Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Oakdale Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Nursing staff left medication carts unlocked and unattended during medication passes, and expired or discontinued medications were found stored in both medication carts and the medication storage room. Additionally, the facility failed to monitor the temperature of the medication storage room as required by policy. These actions were acknowledged by staff and the DON as being contrary to facility procedures.
The facility failed to employ a qualified Dietary Manager with the required CDM credential and did not provide adequate onsite oversight by a Registered Dietitian. The acting DM lacked formal training and supervision for most of the week, while the full-time RD worked remotely and relied on CNAs and LVNs to perform nutrition-focused physical assessments, which is outside their scope. This resulted in insufficient supervision, training, and knowledge among dietetic staff, placing all residents at risk for food safety and nutritional issues.
Expired food and unlabeled personal food items were found in facility refrigerators, including an expired tuna sandwich and a bottle of wine without a received date. Staff interviews revealed that there was no log or checklist to ensure removal of expired items, and facility policy requiring labeling and timely discarding of food was not followed. These failures affected all residents receiving regular diets and at least one resident with a personal food item.
Several residents experienced violations of their rights to dignity and privacy when a Foley catheter bag with visible urine was left uncovered and visible from the hallway, and when dependent feeders were lined up in the hallway and not allowed to enter the dining hall until independent feeders had finished eating. Staff and leadership acknowledged that these practices did not align with facility policy or residents’ rights.
A resident's care plan was not reviewed or revised by the IDT after re-admission, leading to the resident receiving small meal portions instead of the regular portion ordered by the physician. Despite the resident's repeated complaints and clear cognitive status, communication failures between nursing, dietary, and the remote RD resulted in the resident continuing to receive the incorrect diet, contrary to facility policy and physician orders.
A resident received restorative nursing services, such as range of motion exercises and ambulation, from a CNA who was not certified as a Restorative Nurse Assistant (RNA). The CNA performed these duties without the required certification or competency training, and facility leadership was unaware of the certification requirement. Facility records confirmed the CNA was regularly assigned RNA duties, despite the job description requiring RNA certification.
Multiple infection control lapses were observed, including a urinal with urine placed next to food and medication on a resident's bedside table, improper disinfection of a glucometer between uses for two residents, and staff failing to use required PPE while providing direct care to a resident on Enhanced Barrier Precautions for MRSA. These actions did not follow facility policy or standard precautions, as confirmed by nursing and infection prevention staff.
Staff failed to report an allegation of sexual abuse, a nurse did not follow a physician's order for blood pressure management, a resident did not receive required assistive eating devices, and medication was left unattended at a bedside without proper assessment or authorization. These actions and inactions resulted in unaddressed allegations, missed medication administration, lack of support for resident independence, and unsafe medication practices.
A resident did not receive a comprehensive nutritional assessment upon readmission and quarterly, as required, resulting in the resident receiving small meal portions instead of the physician-ordered regular portion. The RD, working remotely, relied on staff reports rather than direct observation or communication with the resident, and the resident's dietary needs and preferences were not addressed due to lack of proper assessment and communication.
Two residents did not receive individualized, person-centered care plans to address their specific needs. One resident with legal blindness lacked a care plan for feeding assistance and safety during meals, resulting in inconsistent staff support. Another resident with a deep tissue injury did not have a care plan for wound treatment, despite having a treatment order, leading to uncoordinated care. Staff interviews confirmed that required care planning procedures were not followed, and the facility's policy for comprehensive care plans was not implemented.
A resident with a recent surgical wound and multiple health conditions was found with dry, flaky, and reddened skin on the scalp and clothing due to inadequate grooming and skin care. CNAs and nursing staff did not provide appropriate scalp care during bed baths, failed to document shower refusals, and did not notify the charge nurse about the resident's condition, leading to the resident feeling uncomfortable and embarrassed.
A resident with severe cognitive impairment and known wandering behavior entered another resident's room and bit their hand while the assigned CNA was on break. The incident occurred due to a lack of monitoring and communication among staff, despite the care plan indicating the need for constant awareness of the resident's location.
The facility failed to document discussions about advance directives during the admission process for three cognitively intact residents. Interviews revealed that the residents were either not offered information or their refusals were not documented, contrary to the facility's policy.
The facility failed to ensure the activity program was directed by a qualified professional, affecting all 99 residents. The Administrator, who was appointed as the Activity Director after the previous AD was terminated, did not meet the required qualifications and had not completed the necessary state-approved training course.
