resident 320) when: 1. Care plans were not developed for the use of indwelling urinary catheters (flexible tube used to empty the bladder and collect urine in a drainage bag) for Resident 364 and 366; and, 2. Care plan for the use of a Bilevel Positive Airway Pressure machine (BiPAP, a device assisting in breathing) was not initiated withing 48 hours of admission. These failures had the potential for residents to not receive appropriate and timely care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop comprehensive, person-centered care plans for eight out of 29 sampled residents (Resident 48, 62, 94, 102, 103, 361, 364 and 366) when care plans were not developed for the use of indwelling urinary catheters (flexible tube used to empty the bladder and collect urine in a drainage bag), psychotropic medications and EBP (Enhanced Barrier Precautions). These failures had the potential for residents to not receive appropriate, adequate timely care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the activities care plan for 5 of 29 sampled residents (Resident 11, Resident 42, Resident 52, Resident 67, and, Resident 76) to reflect current person-centered interventions/tasks for a census of 123. These failures decreased the facility's ability to evaluate the effectiveness of the interventions to improve the residents' physical and social well-being.

Inspectors wroteBased on observation, interview and records review, the facility failed to provide proper respiratory care services for three residents (Resident 320, Resident 81, and Resident 42) of 29 sampled residents consistent with the professional standards of quality, the person- centered care plan, and the residents' choices when: 1. Resident 320's Bilevel Positive Airway Pressure machine (BiPAP, a device assisting in breathing) order did not provide specific pressure parameters and staff providing care were not trained in handling BiPAP equipment; 2. A respiratory care order and care plan was not followed for Resident 81; and, 3. Resident 42's order to use an incentive spirometer (a handheld medical device used to help patients, to take slow and deep breaths, facilitates lung expansion and strengthening) every waking hour was not implemented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document and replace emergency medications (E-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) for a census of 123. These failures resulted in the facility not having accurate accountability of emergency medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility had a 24.14% error rate when seven medication errors out of 29 opportunities were observed during a medication pass for three of four Residents (Residents 39, 43, and 96). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 57) was free of a significant medication error when he received Lantus (a long-acting insulin, medication to lower blood sugar level) two times (doses) past the expiration date. This deficient practice had the potential for ineffective use of insulin, resulting in uncontrolled high blood sugar for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Prepared medications were properly stored and administered at the time of preparation; 2. Expired and discontinued medications were not available for resident use; and, 3. Refrigerated medications were stored in accordance with facility policy & procedure (P&P). The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being securely stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: a) Food packages in the freezer were not tightly closed after use, leaving food exposed to the air; b) A red sanitizer bucket was found with insufficient sanitizing concentration only 2 hours after setting up, and several hours before the second shift staff would conduct the next check; c) Dietary staff were unable to correctly describe the 3-compartment sink set-up for manual dishwashing; d) Kitchen walls and ceiling had missing and/or peeling paint; and, e) Resident refrigerator had expired yogurt available for resident 86, and grapes kept for an unnamed resident, and the resident in that room was on a pureed diet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff with the needed equipment to assist residents in safely accessing and consuming outside food when staff were unable to heat foods to correct serving temperatures. This failure had the potential of limiting food intake leading to malnutrition and/or weight loss, and/or leading to food borne illness for the 125 residents eating facility prepared meals.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure: 1. Nursing staff maintained nails and performed hand hygiene (cleaning hands to prevent the spread of infectious disease) in accordance with nationally accepted standards of practice and facility policy and procedure (P&P); 2. Enhanced Barrier Precautions (EBPs) were utilized for seven residents (Residents 48, 62, 102, 103, 361, 364 and 366) out of 29 sampled residents when staff did not follow infection prevention and control interventions; 3. Staff performed handwashing after handling soiled lenin; 4. Infection Prevention trainings and/or inservices were provided to staff after repetitive cases of urinary tract and upper respiratory infections were identified during infections surveillance; and, 5. The facility's Infection Prevention and Control Program (IPCP) was reviewed annually. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate assessments were performed for two residents (Resident 33 and Resident 23) of 29 sampled residents when: 1. Resident 33's vision assessment was inaccurate; and, 2. Resident 23 did not have a change of condition assessment completed. These failures resulted in Resident 33 and Resident 23 not receiving accurate assessments reflective of their medical status and reduced the facility's potential to identify strengths to maintain or improve functional abilities.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to provide resident centered care for one resident (Resident 368) of 29 sampled residents when the facility did not ensure Resident 368's pressure relief heel boots were put on per comprehensive assessment, plan of care, physician's order, and Resident 368's choices. This failure decreased the potential for Resident 368 to receive effective treatment and necessary care.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to provide appropriate care to maintain good foot health for one resident (Resident 261) of 29 sampled residents when Resident 261's toenails were dirty, long, and untrimmed. This failure reduced to facility's potential to provide appropriate foot care for Resident 261.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure the resident's bed rails were properly installed for one resident (Resident 13) when there was no informed consent and no physician order for bedside rail use. This failure had the potential to result in negative outcomes including accident hazards, physical restraint, decline in Activities of Daily Living and function, and psychosocial outcome.

