Ojai Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ojai Health & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 18, 2025

  Based on interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 was identified as at risk for elopement, left facility without knowledge of staff, and was found a block from the facility.Findings:During an interview on 9/25/25 at 1 p.m. with the director of nursing (DON), the DON stated, We didn't realize Resident 1 was missing until the fire department brought him back. He wasn't gone from the facility that long, so we didn't think reporting to CDPH was necessary. During an interview on 9/25/25 at approx. 1:30 p.m. […]

• Actual harm, isolatedF689Apr 6, 2023

  Based on observation, interview and record review, the facility failed to ensure an environment free of accident hazards when one of three sampled residents (Resident 1), wheeled self out to the patio and opened an unlocked gate. This failure resulted in Resident 1 falling eight steps in her wheelchair and sustaining a broken left wrist, two broken bones of the spine, and a rotator cuff tear (a rip in the group of four muscles and tendons that stabilize your shoulder joint and let you lift and rotate your arm) to her left shoulder. […]

• No harm, potential for more than minimal, widespreadF575May 29, 2024

  Based on observation and interview, the facility failed to accurately post contact information with the name, addresses, and phone number for the State agency (California Department of Public Health [CDPH]) in an accessible and understandable manner and failed to ensure the posting included a statement that the resident may file a complaint with the State Survey Agency. These failures had the potential that residents rights to be informed of these agencies and services would not be supported. Findings: During an interview on 4/25/24 at 10:24 a.m. with Resident 1, Resident 1 stated, I asked the administrator for the phone number to file a complaint and they wouldn't give it to me. […]

• No harm, potential for more than minimal, widespreadF921May 29, 2024

  Based on interview, observation, and record review, the facility failed to provide a safe, functional, and sanitary environment for residents, staff, and the public when the maintenance department was cluttered and trash bins were overflowing. This failure had the potential to create an unsafe environment for the residents and visitors due to possible pest infestation, spread of diseases in the facility, and exposure to hazardous materials. Findings: During an interview on 4/25/24 at 11:05 a.m. with the facility ' s maintenance staff (MS), MS indicated the maintenance department is responsible for providing services to all areas of the facility. During an observation on 4/25/24 at 11:08 a.m. MS opened a door to the maintenance department. […]

• No harm, potential for more than minimal, patternF676Jul 28, 2026

  Based on interview and record review, the facility failed to ensure physician's orders for restorative nursing assignments (RNA - targeted care tasks assigned to nursing staff to help patients maintain or improve their physical, mental, and functional independence) were consistently provided to four of four sampled residents (Resident 1, 2, 3, and 4). This failure has the potential for residents to experience functional decline.The facility policy and procedure (P&P) titled: Activities of Daily Living (ADL), Supporting, dated March 2018, indicates in part, .Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are… […]