Medication Storage and Security Deficiencies
Penalty
Summary
Nursing staff, including RNs and LVNs, repeatedly left medication carts unlocked and unattended during medication passes. On several occasions, nurses walked away from the carts to attend to other tasks, such as checking assignments or entering resident rooms, leaving the carts accessible in hallways. Both staff and the Director of Nursing acknowledged that this practice was against facility policy and posed a safety risk, as outlined in the facility's medication administration guidelines. Expired over-the-counter medications, such as ibuprofen, and eye drops past their use date were found stored in both medication carts and the medication storage room. Staff confirmed that these medications were expired and should have been removed and destroyed according to facility policy. Additionally, discontinued oral medications, eye drops, inhalation, and injectable medications were found stored in drawers labeled for discontinued medications, rather than being promptly removed and disposed of as required by policy. The facility also failed to monitor and document the temperature of the medication storage room, as required by both facility policy and medication manufacturer instructions. Nurses reported that only the medication refrigerator temperature was being checked, and the thermometer in the medication storage room was not functioning. The DON confirmed that monitoring the room temperature was necessary to ensure proper medication storage.
Unqualified Dietary Manager and Inadequate Dietitian Oversight
Penalty
Summary
The facility failed to ensure that dietetic staff had the appropriate qualifications and competencies to carry out the functions of the food and nutrition service. The full-time Dietary Manager (DM) did not possess the required Certified Dietary Manager (CDM) credential, as mandated by state law, and had not yet taken the credentialing exam. The DM had been acting as the kitchen supervisor since the previous DM left, but was only working under the oversight of a Registered Dietitian (RD) who was present onsite one day per week. The DM reported not having received formal training for her role and lacked direct supervision for most of the week. The facility's staffing arrangement further contributed to the deficiency. RD 2, who previously worked full-time onsite, transitioned to per diem status and was only present once a week, leaving the DM without qualified oversight on the remaining days. RD 1, the full-time consultant dietitian, worked remotely from another state and only visited the facility once a year. RD 1 did not provide physical oversight or direct supervision of the DM and was not involved in daily kitchen operations. Interviews with facility leadership confirmed that the DM was unqualified to independently supervise the kitchen without direct oversight and had not received official training for the position. Additionally, RD 1 did not follow current standards of practice for nutrition-focused physical exams, as she relied on Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) to perform physical assessments, which is outside their professional scope. RD 1 completed nutrition assessments and reports based on chart reviews and information provided by CNAs and LVNs, rather than conducting in-person assessments. The Director of Nursing confirmed that CNAs and LVNs were not trained to perform focused nutrition assessments, and this practice placed all residents at risk for inaccurate assessments and nutritional deficiencies.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to ensure that food was stored and served safely in accordance with professional standards, as evidenced by two main findings. First, an individually wrapped tuna sandwich was found expired in the nourishment refrigerator. The Dietary Manager (DM) confirmed that the sandwich was past its expiration date and should have been removed by a dietary aide. The DM also stated that kitchen staff were expected to stock, clean, and remove expired food items from the nourishment refrigerator every morning and evening, but there was no log, record, or checklist to verify these tasks were completed, nor were specific staff assigned to them. Both the Registered Dietician (RD) and the Director of Nursing (DON) confirmed that all residents on regular textured diets were at risk of being served expired food, and that expired items could cause foodborne illness. Second, a bottle of wine belonging to a resident was found in the resident refrigerator without a received date or manufacturer expiration date, only labeled with the resident's name and room number. The DM stated that all personal food items were required to have a received date to determine expiration, and facility policy dictated that such items be discarded after three days. The RD, DON, and a Certified Nursing Assistant (CNA) all confirmed that labeling with a received date was necessary to ensure timely discarding of expired items, and that the absence of such labeling meant there was no way to determine if the item was expired. The resident in question could not recall when the wine was brought into the facility. Review of facility policies and job descriptions confirmed the expectation that food products be stored safely, with potentially hazardous foods discarded after three days, and that all personal food items from outside sources be labeled with the resident's name and received date. However, the lack of documentation, assignment, and verification of these tasks led to expired and unlabeled food items remaining in the refrigerators, putting residents at risk of consuming expired products.
