Oakdale Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Oakdale Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Mar 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were securely stored when: 1.Registered Nurse (RN) 3, Licensed Vocational Nurse (LVN) 2, LVN 4, and RN 2 left the facility's medication cart unlocked when they walked away from during medication pass. This failure had the potential to place facility at risk for unauthorized access to medication cart and possible drug diversion. 2.Expired over the counter (OTC) medications were stored in medication cart and medication storage room; and eye drops was stored in medication cart beyond use date. This failure had the potential for residents to received expired medications that were no longer effective. […]

• No harm, potential for more than minimal, widespreadF801Mar 22, 2025

  Based on interview, and record review, the facility failed to ensure dietetic staff had the appropriate skill sets to carry out the functions of food and nutrition services when: 1. The full-time Dietary Manger (DM) did not have the appropriate qualifications to meet the state requirements of the Health and Safety Code 1265.4 when Registered Dietitian (RD) 2 was only working onsite at the facility one day per week: and 2. RD 1 did not follow current standards of practice for nutrition-focused physical exams when she was a full-time consultant who worked remotely in another state and completed nutrition assessments for the facility. […]

• No harm, potential for more than minimal, widespreadF812Mar 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored, and served safely in accordance with professional standards of food service safety for 91 out of 91 residents eating at the facility when: 1. An individually wrapped tuna sandwich was expired in the nourishment refrigerator. This failure had the potential to result in the serving of an expired tuna sandwich to 35 out of 35 residents eating regular textured diets at the facility which had the potential to lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). 2. A bottle of wine was not labeled and dated in the resident refrigerator. […]

• No harm, potential for more than minimal, patternF557Mar 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 5, Resident 15, Resident 56, Resident 76) were treated with respect and dignity when: 1.Resident 15's foley catheter bag (a collection bag that attaches to a foley catheter, a type of indwelling catheter [a catheter left in place for a period of time], to collect urine drained from the bladder) had urine visible from the hallway and was not covered with a foley catheter decency bag. This failure resulted in violating Resident 15's right to privacy. 2.Resident 5, Resident 56, and Resident 76 were lined up in the hallway outside of the dining hall and not allowed to enter and eat until other residents were done eating. […]

• No harm, potential for more than minimal, patternF657Mar 22, 2025

  Based on observation, interview, and record review, the facility failed to review and revise a care plan (a detailed approach to care customized to an individual resident's needs) to reflect assessment and interventions for one of nine sampled residents (Resident 64) when Resident 64's care plans was not reviewed and revised by the Interdisciplinary team (IDT-group professional and direct care staff that development a plan of care for a resident) after re-admission (12/27/24). This failure resulted in Resident 64 being served the incorrect diet for her meals and had the potential to place Resident 64 at risk for unintended weight loss. Findings: During a concurrent observation and interview on 3/18/25 at 10:48 a.m. […]