Oxnard Manor: Dialysis Access Site Infections Missed - CA
By the time a state inspector arrived at Oxnard Manor Healthcare Center on January 29, the resident, identified in inspection records only as Resident 1, had developed a bacterial infection at the vascular access site used for dialysis. A new antibiotic had been started.
The access site at the center of this failure is an arteriovenous fistula, or AVF, a surgically created connection between an artery and a vein that allows for dialysis. It is not a minor detail of care. It is the portal through which blood leaves and re-enters the body during every treatment. When that site becomes infected, the consequences can be severe. The facility's own written procedures required nurses to inspect the shunt site every shift, checking for color, warmth, redness, swelling, and drainage.
That did not happen.
Inspectors reviewed pre- and post-dialysis records spanning December 2025 through January 2026 and found a pattern: assessments not completed, dressings not removed, signs of infection not looked for.
Licensed Nurse 1 acknowledged signing post-dialysis evaluations on December 28, January 7, January 19, and January 26. She acknowledged there was no documentation showing the dialysis dressings had been removed after any of those treatments. The facility's own protocol required removal within hours of the resident's return.
Licensed Nurse 4's record was worse. On five separate days she was assigned to Resident 1 during dialysis appointment periods — December 21, December 28, January 7, January 16, and January 23 — she performed no pre- or post-dialysis assessments at all. When inspectors asked her about the dressings, she said she had assumed the dressing on the AVF site was one the facility itself had applied for treatment. She did not know it was the dressing from the previous dialysis session. She acknowledged that no one had checked the site for signs of inflammation, infection, warmth, redness, swelling, or drainage.
Licensed Nurse 3 described the assessments that were completed, and the picture was not better. She confirmed that on January 5, January 19, and January 26, the access site had been documented as within normal limits. She acknowledged the site could not have changed so drastically between the facility and the dialysis center that the two assessments would look completely different. The electronic health record offered other options to describe what nurses observed: redness, swelling, pain, bleeding, skin discoloration. Those options were not selected. She was not aware, she said, that the dressing on the AVF site was from the previous dialysis session. She confirmed no observations had been done to monitor for signs of inflammation or infection.
The Director of Nursing confirmed to inspectors that post-dialysis dressings should be removed four to six hours after treatment. She confirmed the dialysis center had communicated to the facility on multiple occasions that Resident 1 had returned to dialysis still wearing the dressing from the prior session, and that this carried real risks to the AVF site.
Multiple occasions. The facility knew.
The gap between what the Director of Nursing described and what three separate nurses reported doing is not a paperwork problem. An AVF site that is never properly inspected, that goes shift after shift without anyone checking for the early signs of infection, that returns to dialysis session after session with an old dressing still in place, is a site where infection is not a surprise. It is a predictable outcome.
The facility's Arteriovenous Shunt Care policy, last revised in January 2012, required nurses to observe for signs of inflammation, infection, and obstruction, and to inspect the total shunt site area for color, warmth, redness, edema, and drainage, once per shift. The Dialysis Management policy required a pre- and post-dialysis evaluation to be completed by a licensed nurse and specifically listed skin integrity, evidence of infection, drainage, redness, and tenderness as items to assess.
The policies existed. The dialysis center flagged the problem. The Director of Nursing knew the dressing protocol. None of it translated into anyone consistently checking the site.
Resident 1 was eventually started on a new antibiotic after a bacterial infection was detected. The inspection report classified the level of harm as minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's language, not necessarily the experience of a dialysis patient whose vascular access site, the one structure that makes their treatment possible, became infected because nurses repeatedly left old dressings in place and marked the site as normal without looking.
The inspection was conducted as a complaint investigation. The deficiency was cited under standards governing the quality of care residents must receive.
Oxnard Manor Healthcare Center is located at 1400 West Gonzales Road in Oxnard.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oxnard Manor Healthcare Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Oxnard Manor Healthcare Center in Oxnard, CA was cited for violations during a health inspection on January 29, 2026.
A new antibiotic had been started.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.