Above average — CMS composite of the measures below.
The next survey window likely opens 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 Oxnard Manor Healthcare Center during CMS and state inspections, most recent first.
A resident with ESRD receiving HD via an AVF in the right upper arm did not receive care consistent with professional standards when facility nurses failed to consistently complete and accurately document pre- and post-dialysis evaluations and AVF site assessments. Dialysis unit records repeatedly noted that dressings applied after HD were left on for multiple days, resulting in damp, longstanding dressings and raw, sore skin at the access site. Facility records lacked documentation that post-dialysis dressings were removed or that the AVF site was monitored for infection, even after a wound culture from the access grew Pseudomonas aeruginosa and Staphylococcus aureus and antibiotics were started. Interviews with LNs and the DON confirmed that assessments were missed, access sites were charted as WNL despite available descriptors for abnormal findings, dressings were assumed to be from facility treatments, and required inspection of the AV shunt site for color, warmth, redness, edema, and drainage was not performed as outlined in facility P&P.
A resident with ESRD and dependence on hemodialysis developed a new infection at the AVF access site, confirmed by wound culture showing Pseudomonas aeruginosa and Staphylococcus aureus and resulting in orders for IV antibiotics. Facility staff did not complete a comprehensive assessment, did not develop an individualized care plan with interventions for the new infection, and did not document monitoring for signs and symptoms of infection or complications. Interviews with LNs confirmed that no change-of-condition process was initiated after dialysis staff reported positive cultures and antibiotic treatment, contrary to the facility’s change-in-condition policy requiring assessment, care planning, and physician notification with lab result reporting.
Oxygen Administered Without Physician Order: A resident with hepatic encephalopathy, alcoholic cirrhosis, and acute respiratory failure with hypoxia received supplemental O2 via nasal cannula, and O2 sat readings were documented while the resident was on oxygen. The OS did not include a provider order for oxygen, and the DON acknowledged the missing order despite staff stating the resident used oxygen.
Incomplete Assessment of Change in Condition: A resident with hepatic encephalopathy, cirrhosis, fluid overload, and acute respiratory failure developed sudden chest congestion and O2 sats around 75%. The CIC noted an abdominal/GI change, but the abdomen was not assessed for pain, distention, or tenderness before transfer to the ER. The hospital later found a painful, significantly distended abdomen with large-volume ascites, and an LPN acknowledged the abdominal assessment was not completed.
Failure to Ensure Physician Review of Abnormal Results A resident with hepatic encephalopathy, cirrhosis, fluid overload, acute respiratory failure with hypoxia, and hypocalcemia had multiple labs and imaging studies ordered, including CBC, CMP, ESR, CRP, H&H, and an abdominal US. The record showed critical and abnormal results, including low calcium, low Hgb/Hct, and abnormal CRP, but documentation did not show consistent physician review or notification for several results, and the DON stated the faxed lab cover sheet was the only evidence available without confirmation of receipt or follow-up.
A resident’s admission record listed alcoholic cirrhosis of the liver without ascites, but the hospital discharge record documented decompensated liver cirrhosis with ascites and fluid volume overload. LN and the MDS Coordinator acknowledged the diagnoses did not align, and the resident’s care plan did not include interventions for decompensated liver cirrhosis with ascites. The DON acknowledged the diagnosis from the hospital records was not included in the admission record.
Inaccurate Pressure Ulcer Staging: A resident with metabolic encephalopathy, speech and language deficits following cerebral infarction, and sepsis had a coccyx PU that was documented inconsistently across the admission skin assessment, MDS, IDT notes, weekly nursing skin assessments, NLTCEs, and SBARs. The wound was initially recorded as stage 2, later reclassified by the wound physician as unstageable and then stage 4, but multiple nursing documents continued to list it as stage 2; the DON acknowledged the discrepancy and said the EHR carried over the initial skin assessment to later assessments.
Incomplete oxygen order not implemented as written. A resident with acute and chronic respiratory failure, COPD, and dependence on supplemental O2 was observed without a nasal cannula while in bed and later while in the dining room. The physician’s order for 2 L/min via NC to keep O2 sat at or above 92% did not specify continuous or PRN use, and the LPN, RN, and DON all acknowledged the order was unclear, with staff stating the resident was only using oxygen at night.
Failure to measure, treat, and consistently document pressure ulcers: A resident was re-admitted with a Stage 3 coccyx PU, but no wound measurements were documented after re-admission. Another resident was admitted with bilateral Stage 2 buttock PUs, yet no wound consult or physician treatment orders were in the record, and the chart contained conflicting skin documentation ranging from no PU to MASD to an open coccyx area; the DON acknowledged the discrepancies.
Failure to Ensure Resident Understood Arbitration Agreement: A resident with a BIMS score of 15 stated he was not fully aware of what he signed on admission, did not know what an arbitration agreement was, did not receive a copy to review, and was unaware it could be canceled within 30 days. The DOA said she presented the agreement and that it was signed electronically, but she could not provide documentation showing it was explained to the resident or that a copy was given.
An electrical outlet in a resident's room was found without a protective cover plate, exposing wiring. The issue was not reported to maintenance or logged for repair, contrary to facility policy requiring hazards to be addressed.
