Whitney Oaks Care Center
WHITNEY OAKS CARE CENTER in CARMICHAEL, CA — inspection on September 23, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observations, interviews, and record review, the facility failed to ensure that one of five sampled residents (Resident 1's) right to send and receive mail was protected when it withheld Resident 1's mail for a period of seven months.This failure had the potential to cause emotional distress such as social isolation, missed important matters, and distrust in care for Resident 1.Findings:Resident 1 was admitted to the facility in March of 2025 with diagnoses that included depression.
During an interview on 9/22/25 at 12:51 p.m. with Resident 1, Resident 1 indicated that she had been waiting for important letters from her insurance and law enforcement that were of significance to her and caused her to worry.
During a concurrent interview and record review on 9/22/25 at 3:59 p.m., with the Activities Director (AD), Resident 1's Order Details, dated 3/7/25, was reviewed.
The Order Details indicated, Resident has capacity to make her decisions.
The AD indicated that Resident 1's mail was being withheld by activities staff since March of 2025, since they believed Resident 1 did not have capacity to make her own decisions.
During an interview on 9/23/25 at 10:47 a.m. with the Director of Nursing (DON), the DON indicated residents at the facility have the right to receive mail and that she expected staff to give the mail directly to the residents when appropriate.During a review of the facility's policy and procedure (P&P) titled, Mail and Electronic Communication, revised 5/17, the P&P indicated, Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email and other electronic forms of communication confidentially.Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries).
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Whitney Oaks Care Center
3529 Walnut Avenue Carmichael, CA 95608
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of five sampled residents (Resident 1) when Resident 1 was not administered glipizide (a medication used to control high blood sugar levels in adults with type 2 diabetes) as prescribed by the physician.This failure had the potential to cause Resident 1 to experience uncontrolled blood sugar levels, which could result in complications such as vision impairment and/or nerve issues related to poor blood sugar control.Findings:Resident 1 was admitted to the facility in March of 2025 with diagnoses that included type two diabetes (a chronic condition that causes a person to have persistently high blood sugar levels).A review of Resident 1's Order Details, dated 3/7/25, indicated, glipiZIDE Oral Tablet 2.5 MG [milligrams, a unit of measurement] Give 1 tablet by mouth one time a day for DMII [type two diabetes] TAKE 30 MINUTES BEFORE MEALS AND HOLD IF BLOOD GLUCOSE IS LESS THAN 100During an observation on 9/23/25 at 8:21 a.m., during a medication administration for Resident 1, Licensed Nurse 1 (LN 1) administered Resident 1's glipizide after Resident 1 had finished her breakfast.
During an interview on 9/23/25 at 9:10 a.m., with LN 1, LN 1 confirmed she did not administer the glipizide per physician orders. LN 1 indicated that it is important to give as ordered to prevent hypoglycemia (low levels of sugar in the blood).
During an interview on 9/23/25 at 10:47 with the Director of Nursing, the DON indicated that she expected nursing staff to administer medications as ordered by the physician.During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 3/18, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the attending physician.
Facility ID: