Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maywood Acres Healthcare during CMS and state inspections, most recent first.
A resident with vascular dementia, intact cognition, and dependence on staff for toileting and showering voiced concerns about several CNAs and requested that certain staff not be assigned to her. A CNA verbally reported these concerns to the charge nurse and the DSD, and the DSD stated they attempted to address the staffing concerns but did not initiate a written grievance. The Social Services Director, responsible for tracking grievances, reported receiving no complaint, and the DON noted the concerns were discussed in QAPI without a corresponding grievance form. The administrator was aware of the issues, while facility policy required staff to complete a grievance form, develop a resolution plan, and have Social Services track and trend grievances, which was not done.
The facility failed to maintain the walk-in refrigerator door in the kitchen, leading to potential temperature abuse, as the door would not remain closed, causing internal temperatures to rise. Additionally, there was no appropriate air gap between the dish machine drain and the floor sink drain, risking backflow contamination. The maintenance supervisor was unaware of the required air gap specifications, and the facility's policy for interior maintenance was not adequately followed.
The facility failed to follow its policy on checking room temperatures, affecting three residents who reported discomfort due to heat. Observations revealed that a resident was lying in bed without clothes, another had two fans blowing warm air, and a third used a fan attached to the bed. The Maintenance Supervisor was unaware of the policy's requirement to check temperatures between noon and 4 p.m., leading to incomplete temperature logs.
A facility failed to complete a CMS-required discharged MDS assessment for a resident who was discharged with orthopedic aftercare of surgical amputation. The MDS discharge assessment was 137 days overdue. The MDS Coordinator acknowledged responsibility for the missed assessment and admitted it could have been completed on time.
A facility failed to conduct accurate assessments for a resident with an AV shunt undergoing dialysis. Observations revealed missing vital signs in the Dialysis Communication Records on multiple occasions, contrary to the facility's Hemodialysis Care policy. Staff confirmed the oversight, acknowledging the absence of required pre and post-dialysis assessments.
The facility failed to develop care plans for two residents using pad alarms as restraints and another resident with Hepatitis C. Observations and record reviews confirmed the absence of care plans, which was acknowledged as an oversight by staff. Facility policy mandates care plans upon admission and updates as needed, but this was not adhered to.
A facility failed to ensure nursing staff competency in medication administration, leading to errors and documentation failures. An LVN administered the wrong medication to a resident, believing it was correct despite discrepancies. Another resident's vital signs were not documented before administering Carvedilol, and a third resident on Apixaban lacked monitoring for side effects. The DON confirmed these deficiencies.
A facility failed to monitor side effects and behaviors for a resident prescribed Mirtazapine for depression. The resident's care plan required monitoring depressive behaviors and documenting side effects every shift, but records show this was only initiated months after the prescription. An LVN confirmed the lack of monitoring, which was against the facility's policy on psychotropic medications.
Two residents on mechanical soft, chopped diets were served meals that did not meet their dietary requirements, with one resident receiving improperly sized food and another receiving unchopped food. The facility's diet manual was not properly implemented, increasing the risk of choking.
The facility failed to serve lunch in an attractive manner, with food items of similar brown color and mushy noodles due to prolonged hot holding. Three residents expressed dissatisfaction, noting mushy vegetables and lack of freshness. The kitchen staff prepared food too early and held it at a cooking temperature, contrary to facility policies. The RD and CDM acknowledged the lack of color and inappropriate preparation timing.
A resident experienced hypoxia and diaphoresis during PT, with oxygen levels fluctuating between 88%-95% RA. The PT assistant informed the charge nurse, who returned the resident to bed and administered oxygen without a physician's order. The physician was notified later, leading to a delay in emergency care. The facility's policy requires immediate reporting of such changes, which was not followed.
The facility failed to follow its policy for residents going out on a leave of absence. For two residents, multiple instances were found where the required documentation, including return time and signatures by a licensed nurse or facility representative, was incomplete or missing.