A facility failed to document and notify a physician about a missed insulin dose for a resident with Type 2 Diabetes Mellitus. The MAR indicated the medication was held, but lacked documentation explaining the reason or any record of physician notification, contrary to facility policy. The DON confirmed these omissions during a review.
A facility failed to follow physician orders and medication administration policy for a resident with liver disease and hypertension. Staff did not seek physician clarification for Lactulose dosage adjustments, failed to notify the physician about the unavailability of Rifaximin, and did not check vital signs before administering Propranolol. These actions were identified during a review of the resident's records and staff interviews.
A facility failed to document a resident's cataract diagnosis, as revealed during a review of medical records and interviews with the DON. Despite evidence from an Eye Health Consult form and a Complete Exam/Visit-Office form from an eye clinic, the resident's diagnosis was not reflected in the facility's records, care plan, or physician orders. This oversight had the potential to negatively impact the resident's care.
The facility failed to label and discard perishable food items in accordance with its policy. During an inspection, an undated container of frozen stew and an undated plastic bag with rolls were found in the resident refrigerator. The facility's policy requires such items to be labeled with the resident's name and date received, and discarded after 48 hours if refrigerated. The DON and Administrator acknowledged the oversight, which could potentially lead to foodborne illness.
A resident at risk for falls due to decreased mobility and weakness sustained a fall. The care plan included hourly rounding to anticipate needs, but the facility failed to document or implement this intervention throughout the month. The Director of Nursing and Administrator confirmed the lack of documentation, highlighting a failure to follow the facility's care planning policy.
The RD at the facility failed to follow current standards of practice in nutrition assessments for obese residents and those with unstageable pressure injuries. The RD used an adjusted body weight method for an obese resident, potentially promoting unplanned weight loss, and did not reassess nutritional needs for a resident with an unstageable pressure injury. Additionally, the RD did not communicate a resident's diet preferences to the dialysis center, affecting coordinated care.
The facility failed to follow planned menus for therapeutic diets, affecting residents on mechanical soft and renal diets. Observations showed that residents on mechanical soft diets received intact salad instead of soft chopped vegetables, and a resident on a renal diet received milk at lunch against meal ticket instructions. These errors were identified by staff during meal service, highlighting the need for adherence to dietary guidelines.
The facility failed to maintain a homelike environment, as observed in one resident room with wall damage and a damaged bathroom door frame, and in two shower rooms with disrepair issues. The maintenance assistant and Environmental Services Director confirmed these deficiencies, which contradict the facility's policy to provide a safe, clean, and comfortable environment.
The facility failed to develop comprehensive care plans for two residents, leading to unmet needs. One resident's preference for warm water was not documented, requiring self-service. Another resident's nutrition care plan lacked clear weight goals and did not involve the responsible party in diet decisions. These oversights violated facility policies on resident rights and care planning.
A resident undergoing dialysis treatments did not have Lidocaine-Prilocaine cream documented as administered before treatment, and several medications were incorrectly signed as given while the resident was out of the facility. The DON confirmed these discrepancies, which contradict the facility's medication administration policy.
A resident with hearing impairment was not adequately assessed or assisted in obtaining a hearing device during their stay. Despite having a care plan recognizing the risk of miscommunication, there was no documentation of actions to address the resident's hearing condition. An audiology consult was scheduled, but the facility's policy to inquire about and secure the resident's hearing aid was not followed.
A facility failed to conduct proper post-dialysis assessments and maintain communication with a dialysis clinic for a resident. The resident's dialysis binder, containing instructions for post-dialysis care, was not reviewed, and there was no documentation of pain relief or vital signs. Additionally, the facility did not follow up on the resident's hospitalization after a change of condition during dialysis, as required by their contract with the dialysis clinic.
The facility failed to ensure the pureed spaghetti with meat sauce was prepared to the required smooth, pudding-like consistency, as observed during meal preparation. Despite guidelines, the initial and subsequent attempts by the Head Cook did not meet the necessary texture, potentially affecting residents with swallowing difficulties.
A dietary aide in an LTC facility failed to wash hands after handling dirty dishes before touching clean ones, as observed by another aide. The aide admitted to not being trained in proper hand hygiene. The dietary supervisor confirmed the lapse and found no competency assessment for the aide, contrary to facility policy.
A facility failed to update a resident's medical record to reflect a change in their POLST from Full Code to DNR. Despite a physician order indicating the change, the updated POLST was not uploaded into the EHR, contrary to facility policy. This oversight was confirmed during an interview and record review with an MDS nurse.
A facility failed to provide an arbitration agreement in a language that a resident's representative could understand, potentially violating the resident's rights. The resident's MDS indicated a preference for Spanish and a need for an interpreter, yet the agreement was only available in English. Interviews confirmed the representative's inability to communicate in English and the facility's practice of providing agreements solely in English.
A resident with moderate cognitive impairment left the facility unnoticed and was found at a local restaurant. The resident was not identified as an elopement risk, and staff interviews revealed a lack of adequate supervision. The facility's policy required a care plan for individual risk factors, which was not effectively implemented.
A facility failed to implement care planned interventions and physician orders for a resident, leading to missed occupational therapy sessions and inadequate follow-up on shower refusals. The resident did not receive all ordered OT treatments, and there was no documentation of attempts to address shower refusals as per the care plan.