Failure to Maintain Resident Dignity and Privacy in Catheter Care and Dining Practices
Penalty
Summary
Four residents experienced violations of their rights to dignity and respect due to facility staff actions and inactions. One resident, who was bedbound, had a Foley catheter bag with visible urine hanging on the side of the bed that was clearly visible from the hallway. The resident’s room was located near a busy area, and the bag was not covered with a decency bag as required by the resident’s care plan and facility policy. Multiple observations confirmed that the catheter bag was visible to anyone passing by, including staff, residents, and visitors. Both nursing and CNA staff acknowledged that the bag should have been covered or positioned to maintain privacy, and the DON confirmed that the care plan was not followed, resulting in a violation of the resident’s dignity and privacy. Three other residents, all with severe cognitive impairment and significant physical disabilities, were lined up in the hallway outside the dining hall and not allowed to enter or eat until other residents, who were independent feeders, had finished their meals. Observations showed that these dependent feeders had to wait in the hallway, watching others eat, before being allowed into the dining hall. Staff interviews revealed that this practice had been ongoing for at least 2.5 years, with dependent feeders consistently made to wait until the dining room was cleaned after the independent feeders finished. Staff, including CNAs and RDs, stated that this practice was not appropriate and that it violated the residents’ rights and dignity. Facility policies and job descriptions reviewed during the investigation emphasized the importance of respecting residents’ rights to privacy, dignity, and respectful care. Despite these policies, the observed practices did not align with the stated expectations, resulting in residents being denied privacy and equal access to dining, and being subjected to undignified treatment. The DON and other staff confirmed that these actions were inconsistent with facility policy and the residents’ rights.
Failure to Update Care Plan After Re-Admission Results in Incorrect Diet Served
Penalty
Summary
The facility failed to review and revise the care plan for one resident following her re-admission, as required by facility policy and federal regulations. After being re-admitted, the resident's care plan was not updated by the Interdisciplinary Team (IDT) to reflect her current dietary needs and physician's orders. The resident, who was cognitively intact and able to communicate her preferences, repeatedly expressed concerns about receiving small food portions instead of the regular portion specified in her physician's order. Despite her complaints to both the kitchen manager and staff, her meal portions remained unchanged. Record reviews and staff interviews revealed that the resident's care plan still listed a small portion diet, even though the physician's order upon re-admission specified a regular portion with no added salt and regular texture. The Dietary Manager was not informed of the diet change, and the Registered Dietitian, who worked remotely, was unaware of the updated dietary order. Communication breakdowns between nursing, dietary, and the dietitian led to the resident continuing to receive the incorrect diet for an extended period. Further review of the facility's policies confirmed that care plans are to be reviewed and updated upon re-admission, as well as during regular intervals and significant changes in condition. However, the last documented IDT weight meeting and care conference for the resident occurred months prior to her re-admission, and the care plan was not revised to reflect her current dietary needs. This failure resulted in the resident being served the incorrect diet and had the potential to place her at risk for unintended weight loss.
Uncertified CNA Provided Restorative Nursing Services
Penalty
Summary
Nursing staff at the facility failed to ensure that only individuals with the appropriate competencies and certifications provided restorative nursing services. A Certified Nursing Assistant (CNA) who was not certified as a Restorative Nurse Assistant (RNA) was assigned and performed restorative nursing services, including range of motion exercises and ambulation, for a resident. The CNA confirmed during interviews that she was not RNA certified, despite being assigned to deliver RNA programs to multiple residents without supervision. The facility's Director of Staff Development was unaware that RNA certification was required, and no RNA competency training or checklist was provided by the facility. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, and was observed receiving restorative services from the uncertified CNA. Facility records and interviews with other staff confirmed that the CNA was regularly assigned RNA duties and documented RNA services for several residents. The facility's job description for the RNA position explicitly required an RNA certificate, but this requirement was not enforced, and the Director of Nursing acknowledged that the CNA should have been RNA certified before performing RNA duties.
Infection Control Failures in Resident Care and Equipment Disinfection
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for four residents, resulting in multiple infection control deficiencies. In one instance, a cognitively intact resident with a history of sepsis, cellulitis, chronic kidney disease, and anxiety was found with a urinal filled with urine placed on his bedside table next to drinking cups, protein shakes, and medication. The resident stated the urine had been there for a while. Multiple staff, including the ADON, IP, CNA, RN, and DON, confirmed that this was a violation of standard precautions and acknowledged the risk of cross-contamination, as the urinal should not have been placed near food or drink items. In another instance, an LVN failed to properly clean and disinfect a glucometer after use with two residents. The LVN used a disinfecting wipe for only a few seconds and did not follow the manufacturer's recommended contact time for disinfection. The glucometer was also placed on the medication cart without a barrier. Both the IP and DON admitted confusion regarding the correct procedure and acknowledged that the facility's training and policy did not align with the manufacturer's guidelines for disinfection, increasing the risk of infection transmission between residents. Additionally, staff did not adhere to Enhanced Barrier Precautions (EBP) for a resident with MRSA in the urine. Both the DSD and a CNA provided direct care, including meal setup and feeding, without wearing gowns or gloves, despite clear facility policy and signage indicating the need for EBP. The DON, IP, and RN confirmed that all staff were expected to use appropriate PPE when providing high-contact care to residents on EBP, and that failure to do so placed other residents at risk for cross-contamination and infection.