Inspectors wroteBased on observation, interview and record review, the facility failed to have the Medical Doctor's (MD) notes signed. This failure had the potential for Resident 99 to received confusing, inaccurate, and inadequate care for a census of 123.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a newly admitted resident (Resident 99) was seen by the Medical Doctor (MD) once every 30 days for the first 90 days upon admission. This failure had the potential for Resident 99 to received inadequate and inaccurate care and assessment for a facility census of 123.

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (Resident 94) out of 29 sampled residents was free from unnecessary psychotropic medications when Resident 94 was prescribed an order for buspirone (a psychotropic medication that affects the brain associated with mental processes and behavior) as needed for 14 weeks. This failure had the potential to cause medication interactions, confusion, and falls.

Inspectors wroteBased on interview and record review the facility failed to promote dignity when one of three sampled residents (Resident 1) stated she had been pinned down and hit during care by two Certified Nurse Assistants (CNA 3 and CNA 4). This failure caused Resident 1 to be fearful and to feel she was being bullied and had the potential to affect the resident's self-esteem, self-worth, and diminish her quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) for one of three sampled residents (Resident 1) when staff did not timely report an allegation that a staff member hit a Resident. This failure resulted in Resident 1 not receiving an immediate assessment and interventions to ensure safety.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, when the facility failed to thoroughly investigate an allegation of physical and verbal abuse towards one of three sampled residents (Resident 1) by a certified nursing assistant (CNA 3). Resident 1 alleged CNA 3 yelled at her, punched her, and hit her with a cane. This failure had the potential to expose Resident 1 and other residents to abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an environment free of accident hazards, when one of four sampled residents (Resident 1) had an ordered fall mat that was not on the floor. This failure had the potential for Resident 1 to sustain a fall with injury.

Inspectors wroteBased on interview and record review, the facility failed to provide written bed-hold information to a resident and resident representative for one of three sampled residents (Resident 1) in a census of 116 when Resident 1 was sent to a general acute care hospital (GACH) and did not have any documentation they were given bed-hold information. This failure had the potential to decrease Resident 1's right to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the health, safety and security of one of three residents (Resident 1) when the facility failed to report an alleged harm. This failure had the potential to endanger the health and well-being of all 117 residents in the facility.

Inspectors wroteBased on observation, interview and document review, resident privacy was compromised when tray tickets were thrown into the kitchen garbage. This failure had the potential of compromising resident information for 107 residents receiving facility provided meals for a census of 111.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were honored for five residents (Resident 10, Resident 20, Resident 45, Resident 52, and Resident 160) for a census of 111. These failures had the potential to lead to poor intake, inadequate nutrition, and/or weight loss.

Inspectors wroteBased on observation, interview and document review, the facility, for a census of 111, failed to ensure: 1. Opened, refrigerated foods were properly labeled with open date and used by date; and, 2. Food preparation equipment were properly cleaned and dried before storing for next use; and, 3. Foods brought in by resident's family were labeled properly inside the resident refrigerator. These failures had the potential of causing food borne illness for the 107 residents who ate at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection control practices were performed for 11 residents (Resident 5, Resident 7, Resident 26, Resident 36, Resident 47, Resident 86, Resident 103, Resident 156, Resident 158, Resident 160, Resident 354) of 24 sampled residents, when: 1. The Director of Nursing (DON) and Certified Nurse Aide 3 (CNA 3) entered resident rooms without wearing proper Personal Protective Equipment (PPE) according to posted signs on the door; 2. Staff did not follow the manufacturer's instruction on disinfectant contact time; 3. Hand hygiene was not performed between glove change, and staff donned PPE improperly; and, 4. Hand hygiene was not initiated before meals for two residents. These failures reduced the facility's potential to prevent a spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 91) received regular insulin (a medication used to treat high blood sugar levels in the body) as ordered by the physician. This failure increased Resident 91's risk of complications of diabetes (a chronic long-lasting health condition that affects how your body turns food into energy). The facility census was 111.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 91) was free from significant medication errors when regular insulin (an injectable medication used to treat high blood sugar levels in the body) was administered late. This failure to administer the medication on time increased Resident 91's risk of complications from diabetes (a chronic long-lasting health condition that affects how your body turns food into energy). The facility census was 111.