Failure to Perform and Document Pre/Post-Dialysis Assessments and AV Fistula Site Care
Penalty
Summary
The deficiency involves the facility’s failure to provide hemodialysis care and services consistent with professional standards of practice for a resident with End Stage Renal Disease who was dependent on renal dialysis. The resident had an AV fistula in the right upper arm and standing orders for hemodialysis three times weekly, as well as an order directing staff to apply pressure and notify the MD if bleeding occurred at the AV shunt after dialysis. The resident’s care plan required staff to check and change the dressing daily at the access site, document this care, and monitor, document, and report signs and symptoms of infection and other complications. However, review of the medical record showed that pre- and post-dialysis evaluations were not consistently completed by licensed nurses on multiple dates when the resident had dialysis appointments. Dialysis documentation from the dialysis unit showed repeated comments over several weeks that the dressing on the hemodialysis access was being left on after treatment and not removed at the facility. Entries included notations that the dressing had been left on since prior treatments, that it must be removed to prevent clotting or damage to the access, and that dressings from prior dates remained in place. On one date, the dialysis staff documented that a dressing left on since a previous treatment was damp and had left raw skin and soreness at the access site. A subsequent wound culture from the access site grew heavy Pseudomonas aeruginosa and moderate Staphylococcus aureus, and the physician ordered antibiotics including Vancomycin and Ceftazidime. Despite this, there was no documentation in the facility record that the access site was monitored for infection after the positive culture and initiation of new antibiotic therapy. Interviews with multiple licensed nurses and the DON confirmed gaps and inaccuracies in assessment and documentation. One nurse acknowledged signing post-dialysis evaluations without documenting removal of the dialysis dressings. Another nurse acknowledged that pre-dialysis assessments documented the access site as within normal limits even though the electronic record offered more specific options such as redness, swelling, pain, bleeding, or skin discoloration, and that these more accurate descriptors were not selected. This nurse also stated she was unaware that the dressing on the AVF site was from the previous dialysis session and confirmed that no observations were done to monitor for signs of inflammation, infection, or to inspect the shunt site for color, warmth, redness, edema, and drainage. A third nurse confirmed that on several dates when she was assigned to the resident, pre- or post-dialysis assessments were not performed, and she had assumed the dressings on the AVF site were for facility-provided treatment. The DON confirmed that post-dialysis dressings should be removed within a specified time frame and that the dialysis center had communicated multiple times that the resident was returning with dressings still in place from prior treatments, contrary to facility policies requiring daily assessment and inspection of the AV shunt site once per shift.
Failure to Assess and Care Plan for New Dialysis Access Infection
Penalty
Summary
The deficiency involves the facility’s failure to ensure licensed nurses were competent in providing quality care by not completing a comprehensive assessment and individualized care plan for a resident who developed a new infection at a dialysis access site. The resident was admitted with end stage renal disease and dependence on hemodialysis, with orders for dialysis three times weekly and specific instructions for managing bleeding at the arteriovenous fistula in the right upper arm. A microbiology report dated 1/24/26, from a wound culture collected at the access site, showed heavy growth of Pseudomonas aeruginosa and moderate growth of Staphylococcus aureus, and the physician ordered Vancomycin and Ceftazidime. Despite these findings and the initiation of antibiotic therapy, the medical record contained no documentation of a comprehensive assessment, no individualized care plan with interventions related to the new onset infection, and no monitoring for signs and symptoms of infection or complications. Interviews and record reviews further confirmed that required change-of-condition procedures were not followed. One licensed nurse acknowledged there was no change-of-condition documentation in the resident’s record related to the positive culture results and antibiotic therapy and stated that a change of condition should have been initiated but was not. Another licensed nurse, who was assigned to and familiar with the resident, confirmed that the receiving nurse did not initiate a change of condition when dialysis staff communicated that the resident had positive bacterial cultures and was receiving antibiotics. This was inconsistent with the facility’s “Change in Condition” policy, which requires the licensed nurse to assess the change, determine appropriate nursing interventions, and notify the physician/APP with a summary of the condition change, vital signs, and focused system review, including reporting laboratory and diagnostic results.
Oxygen Administered Without Physician Order
Penalty
Summary
The facility failed to obtain and clarify a physician order for oxygen administration for one sampled resident who received supplemental oxygen without an order. The resident was admitted and later re-admitted with diagnoses including hepatic encephalopathy, alcoholic cirrhosis of the liver without ascites, and acute respiratory failure with hypoxia. A hospital discharge summary stated the resident used oxygen at the care facility at 1 to 2 liters, and facility documentation showed oxygen saturation was 95% on room air with breathing even and unlabored on room air during the admission assessment. Review of the resident’s Weights and Vitals Summary showed oxygen saturation readings were obtained while the resident was on oxygen via nasal cannula on multiple dates. However, the resident’s Order Summary did not include a physician order for oxygen. During interviews, two CNAs stated the resident used oxygen via nasal cannula, with one stating the resident used it all the time. The DON reviewed the records and acknowledged that the oxygen saturation results were taken while the resident was on oxygen via nasal cannula even though no physician order for oxygen administration was present. The facility policy stated oxygen will be initiated with a provider order.