Failure to Document and Process Resident Grievance per Facility Policy
Penalty
Summary
The facility failed to implement its grievance and complaints policy for one resident when staff did not document the resident’s expressed concerns or the facility’s actions and resolution. The resident, admitted with weakness and vascular dementia but assessed with intact cognition, had behavioral symptoms including verbal aggression and refusal of care. She required maximal assistance with toileting and was dependent for showering. During an observation and interview, the resident, who was alert, oriented, calm, and cooperative, stated she had requested that the supervisor not assign certain CNAs because they did not know their jobs and also voiced concerns about another CNA. A CNA reported that the resident disliked a particular staff member and that this concern was verbally communicated to the charge nurse and the Director of Staff Development (DSD). The DSD stated that their office received and attempted to resolve the resident’s staffing concerns but did not initiate any written grievance form. The Social Services Director, who is responsible for tracking facility grievances, confirmed not receiving any complaints from the resident or staff. The DON stated the resident’s concerns were discussed in QAPI but acknowledged there was no written grievance form for her complaints. The administrator was aware of the resident’s issues and acknowledged the importance of documenting concerns being mitigated by the facility. Review of the facility’s grievance and complaints policy showed that team members are required to initiate and complete a grievance form, develop a plan of resolution by the appropriate department, and that Social Services tracks and trends grievances, which did not occur in this case.
Refrigerator Door and Dish Machine Air Gap Deficiencies
Penalty
Summary
The facility failed to maintain the door of a walk-in refrigerator in the kitchen in a safe, operating condition. During observations and interviews, it was noted that the door would not remain closed after being pushed shut, leading to potential temperature abuse. The internal thermometer of the refrigerator read 50 degrees Fahrenheit, and a milk carton inside measured 53 degrees Fahrenheit, indicating a failure to maintain appropriate food storage temperatures. The external thermometer used by dietary staff showed compliance, but the door was observed not to be completely shut, with a visible gap allowing warm air to enter. The maintenance supervisor acknowledged the issue and mentioned previous attempts to fix the door, but no follow-up was conducted to ensure the problem was resolved. Additionally, the facility did not ensure an appropriate air gap between the dish machine drain and the floor sink drain, which is necessary to prevent contaminated water from backing up into the dish machine. Observations revealed that the black plastic pipe draining wastewater from the dish machine was near the floor of the floor sink drain, lacking the required air gap. The maintenance supervisor was unaware of the appropriate air gap specifications according to plumbing codes or the FDA food code, and the registered dietitian confirmed the absence of an appropriate air gap, highlighting the potential for backflow contamination. The facility's policy and procedure for interior maintenance, which includes checking major kitchen equipment and plumbing connections, was not adequately followed. The FDA Food Code specifies the need for proper maintenance of equipment to prevent health risks, such as ensuring refrigeration units are capable of maintaining safe temperatures and providing an air gap to prevent backflow contamination. The facility's failure to adhere to these guidelines resulted in deficiencies that could compromise resident safety.
Failure to Implement Room Temperature Policy
Penalty
Summary
The facility failed to implement its policy on checking resident room temperatures, affecting three of nine sampled residents. During observations and interviews, it was noted that Resident 50 was lying in bed without clothes, covered only by a sheet, and expressed discomfort due to the heat. Resident 78 had two fans blowing towards her but still felt hot, indicating that the fans were only circulating warm air. Resident 45 was using a fan attached to the bed's siderail and also reported that the room was too hot. The Maintenance Supervisor (MS) was interviewed and revealed that room temperatures were checked and recorded daily at 10:00 a.m., but the logs did not indicate the time of the temperature checks. Upon reviewing the facility's policy, it was found that room temperatures should be checked between 12 noon and 4 p.m., when temperatures typically peak. The MS was unaware of this requirement and had been using a form provided to him since he started in January 2023, which did not include a section to record the time of temperature checks.
Failure to Complete Timely MDS Discharge Assessment
Penalty
Summary
The facility failed to complete a CMS-required discharged Minimum Data Set (MDS) assessment for a resident who was discharged. The facility's policy and procedure, dated May 2016, mandates adherence to the Resident Assessment Instrument (RAI) Manual Assessment schedules as required by federal and state agencies. The Resident Assessment Coordinator (RAC), who is a Registered Nurse, is responsible for the effective and efficient interdisciplinary care coordination and completion of a comprehensive plan of care from admission to discharge. The resident in question was admitted to the facility with diagnoses including orthopedic aftercare of surgical amputation. The resident was discharged home, as indicated in the Nursing Progress Notes, but the MDS discharge assessment was not completed in a timely manner, being 137 days overdue. The MDS Coordinator acknowledged the responsibility for the missed discharged assessment and admitted that the assessment could have been opened and completed prior to the resident's discharge.
