Oakwood Healthcare Center

F-F656)

These failures had the potential for changes in Resident 1's condition to go unrecognized and nursing staff that were not prepared to address emergencies related to Resident 1's SUD, which could result in negative clinical outcomes and harm for Resident 1.

Findings:

A review of the facility's policy titled, Resident Safety revised 4/15/21, indicated, To provide a safe and hazard free environment. During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident's safety risk .as well as any other Resident specific safety risks. Residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the Resident. II. During the quarterly care plan review, when there is a change in condition or if an accident or incident occurs that involves the Resident's safety, the Resident's safety risk will be reevaluated. After a risk evaluation is completed, a Resident-centered care plan will be developed to mitigate safety risks factors.

1. A review of Resident 1's admission record showed he was initially admitted to the facility on [DATE REDACTED] with diagnoses that included osteomyelitis of vertebra (a bone infection of the spine), end stage renal disease (kidney disease), diabetes (high sugars in the blood), heart failure, and paraplegia (weakness or paralysis in both legs), dialysis (artificial means of cleansing the bloodstream when kidneys can no longer filter the blood), and a dialysis shunt (where a vein and artery are surgically connected for direct permanent access to

the bloodstream). Resident 1 was capable of making his own healthcare decisions.

A review of Resident 1's History and Physical (H&P) dated 3/12/21, reflected the facility's Medical Director (MD) documented that Resident 1's had a history of Meth Abuse [Methamphetamines, illegal drug in the form of [NAME] Meth and is highly addictive and causes feelings of euphoria and increased alertness and energy and can cause violence, paranoia, anxiety, rapid heart rate, irregular heartbeat, stroke, or even death].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 055656 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 1's Behavior Contract by Administrator (Admin) dated 10/21/24, indicated .CNA [Certified Nursing Assistant] saw a clear Ziploc type baggie containing what was described as white Level of Harm - Minimal harm or crystalized small size broken up rock substances under his [Resident 1's] pillow. Officer [name] of the [name] potential for actual harm Police Department . identified the contents as [NAME] Meth.

Residents Affected - Few A review of Resident 1's drug screen test, that was required and requested by the Police Department, date collected 10/18/24 and date reported 10/29/24, indicated Resident 1 tested positive for Methamphetamine.

A review of Resident 1's Physician's Order Summary Report, dated 2/24/25, reflected that Resident 1 had a physician's order, Standing order resident [Resident 1] allowed to sign self OOF [out of facility] daily must return to facility before midnight.

During an interview with Licensed Nurse (LN) B on 4/24/25 at 8:45 am, LN B indicated that Resident 1 often leaves the facility and stays out until midnight.

During an interview with LN A on 4/29/25 at 3:26 pm, LN A stated, He [Resident 1] has incidences where he goes out of the facility.

A review of facility's, Resident Sign In/Sign Out document, dated from 4/8/25 thru 4/24/25, showed that Resident 1 had signed himself out of the facility on 4/8/25 at 5:30 pm, and on 4/19/25 at 2:45 pm. There was no documentation of when Resident 1 returned to the facility or his condition upon his return.

During a concurrent interview and record review with the Front Desk Attendant (FDA) on 5/1/25 at 1:07 pm,

the facility's, Resident Sign In/Sign Out document dated 4/8/25 thru 4/24/25 was reviewed. FDA confirmed that Resident 1 had signed himself out of the facility on 4/8/25 and 4/19/25, but did not sign back in when he returned to the facility. FDA indicated that Resident 1 goes out a couple times a week but does not always sign out or back in.

A review of Resident 1's Nursing Progress notes, dated 4/8/25 and 4/19/25, had no documentation that Resident 1 had signed himself out of the facility or when he returned.

During an interview with LN E on 5/1/25 at 4:09 pm, LN E indicated that Resident 1 was allowed to leave the facility on his own and comes back later at random times. LN E indicated that staff should be monitoring his condition upon return for drug use but was not sure if they were.

During a concurrent interview and record review with the Director of Nursing (DON) on 5/1/25 at 4:36 pm, Resident 1's 4/8/25 and 4/19/25 Nursing Progress notes were reviewed. DON confirmed that nurses had not documented when Resident 1 left the facility or when he returned and his condition upon return, and there should have been. DON indicated that Resident 1 should be monitored and assessed for drug overuse when

he returns to the facility from his leave of absence, and the facility had not been doing this.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 055656 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 2. During an interview on 4/22/25 at 10:53 am, Restorative Nursing Assistant (RNA, a certified nursing assistant who works with residents to restore strength) indicated Resident 1 had episodes of aggression, Level of Harm - Minimal harm or throws food, yells and swears at residents and staff. RNA indicated she had not had training for behavioral potential for actual harm management of residents with SUD or signs and symptoms of being under the influence of drugs.