Incomplete Assessment of Change in Condition
Penalty
Summary
The facility failed to accurately assess a change in condition for one resident when the resident developed sudden chest congestion and oxygen saturation trending around 75%. The resident had diagnoses including hepatic encephalopathy, alcoholic cirrhosis of the liver without ascites, fluid overload, and acute respiratory failure with hypoxia. A change in condition form documented the sudden respiratory decline and marked the abdominal/GI section as yes, but the follow-up section for abdominal findings was completed as “no changes observed,” and the record did not show that the resident’s abdomen was assessed for pain, distention, or tenderness before the resident was sent to the ER at the resident’s request and per physician recommendation. Weekly evaluations before the event documented the resident’s abdomen as flat and non-tender or non-tender. The hospital record later showed the resident was admitted for acute shortness of breath, and the hospital physical examination found a painful abdomen and significant abdominal distention. Imaging confirmed large-volume ascites, and 4600 mL of ascites was removed by paracentesis. During interview, the nurse acknowledged the resident’s abdomen was not assessed or evaluated for abdominal pain or distention. The facility policy stated the licensed nurse must assess the change in condition and observe and assess the overall condition using a physical assessment and chart review before notifying the physician or APP.
Failure to Ensure Timely Physician Notification and Review of Lab and Radiology Results
Penalty
Summary
The facility failed to ensure timely communication and physician review of multiple laboratory and radiology results for one resident with hepatic encephalopathy, alcoholic cirrhosis without ascites, fluid overload, acute respiratory failure with hypoxia, and hypocalcemia. An order was placed for an x-ray of the sacrum/coccyx and for several labs, including WBC, ESR, vitamin D, CMP, CRP, and prealbumin. The record later showed a critical low calcium level of 6, and the facility documented that the physician was told and recommended continued monitoring. Additional testing was ordered, including CBC with differential, PT/INR/PTT, CMP, AFP, ammonia, AMA, and anti-smooth muscle antibody. The chart showed that results were sent to the physician and that the calcium supplement was increased to twice daily, but the documentation did not show that the attending physician reviewed the x-ray or that the abdominal ultrasound results were reviewed by the physician. The abdominal ultrasound showed cholelithiasis and mild ascites in the right upper abdomen, and the record contained no evidence that the physician was notified of those findings. The record also showed repeated inflammatory and blood count testing with incomplete evidence of physician notification or review. CRP and ESR were ordered and later documented as reported to the physician, with notes indicating no new order at one point and that responses were still pending at another. A hemoglobin and hematocrit were ordered and resulted at 8.0 and 24.9, respectively, but there was no evidence the attending physician was notified or reviewed those results. Later CRP and ESR testing again lacked evidence of physician review, with CRP documented as abnormal at 12.05. During interview, the DON stated the faxed lab cover sheet was the only record available and did not confirm receipt or follow-up, and the MD did not recall being informed of the abnormal radiology and laboratory results.
Inaccurate Admission Record for Liver Cirrhosis Diagnosis
Penalty
Summary
The facility failed to ensure that one sampled resident had an accurate medical record when the admission record did not include decompensated liver cirrhosis with ascites, even though the hospital discharge record listed that diagnosis. The resident’s admission record dated 10/15/25 showed diagnoses including hepatic encephalopathy and alcoholic cirrhosis of the liver without ascites, while the hospital discharge record dated 10/27/25 documented a past medical history of decompensated liver cirrhosis with ascites and fluid volume overload. The resident’s care plan also did not contain nursing interventions for decompensated liver cirrhosis with ascites. During a concurrent interview and record review, LN 1 acknowledged that the admission record diagnosis of alcoholic cirrhosis of the liver without ascites did not align with the hospital discharge diagnosis of decompensated cirrhosis with ascites and stated both diagnoses should be aligned to ensure appropriate care. The MDS Coordinator stated not knowing where the term without ascites came from and acknowledged that the diagnosis of alcoholic cirrhosis of the liver without ascites on the admission record was incorrect. The DON later acknowledged that the admission record did not list the diagnosis of decompensated liver cirrhosis with ascites that was included in the hospital records received before the resident’s readmission.
Inaccurate Pressure Ulcer Staging
Penalty
Summary
The facility failed to accurately assess one of five sampled residents, Resident 6, for pressure ulcer skin integrity. The facility’s Skin Integrity Management policy required a licensed nurse to complete a skin evaluation when there is a change in skin integrity and weekly thereafter, and to document the effectiveness of current treatment weekly. Resident 6 was admitted with diagnoses including metabolic encephalopathy, speech and language deficits following cerebral infarction, and sepsis. The admission skin assessment indicated the resident was admitted with a stage 2 pressure ulcer on the coccyx, but the MDS dated 11/17/25 indicated unhealed pressure ulcers while section M0300 recorded 0 for all pressure ulcer stages. The resident’s coccyx pressure ulcer was later evaluated by the facility’s wound physician and reclassified in IDT notes as unstageable and then as stage 4. Despite those reclassifications, multiple subsequent nursing long-term care evaluations, nursing skin assessments, and SBARs continued to categorize the coccyx wound as stage 2. During interview and record review, the DON acknowledged the discrepancy between the admission skin assessment, IDT notes, weekly nursing skin assessments, NLTCEs, and SBARs, and stated the electronic medical system carries over the initial skin assessment to future nursing skin assessments, which may have contributed to the staging discrepancies.