Failure to Meet Professional Standards in Abuse Reporting, Medication Administration, and Resident Support
Penalty
Summary
The facility failed to meet professional standards of practice in several instances involving four residents. In one case, a resident reported to a CNA that another CNA had committed sexual abuse during personal care. The CNA who received the allegation did not file a report or notify management or authorities, as instructed by a charge nurse who dismissed the claim based on the resident's history. The incident was not investigated, and the required abuse reporting protocols were not followed, despite the resident being cognitively intact and staff being trained as mandated reporters. In another instance, a registered nurse did not follow a physician's order to administer antihypertensive medication when a resident's systolic blood pressure exceeded the prescribed threshold. The nurse also failed to document the elevated blood pressure in the clinical chart. This omission resulted in the resident not receiving the prescribed medication and the physician not being notified of the resident's condition, contrary to facility policy and professional standards. Additional deficiencies included a resident not receiving assistive eating devices as ordered on her diet tray card, with kitchen staff failing to provide foam grips on silverware to support the resident's independence during meals. Furthermore, another resident was found with medication left unattended at the bedside without a completed self-administration assessment or a physician's order, and without nursing staff present. The nurse responsible left the medication due to time constraints, which was against facility policy and created a safety issue, as confirmed by interviews with nursing leadership.
Failure to Complete Comprehensive Nutritional Assessment and Ensure Appropriate Diet
Penalty
Summary
A deficiency occurred when a resident did not receive a comprehensive nutritional assessment upon readmission and at the required quarterly interval, as mandated by federal regulations. The resident, who was cognitively intact and able to communicate her needs, expressed dissatisfaction with receiving small meal portions and stated she had not been assessed by a dietitian nor had her preferences addressed, despite informing the kitchen manager. The resident's medical record indicated a physician's order for a regular portion, no added salt diet, but the resident continued to receive small portions due to a lack of updated assessment and communication. The Registered Dietitian (RD) responsible for nutritional assessments worked entirely remotely and relied on Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), and the Dietary Manager (DM) to provide information for assessments, rather than conducting direct observation or communication with the resident. The RD completed assessments primarily through chart reviews and staff reports, without direct resident interaction. The facility's policies required comprehensive assessments, including direct observation and resident interviews, but these were not followed in this case. Record reviews showed that the resident's nutritional risk assessments were not completed at readmission or quarterly as required, and the assessments that were completed did not involve direct observation or communication with the resident. The DON confirmed that the RD should have completed these assessments and that the resident's diet order was not properly communicated to the kitchen. As a result, the resident did not receive an appropriate diet consistent with her needs and preferences.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies in meeting their individualized care needs. For one resident with legal blindness, epilepsy, major depressive disorder, and morbid obesity, the care plan addressed insufficient vision but did not include specific interventions for feeding assistance or monitoring during meals. Observations revealed that staff provided some verbal prompts at the start of meals but left the resident alone at times, leading the resident to use his fingers to identify food items and express difficulty eating without continuous guidance. Interviews with staff confirmed that there was no care plan addressing the resident's need for ongoing assistance and safety during meals, despite recognition of the risks involved. For another resident with a deep tissue injury (DTI) to the outer left foot, the facility did not create a care plan for wound treatment, even though a treatment order was in place. Staff interviews indicated that a care plan should have been developed concurrently with the treatment order to ensure the wound was properly acknowledged and managed. The absence of a care plan meant that goals and interventions specific to the DTI were not established or tracked, and communication among staff regarding the resident's wound care was lacking. The resident had multiple diagnoses, including hemiplegia, hemiparesis following a stroke, dysphagia, Parkinsonism, and constipation, and was assessed as having severe cognitive impairment. Facility policy required comprehensive care plans with measurable objectives and time frames for each resident, incorporating identified or potential problem areas and risk factors. However, in both cases, the required person-centered care plans were not developed or implemented, and staff acknowledged that the facility's policy and procedure for comprehensive care planning was not followed. The lack of individualized care planning for these residents resulted in unmet care needs and potential safety concerns, as documented by staff and observed during the survey.