Inaccurate Assessment of Dialysis Care
Penalty
Summary
The facility failed to ensure an accurate assessment reflective of a resident's status at the time of the assessment. This deficiency was identified for one resident who had an AV shunt for dialysis access. During an observation, the resident was noted to have a clean and well-maintained AV shunt and reported attending dialysis sessions three times a week. However, discrepancies were found in the documentation of the resident's dialysis schedule and vital signs assessments. The Dialysis Communication Records for the resident were missing vital signs for several dates, indicating a lack of pre and post-dialysis assessments as required by the facility's policy. Both a registered nurse and the Medical Records Director confirmed the absence of these vital signs, acknowledging that the assessments were not conducted. The facility's policy on Hemodialysis Care mandates conducting pre and post-dialysis assessments, which were not adhered to in this case.
Failure to Develop Care Plans for Restraints and Hepatitis C
Penalty
Summary
The facility failed to develop care plans for three residents, which led to deficiencies in their care. For two residents, pad alarms were used as restraints, but there were no care plans in place to address this. During observations, one resident was seen in bed with a pad alarm, and another was in a wheelchair with a similar device. Upon reviewing the medical records, it was confirmed by the RN and Medical Records Director that care plans for these restraints were missing, which they attributed to oversight. Additionally, a third resident with a diagnosis of Hepatitis C did not have a care plan addressing this condition. The absence of a care plan was confirmed during a review of the resident's clinical records and an interview with an LVN. The facility's policy requires care plans to be initiated upon admission and updated as needed, but this was not followed, resulting in the lack of appropriate care planning for the residents involved.
Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in medication administration, leading to several deficiencies. One incident involved a Licensed Vocational Nurse (LVN) administering the wrong medication to a resident. The resident was prescribed Senna 8.6 mg, but the LVN administered Senna Plus, which contains both Senna and Docusate sodium. The LVN mistakenly believed that Senna Plus was the correct medication, despite the discrepancy in the medication order. This error was acknowledged by the Director of Nursing (DON) after being informed of the situation. Another deficiency was identified when staff failed to accurately document blood pressure and heart rate readings for a resident before administering Carvedilol, a medication used to treat high blood pressure. The resident's Medication Administration Record (MAR) showed only four blood pressure readings and no heart rate readings, contrary to the requirement to check these vital signs before administering the medication. The LVN and DON confirmed the lack of documentation, acknowledging the oversight in monitoring the resident's condition prior to medication administration. Additionally, the facility did not implement monitoring for medication side effects and bleeding complications for a resident receiving Apixaban, a medication that prevents blood clots. The MAR for this resident did not include any monitoring orders for potential side effects or complications associated with the medication. Both the LVN and DON confirmed the absence of necessary monitoring orders, recognizing the failure to adhere to the facility's policy and procedures for medication administration.
Failure to Monitor Side Effects and Behaviors for Antidepressant Use
Penalty
Summary
The facility failed to ensure proper monitoring for side effects and manifestations of behaviors for a resident prescribed Mirtazapine, a medication used to treat depression. The resident, diagnosed with Major Depressive Disorder, was prescribed Mirtazapine on April 24, 2024, due to depression manifested by a lack of interest in food. The care plan for the resident, dated May 2, 2024, included interventions to monitor depressive behaviors and document side effects and effectiveness every shift. However, the Medication Administration Record (MAR) for August 2024 showed that monitoring for depressive episodes and side effects was only initiated on August 20, 2024, indicating a lack of documentation and monitoring from April 24, 2024, to August 19, 2024. During an interview on August 20, 2024, a Licensed Vocational Nurse confirmed the absence of monitoring for behavior occurrences or side effects related to Mirtazapine. The facility's policy on Psychotropic Medications and Behavior Management required documentation of behaviors for which psychotropic medications are used, to be recorded on the Monthly Behavior Monitoring Sheet and/or MAR every shift. This lack of adherence to the policy resulted in the potential for unrecognized side effects and manifestations of behaviors in the resident.