Incomplete oxygen order not implemented as written
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards of practice for one sampled resident who had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, COPD, and dependence on supplemental oxygen. The physician’s order for oxygen read oxygen at 2 L/min via nasal cannula to keep O2 saturation at or above 92% for COPD, but the order did not specify whether the oxygen was continuous or PRN. During observation, the resident was found in bed without a nasal cannula and later was observed in the dining room without a nasal cannula or oxygen therapy while waiting for lunch. During interview, the resident stated oxygen was not used when out of bed and that the nasal cannula was placed over the resident’s head at night. In a concurrent interview and record review, an LPN stated the resident was okay without oxygen and only needed it at night, while acknowledging the order did not specify continuous or PRN use. An RN acknowledged the oxygen order was inadequate and said it should be clarified with the physician. The DON also acknowledged the order should specify PRN or continuous use and stated that, in the absence of that information, the resident should always be on continuous oxygen via nasal cannula unless PRN is specified in the order. The facility’s oxygen procedure stated oxygen therapy will be administered as ordered, and the physician orders policy required clear and complete treatment orders.
Failure to Measure, Treat, and Consistently Document Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to ensure two sampled residents received necessary treatment and monitoring for pressure ulcers. Resident 10 was re-admitted with a Stage 3 coccyx pressure ulcer, but no wound measurements were documented by the admitting nurse on the day of re-admission or by the wound treatment nurse the next day, and the Director of Nursing could not locate any wound measurements after re-admission. The DON stated there were no wound measurements done. Resident 52 was admitted with bilateral buttock Stage 2 pressure ulcers and a Braden Score of 16 that later changed to 14. The admission skin assessment documented a right buttock ulcer measuring 2.5 cm by 3 cm by 0.1 cm and a left buttock ulcer measuring 2 m by 3 cm by 0.02 cm, and multiple nursing evaluations and skin assessments continued to identify bilateral Stage 2 pressure ulcers. However, no wound consultation or physician treatment orders were present in the medical record for the bilateral buttock ulcers. In addition, the resident's admission skin assessment, NLTCEs, weekly skin assessments, and progress notes contained inconsistent documentation, with some records describing no pressure ulcers, others describing MASD on bilateral buttocks, and others noting an open area or lesion to the coccyx; the DON acknowledged the discrepancy in the pressure ulcer staging across the assessments.
Failure to Ensure Resident Understood Arbitration Agreement
Penalty
Summary
The facility failed to ensure that Resident 108 understood the arbitration agreement signed during admission. Resident 108 was admitted with diagnoses including infection following a procedure, and a Social Services Assessment dated 12/11/25 documented a BIMS score of 15, indicating no cognitive deficits. During an observation and interview on 12/18/25, Resident 108 stated he was not fully aware of what he signed, did not know what an Arbitration Agreement was, did not receive a copy to read thoroughly, and did not know the agreement could be canceled within 30 days after signing. He also stated the agreement was presented when he was incoherent from medications at the time of transfer to the facility, and he wanted to speak with the Admissions person again to better understand it. During an interview on 12/19/25, the Director of Admissions stated she was responsible for presenting the Arbitration Agreement and that Resident 108 signed it electronically on 12/08/25. However, she was unable to provide documented evidence that the agreement was explained to Resident 108 or that a copy was provided. The facility policy titled Arbitration Agreements dated 05/26/23 stated that when an arbitration agreement is presented, the person presenting it will explain the agreement in a form and manner the resident understands and confirm that the resident understands the agreement.
Uncovered Electrical Outlet Found in Resident Room
Penalty
Summary
The facility failed to maintain a safe and operable environment for residents by not ensuring that an electrical outlet in one of the resident rooms was in good repair. During an observation, it was found that the wall electrical outlet outside the bathroom in the specified room was missing a cover plate, leaving electrical wiring exposed. Review of the maintenance logbook revealed that no requisition for repair of the open outlet had been made, and the maintenance supervisor confirmed that the issue had not been reported to him or entered into the logbook by any staff. The facility's policy and procedure required the maintenance department to keep the building in good repair and free from hazards at all times.
Failure to Document and Notify Physician of Missed Medication Dose
Penalty
Summary
The facility failed to ensure accurate documentation and physician notification regarding a missed medication dose for a resident with Type 2 Diabetes Mellitus. The resident was prescribed Insulin Glargine Solution to be administered subcutaneously twice daily. On one occasion, the medication was not given, and the MAR indicated a hold with a note to see the progress note. However, there was no documentation on the back of the MAR explaining why the medication was held, nor was there any record of physician notification, as required by the facility's policy. During a review, the Director of Nursing confirmed the absence of necessary documentation and notification.
Failure to Follow Physician Orders and Medication Administration Policy
Penalty
Summary
The facility failed to adhere to physician orders and its medication administration policy for a resident with liver disease and hypertension. The resident had a physician order for Lactulose to be administered every four hours with the goal of achieving four bowel movements per day. However, the staff did not seek physician clarification when the resident had fewer than four bowel movements on consecutive days. Additionally, the staff did not notify the resident's physician about the continued unavailability of the prescribed medication Rifaximin, which was on hold due to pharmacy issues, nor did they follow up with the pharmacy to obtain the medication. Furthermore, the facility did not check the resident's blood pressure or heart rate before administering Propranolol, as required by the physician's order. The medication was administered on eight occasions without the necessary vital sign checks. The facility's policy on medication administration requires that vital signs be checked and recorded when medication administration is dependent on them, but this was not done. These failures were identified during a review of the resident's medical records and interviews with facility staff.