Failure to Maintain Resident Grooming and Skin Care
Penalty
Summary
The facility failed to maintain proper grooming for one resident who was unable to perform activities of daily living independently. During observation, the resident was found with patches of dry, white flakes and redness on his scalp, as well as flakes on the front of his shirt and pants. The resident, who had a recent surgical wound and was refusing showers to avoid getting his dressing wet, expressed feeling bad, uncomfortable, and embarrassed about his appearance. Certified Nursing Assistants (CNAs) and nursing staff acknowledged that the resident's grooming needs, specifically scalp care, were not met, and that the condition of his skin was not normal for him. The CNAs admitted that they should have washed, brushed, and applied lotion to the resident's scalp during bed baths or showers, and should have reported the condition to the charge nurse. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that CNAs were responsible for daily grooming and skin checks, and that documentation and notification protocols were not followed when the resident refused showers or when skin issues were observed. The resident's medical record indicated diagnoses including cancer, diabetes, muscle weakness, and a need for assistance with personal care, with cognitive function assessed as intact. Facility policies required daily grooming and skin care to prevent injury and infection, but these were not adhered to in this case, resulting in the resident experiencing discomfort and embarrassment due to inadequate grooming.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to implement a resident-centered comprehensive care plan for a resident with known wandering behavior, resulting in an altercation. On 4/10/24, Resident 1, who has severe cognitive impairment and a history of wandering into other residents' rooms, entered Resident 2's room and bit Resident 2's hand. This incident occurred while the assigned CNA was on break, and the LVN on shift was not aware of Resident 1's wandering behavior, highlighting a lapse in monitoring and communication among staff. Resident 1's care plan, dated 8/18/23, indicated that all staff should be aware of Resident 1's location and distract her from wandering by offering pleasant diversions. However, on the day of the incident, Resident 1 was left unattended, leading to the altercation with Resident 2. Interviews with staff revealed that Resident 1's behavior was known, but proper monitoring was not in place during the CNA's break, and the LVN was not informed about Resident 1's tendencies. The Director of Nursing emphasized the importance of the care plan in ensuring staff awareness of residents' specific care needs. The failure to monitor Resident 1 and prevent her from entering other residents' rooms directly led to the altercation with Resident 2. This deficiency highlights the need for consistent implementation and communication of care plans to ensure resident safety.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to ensure there was documented evidence to indicate advance directives were discussed during the admission process for three residents. Resident #11, admitted on 06/15/2016, was cognitively intact with a BIMS score of 13. The social services (SS) staff person stated that Resident #11 refused to complete the advance directive form, but there was no documentation to indicate the resident's refusal. Resident #11 also stated that the facility had not offered information about advance directives. Similarly, Resident #31, admitted on 03/20/2021, was also cognitively intact with a BIMS score of 13. The SS staff person mentioned that Resident #31 declined to complete the advance directive form, but again, there was no documentation to indicate the resident's refusal. Resident #31 also confirmed that they had not been offered information about advance directives by the facility. Resident #89, admitted on 10/31/2023, was cognitively intact with a BIMS score of 15. Resident #89 stated that no one from the facility had talked with them about advance directives. Interviews with the Director of Nursing and the Administrator revealed that they were not fully aware of the details of the advance directive process, although the Administrator expected SS to offer advance directives information to residents and their responsible parties. The facility's policy required that advance directives be discussed during the admission process, but this was not documented for the three residents mentioned.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activity program was directed by a qualified professional, affecting all 99 residents. The job description for the Director of Activities required completion of rehabilitation/recreational therapy coursework or equivalent qualifications. However, the Administrator, who was appointed as the Activity Director after the previous AD was terminated, did not meet these qualifications. The Administrator acknowledged his lack of eligibility for certification as a therapeutic recreation specialist or activity professional and admitted he had not completed the required state-approved training course. The appointment was made by the chief financial officer and chief executive officer following staff layoffs, and the Administrator had not had time to complete the necessary training since the termination of the previous AD.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 204 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oakdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverbank Post-acute | 5.1 mi | ★★★★★ | 12 | 0 |
| Crestwood Manor | 8.5 mi | ★★★★★ | 11 | 0 |
| Golden Modesto Care Center | 9 mi | ★★★★★ | 5 | 0 |
| River View Post Acute | 9.6 mi | ★★★★★ | 35 | 0 |
| Modesto Post Acute Center | 9.7 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oakdale Nursing And Rehabilitation Center.
100% money-back within 48 hours.
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.