Failure to Adhere to Prescribed Diets for Residents
Penalty
Summary
The facility failed to ensure that the dietary needs of two residents on a mechanical soft, chopped diet were met according to their physician's orders and the facility's diet manual. During an observation, Resident 19's lunch was found to have pieces of baked chicken larger than the specified 1/2 inch size for a chopped diet. Despite the Registered Dietitian initially stating the meal was acceptable, a review of the diet manual confirmed that the pieces were too large, and the mechanical soft, chopped diet was not followed. Additionally, Resident 19's meal tray card did not provide instructions for the double portions required by the physician's order. In another instance, Resident 1 was served a meal that did not adhere to the prescribed mechanical soft, chopped consistency. The meal included chicken chow mein and other items that were not chopped as required. A licensed nurse confirmed that the meal did not match the prescribed diet after inspecting the tray. Resident 1's records indicated a need for a mechanically altered diet due to swallowing and nutritional status requirements. The facility's policies and procedures, including the diet manual and tray service protocol, were reviewed and found to lack proper implementation. The diet manual was not signed by the Registered Dietitian, indicating a lack of formal approval. The facility's failure to adhere to the prescribed dietary requirements increased the risk of choking for the residents involved.
Deficiency in Food Presentation and Preparation
Penalty
Summary
The facility failed to ensure that residents' lunch was served in an attractive and appetizing manner, as observed during a survey. The food items on the plate were of similar brown color, and the noodles were mushy due to being hot held for a prolonged period before the lunch meal service. Three residents expressed dissatisfaction with the facility's food, noting that the vegetables were mushy and lacked freshness, primarily using frozen vegetables. The facility's menu planning did not adhere to the standard practice of including a variety of colors to present food attractively, which could lead to reduced food intake and potential weight loss. During the survey, it was observed that the kitchen staff prepared the chicken chow mein and vegetables early in the morning and hot held them at 350 degrees Fahrenheit, which is a cooking temperature rather than a holding temperature. This resulted in the noodles becoming mushy and the vegetables losing their color and texture. The pureed food served to residents also lacked color, with two brown scoops of food on the plate that were indistinguishable without a menu. The facility's recipe and policy indicated that food should be prepared close to serving time to maintain its nutritive value and appearance, which was not followed in this instance. The facility's policies and procedures, as well as the recipe for chicken chow mein, were reviewed and found to emphasize the importance of preparing food close to serving time and maintaining its attractiveness and nutritive value. However, these guidelines were not adhered to, resulting in the deficiency. The Registered Dietitian (RD) acknowledged the lack of color and the mushy appearance of the food, which did not meet the standards of practice in menu planning. The Certified Dietary Manager (CDM) also confirmed that the food was prepared too early and held at an inappropriate temperature.
Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a change in condition for a resident, which could have delayed emergency medical care. The resident experienced hypoxia and diaphoresis during a physical therapy session, with oxygen saturation levels fluctuating between 88% and 95% on room air. The physical therapy assistant noticed the resident's condition and informed the charge nurse, who returned the resident to bed and administered two liters of oxygen without a physician's order, citing it as an emergency. The incident occurred between 10:30 a.m. and 11:00 a.m., but the physician was not notified until 12:00 p.m., when orders were given to transfer the resident to the emergency room. The facility's policy requires immediate reporting of changes in condition to the physician, which was not followed in this case. The delay in notification and the administration of oxygen without a physician's order were key factors in the deficiency.
Failure to Follow Leave of Absence Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding residents going out on a leave of absence for two sampled residents. According to the facility's policy, residents must fill out a Release of Responsibility for Leave of Absence Form, which includes the name and signature of the person accompanying the resident, the time the resident left, and the destination. Upon return, a licensed nurse or facility representative must document the return time and sign the form. However, for Resident 1, out of 14 instances of leaving the facility, 13 times lacked documentation of the return time and signature by a licensed nurse or facility representative. Similarly, for Resident 2, out of 22 instances, 21 times lacked the destination information, and on four occasions, the return time and signature were missing. During a concurrent record review and interview with the Director of Nursing (DON) and the Director of Staff Development (DSD), it was acknowledged that the forms for both residents were incomplete and did not comply with the facility's policy. The DON and DSD confirmed that the forms were filled out incorrectly on the specified dates, indicating a failure to follow the established procedures for residents going out on a leave of absence. This deficiency highlights the facility's lapse in ensuring proper documentation and supervision of residents when they leave and return to the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oxnard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shoreline Care Center | 0.6 mi | ★★★★★ | 17 | 0 |
| Glenwood Care Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Oxnard Manor Healthcare Center | 3.1 mi | ★★★★★ | 13 | 0 |
| Victoria Care Center | 6.2 mi | ★★★★★ | 0 | 0 |
| Coastal View Healthcare Center | 7.5 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.