Failure to Document Resident's Cataract Diagnosis
Penalty
Summary
The facility failed to recognize and document a resident's diagnosis of cataracts, which was identified during a record review and interview with the Director of Nursing (DON). The DON confirmed that the facility's records did not indicate the resident had cataracts, despite evidence from an Eye Health Consult form and a Complete Exam/Visit-Office form from an offsite eye specialty clinic, both of which documented the diagnosis. The resident's medical records, including the care plan and physician orders, did not reflect this diagnosis, and the facility was unable to determine how long the resident had been at the facility with this condition. This oversight had the potential to negatively impact the resident's care.
Failure to Label and Discard Perishable Food Items
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the labeling and discarding of perishable food items brought in by visitors. During an inspection of the resident refrigerator, it was observed that there was one undated container of frozen stew and one undated plastic bag containing three rolls. According to the facility's policy, food brought in by visitors must be labeled with the resident's name and date received, and perishable food requiring refrigeration should be discarded after 48 hours if not consumed. The Director of Nursing and the Administrator acknowledged that the items should have been dated when placed in the refrigerator but were not, indicating a lapse in following the established procedures. This oversight had the potential to lead to negative outcomes for residents, including foodborne illness.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall care planned interventions for a resident, identified as Resident 1, who was at risk for further falls due to decreased physical mobility, decreased endurance, and weakness. On December 2, 2024, Resident 1 sustained a fall, as documented in the Change in Condition Evaluation form. The form noted that a loud noise was heard in Resident 1's room, and upon checking, the resident was found lying on the floor with their head by the bathroom door. The resident's care plan included an intervention for every one-hour (Q1H) rounding to anticipate needs, which was not documented as being carried out throughout December 2024. During an interview and record review on January 16, 2025, with the Director of Nursing and the Administrator, it was confirmed that the facility could not provide documentation to show that the Q1H rounding intervention was implemented for Resident 1 during the specified period. The facility's policy on Comprehensive Person-Centered Care Planning, dated November 2018, emphasizes providing person-centered, comprehensive, and interdisciplinary care to meet residents' health, safety, psychosocial, behavioral, and environmental needs. The lack of documentation and implementation of the care plan intervention for Resident 1 represents a failure to adhere to this policy.
Deficiencies in Nutrition Assessment and Communication
Penalty
Summary
The Registered Dietitian (RD) at the facility failed to implement current standards of practice in nutrition assessments, particularly for elderly residents classified as obese. The RD used an adjusted body weight method to assess the nutritional needs of Resident 53, who was obese, without considering the resident's actual body weight or discussing weight goals and preferences with the resident or responsible party. This approach contradicted the resident's nutrition plan of care aimed at weight maintenance and had the potential to promote unplanned weight loss. The RD acknowledged that this was her usual practice for residents who were 150% of their ideal body weight, despite professional standards recommending the use of actual body weight for such assessments. The RD also demonstrated a lack of awareness regarding the appropriate nutritional assessment for unstageable pressure injuries. Resident 28, who had an unstageable pressure injury, was assessed using the same criteria as for a Stage 1 pressure injury, rather than the more intensive nutritional needs required for Stage 3 or 4 injuries. This oversight could delay accurate nutrition assessments and timely interventions necessary for wound healing. The facility's policies and procedures lacked adequate directives to ensure nutrition assessments were performed according to professional standards, contributing to the RD's misunderstanding of the requirements for unstageable pressure injuries. Additionally, the RD failed to communicate effectively with the RD at the dialysis center regarding Resident 40's diet order. Resident 40, who had moderate dementia and attended a dialysis center, was not on a renal diet due to personal preference, but this information was not shared with the dialysis center's RD. This lack of communication hindered the coordination of care and could lead to inconsistencies in the resident's dietary management. The facility's policy on dialysis management emphasized the importance of communication between the facility and the dialysis provider, which was not adhered to in this case.
Failure to Follow Therapeutic Diet Menus
Penalty
Summary
The facility failed to adhere to the planned menu for therapeutic diets, specifically for residents on mechanical soft diets and a renal diet. Observations revealed that three residents, who were prescribed a mechanical soft diet, received intact salad instead of the appropriate soft chopped vegetables. The Dietary Supervisor confirmed that the menu should have included cooked chopped carrots or other soft, cooked vegetables, not raw lettuce salad. This discrepancy was noted during meal service, and the error was acknowledged by the Dietary Supervisor. Additionally, a resident on a therapeutic renal diet received a carton of regular milk during lunch, contrary to the meal ticket instructions that specified milk only for breakfast. The Licensed Nurse and Dietary Supervisor both identified the error, and the milk was replaced with a fruit drink as per the renal diet menu. This oversight in following the meal ticket instructions was observed during the lunch meal service. The facility's failure to follow the planned menus for therapeutic diets had the potential to increase the risk of choking for residents on mechanical soft diets and could impede the health status of the resident on a renal diet. The report highlights the importance of adhering to dietary guidelines to ensure the safety and nutritional needs of residents are met.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in one resident room and two shower rooms, as observed during a survey. In an interview with the maintenance assistant, it was confirmed that the facility was believed to be up to date with repairs. However, during a tour, an unoccupied room was found to have wall damage with peeling paint and a damaged bathroom door frame. The maintenance assistant confirmed these damages. Additionally, during a tour of the facility's two shower rooms with the Environmental Services Director, it was observed that the east side shower room had a door frame in disrepair, and the west side shower room had broken tiles along the wall's baseboards. The Environmental Services Director confirmed these issues and acknowledged the need for repairs. The facility's policy, dated 1/1/12, states that it provides residents with a safe, clean, comfortable, and homelike environment. However, the observed damages in the resident room and shower rooms indicate a failure to adhere to this policy, potentially impacting the residents' environment negatively.
Deficiencies in Person-Centered Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for two residents, leading to deficiencies in meeting their specific needs. For Resident 65, the care plan did not identify the resident's preference for warm drinking water, resulting in the resident having to obtain warm water independently from a dispenser. This oversight was confirmed during an interview with the Dietary Supervisor, who was unaware of the resident's preference. The facility's policy on resident rights emphasizes the importance of documenting personal preferences, which was not adhered to in this case. For Resident 40, the interdisciplinary team (IDT) nutrition care plan lacked clear, measurable objectives and did not involve the resident or responsible party in setting goals related to weight management. The care plan was unclear about the specific weight maintenance goal, which impeded effective monitoring and evaluation. Interviews with the Licensed Nurse and Director of Nursing revealed uncertainty about the resident's ideal weight, and the Registered Dietitian confirmed the absence of a detailed weight goal. The facility's policy requires the inclusion of resident preferences in care planning, which was not followed. Additionally, the facility failed to involve Resident 40's responsible party in decision-making regarding the refusal of a renal diet. The Registered Dietitian admitted to not informing the responsible party of the risks and benefits associated with the diet change. The facility's policy mandates the engagement of residents and their representatives in care planning, which was not observed in this instance. This lack of communication and documentation contributed to the deficiency in providing person-centered care.
Inaccurate Medication Documentation for Dialysis Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the electronic medical record (eMAR) for a resident undergoing dialysis treatments. The resident, who required Lidocaine-Prilocaine cream to be applied to the dialysis access site before treatment, did not have this medication documented as administered on a specific date prior to being picked up for dialysis. Additionally, several medications, including Clonidine HCl, Miralax Oral Powder, Calcium Acetate, and Hydralizine HCl, were signed as administered in the eMAR while the resident was out of the facility for dialysis treatment, indicating a discrepancy in medication administration records. The Director of Nursing (DON) confirmed these findings during an interview and was unable to provide additional information regarding the administration of Lidocaine or the incorrect eMAR entries. The facility's policy and procedure for medication administration emphasize the importance of accurate documentation and administration as prescribed, which was not adhered to in this case. This lack of accurate documentation and administration has the potential to impact the resident's quality of life and well-being.
Failure to Assist Resident with Hearing Impairment
Penalty
Summary
The facility failed to ensure that a resident who was hard of hearing was assessed and assisted in obtaining a hearing device during their stay. The resident, identified as Resident 65, was observed in a wheelchair and expressed difficulty in hearing, stating that they left their hearing aids at home to prevent them from being lost. The medical record for Resident 65 indicated a care plan initiated in June, which recognized the risk of miscommunication due to impaired hearing. However, there was no documentation of actions or plans to address the resident's hearing condition, nor was there any record of the existence of a hearing aid at home. An audiology consult was scheduled for the resident, but the facility's policy and procedure for the care of hearing-impaired residents, which included asking the resident if they had a hearing aid and requesting family members to bring it, was not followed. During an interview, the social worker mentioned an ongoing audio consult but could not provide additional information regarding the resident's hearing aids at home. This lack of action and documentation potentially compromised the resident's ability to communicate effectively with the staff.
Failure in Post-Dialysis Assessment and Communication
Penalty
Summary
The facility failed to ensure proper post-dialysis assessment and communication for a resident who required dialysis services. Upon observation, it was noted that the dialysis binder book, which should contain forms and information exchanged between the facility and the dialysis clinic, was left in the resident's room without being reviewed since the resident's return from dialysis. The binder contained a form indicating that the resident was to receive Tylenol for right leg pain post-dialysis, but there was no documentation on whether the pain was relieved or any post-dialysis vital signs were recorded. Additionally, the facility did not follow up on a previous incident where the resident experienced a change of condition during dialysis and was sent to the hospital. There was no documentation or communication from the dialysis clinic regarding this hospitalization, and the facility did not request any information. This lack of communication and documentation was acknowledged by the facility's administrator during an interview. The facility's contract with the dialysis clinic requires the clinic to provide information on the management of the resident's care, including emergencies, which was not adhered to in this case.
Failure to Follow Pureed Diet Consistency Guidelines
Penalty
Summary
The facility failed to ensure that the pureed recipe for spaghetti with meat sauce was followed correctly, resulting in a texture that was not smooth, pudding-like, or of a soft mashed potato consistency as required. During an observation, the Head Cook (HC) was seen preparing pureed spaghetti with meat sauce for residents with a pureed diet order. After blending the food, the HC transferred it to a pan, believing it was ready to be served. However, upon inspection by the Dietary Supervisor (DS) 1, it was noted that the consistency was incorrect, with small noodle particles still present. DS 1 instructed the HC to further puree the mixture, and even after a second attempt, the consistency was still not appropriate. The facility's recipe and policy for pureed diets clearly indicated the need for a smooth, pudding-like consistency to prevent potential risks such as choking and aspiration in residents with swallowing difficulties. Despite these guidelines, the HC and DS 1 initially failed to achieve the correct texture, potentially affecting eight residents with a puree diet order. The facility's policy also required the Dietary Manager and Dietitian to observe meal preparation to ensure compliance with dietary orders, which was not adequately followed in this instance.
Sanitary Practices Lapse in Dietary Department
Penalty
Summary
The facility failed to ensure sanitary practices in the dietary department, as observed during a survey. A dietary aide was seen handling dirty dishes and then moving to handle clean dishes without changing gloves or washing hands. This action was observed by another dietary aide who informed the first aide of the oversight. The dietary aide admitted to not washing her hands and also indicated that she had not been trained to do so after handling dirty dishes. Further investigation revealed that the dietary supervisor acknowledged the lapse in hand hygiene and confirmed that the dietary aide should have washed her hands after handling dirty dishes. Upon reviewing the dietary aide's competency documentation, it was found that there was no competency assessment completed for the aide, which was against the facility's policy. The facility's policy on infection control clearly stated the need for proper hand washing after handling soiled equipment or utensils, and the staff competency assessment policy required department managers to ensure competency assessments were performed for their staff.
Failure to Update POLST in Resident's Medical Record
Penalty
Summary
The facility failed to update the medical record of a resident to reflect changes in the Physician Orders for Life-Sustaining Treatment (POLST). Specifically, the resident's electronic health record (EHR) indicated a POLST dated July 11, 2023, for a Full Code status, meaning the resident was to receive all resuscitative treatment. However, a subsequent physician order dated September 19, 2023, changed the resident's status to Do Not Resuscitate (DNR), indicating no life-sustaining resuscitation should be performed. This change was not updated in the resident's EHR, as confirmed during an interview and record review with the Minimum Data Set Nurse (MDS 1). The facility's policy and procedure for handling POLST forms require that any updates be scanned and placed in the appropriate section of the health care record. Despite this policy, the updated POLST form dated September 19, 2023, was not uploaded into the EHR, as acknowledged by MDS 1. This oversight had the potential to result in the resident's life-saving preferences not being carried out as ordered by the physician, as the facility did not adhere to its policy of ensuring the POLST form was accurately reflected in the resident's medical records.
Failure to Provide Arbitration Agreement in Understandable Language
Penalty
Summary
The facility failed to provide an arbitration agreement in a language that Resident 1 or their representative could understand, which had the potential to violate the resident's rights. Resident 1's Minimum Data Set indicated a preference for Spanish and a need for an interpreter to communicate with healthcare staff. Despite this, the arbitration agreement, dated 10/5/20, was signed by Resident 1's responsible party on 10/8/24, and was entirely in English. During interviews, the Director of Admissions confirmed that the representative could not communicate in English and that the facility only provided the arbitration agreement in English. The Administrator acknowledged that the arbitration agreement should be provided in a language the resident or their representative can understand.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident, leading to the resident leaving the facility without staff knowledge. The resident, who was admitted for post-surgery care and had moderate cognitive impairment, was not identified as an elopement risk in the admission baseline care plan. Despite this, the resident managed to leave the facility unnoticed and was later found alone at a local fast-food restaurant. Interviews with facility staff revealed that the resident was discovered missing by a certified nurse assistant and reported to the charge nurse. The facility's policy on wandering and elopement required the interdisciplinary team to develop a care plan considering individual risk factors, but this was not effectively implemented for the resident in question. Upon returning to the facility, the resident was evaluated and found to be without injuries.
Failure to Implement Care Plan and Physician Orders
Penalty
Summary
The facility failed to implement care planned interventions and physician orders for a resident, which had the potential to lead to negative outcomes. During a record review and interview, it was found that the resident had an order for skilled occupational therapy (OT) three times a week for four weeks. However, the resident only received two of the ordered three treatments during a specific week. The Director of Rehab acknowledged the missed visit, and neither the Director of Nursing nor the Director of Rehab could provide documentation explaining why the resident did not receive the ordered OT sessions. Additionally, the facility did not follow the care plan interventions for the resident who was at risk for injury or decline due to refusal of showers. The care plan included interventions such as attempting the procedure again later and explaining the risks and benefits of refusal to the resident. However, documentation showed that the resident refused a bath on a specific date, and there was no documentation indicating that the resident was informed of the risks or that another attempt was made to provide the bath later in the day. The Director of Nursing confirmed the lack of documentation for these actions.
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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) |
|---|---|---|---|---|
| Glenwood Care Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Maywood Acres Healthcare | 3.1 mi | ★★★★★ | 18 | 0 |
| Shoreline Care Center | 3.1 mi | ★★★★★ | 17 | 0 |
| Victoria Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Coastal View Healthcare Center | 4.5 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.