Residents Affected - Few During a concurrent interview and record review with the Director of Staff Development (DSD) on 4/22/25 at 12:26 pm, April 2024 to April 2025 staff training records were reviewed. DSD confirmed there had not been any staff training on SUD.

During an interview on 4/22/25 at 2:11 pm, Social Service Director (SSD) confirmed that [NAME] Meth had been found in Resident 1's room on 10/18/24, and that she was aware that Resident 1 had a past history of drug abuse. SSD indicated she had not received training on SUD.

During an interview on 4/24/25 at 8:45 am, LN B indicated that it would be helpful to have training concerning SUD and to know how to deal with Resident 1's behavior outbursts and potentials for an overdose. LN B confirmed training on the management of a resident with SUD had not happened.

During an interview on 4/29/25 at 3:26 pm, LN A confirmed she has not had training for the management of a resident with SUD.

During an interview on 4/24/25 at 12:33 pm, the Director of Nursing (DON) indicated that Resident 1 was found to have illegal drugs in his possession and tested positive for drugs back in October 2024. DON confirmed that Resident 1 had numerous physical and verbal altercations with other residents and staff and had had frequent outbursts of anger and using inappropriate language around facility. DON indicated the facility had not done training on SUD, but should have.

3. During a concurrent interview and record review with Minimum Data Set Nurse (MDS) on 5/1/25 at 1:29 pm, Resident 1's Care Plans were reviewed. MDS confirmed Resident 1 did not have a care plan developed with interventions to manage Resident 1's SUD and one should have been developed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 055656 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43755

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure that staff were trained and competent to care for one of one sampled resident (Resident 1) who had a Substance Use Disorder (SUD,

an individual who uses and/or abuses illegal drugs and alcohol) when Resident 1 had many numerous physical and verbal altercations with other residents and staff over the past year, and staff indicated they did not know how to deal with these behaviors of someone with a SUD and indicated they had not received training on it.

This failure has the potential for Resident 1 not to receive care and services to safely manage his SUD and result in a decline in his physical, emotional and psychosocial well-being and put other residents' health, safety and welfare at risk.

Findings:

A review of the, Facility Assessment (an assessment to determine what resources are necessary to care for its residents competently during both day-to day operations [including nights and weekends] and emergencies) dated 12/6/24, indicated the facility assessment identified serving a population of residents with, Active or current substance use disorders. The Facility assessment indicated that the assessment will be used to, Inform staffing decisions to ensure that there are a sufficient number of staff with appropriate competencies and skill sets necessary to care for the residents' needs as identified through the resident assessment and plan of care.

A review of Resident 1's Admission record showed he was initially admitted to the facility on [DATE REDACTED] with diagnoses that included osteomyelitis of vertebra (a bone infection of the spine), end stage renal disease (kidney disease), diabetes (high sugars in the blood), heart failure, and paraplegia (weakness or paralysis in both legs). Resident 1 was capable of making his own healthcare decisions. There was no documentation on Resident 1's Admission record that he had a history of substance abuse.

A review of Resident 1's, General History and Physical (H&P) note, dated 2/5/21, the acute hospital Physician (PHY) indicated Resident 1 had a history of methamphetamine abuse (illegal drug in the form of [NAME] Meth and is highly addictive and causes feelings of euphoria and increased alertness and energy. Some side effects from using crystal meth include violence, anxiety, and skin sores).

During an interview on 4/22/25 at 10:53 am, Restorative Nursing Assistant (RNA, a certified nursing assistant who works with residents to restore strength) indicated Resident 1 had episodes of aggression, throws food, yells and swears at residents and staff. RNA indicated she had not had training for residents with SUD.

During a concurrent interview and record review with the Director of Staff Development (DSD) on 4/22/25 at 12:26 pm, the DSD confirmed that the facility had never conducted any trainings to staff about SUD. After a

review of all of the trainings that had been provided to staff, the DSD could only show evidence of Dementia trainings from 12/31/24 to 1/3/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 055656 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055656 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 During an interview on 4/22/25 at 2:11 pm, Social Service Director (SSD) indicated that Resident 1 had behavior outbursts with yelling, screaming and using profanity toward staff and residents. SSD indicated she Level of Harm - Minimal harm or had offered to schedule psychiatric services for Resident 1 but that he had refused in the past. SSD potential for actual harm indicated that [NAME] Meth had been found in Resident 1's room on 10/18/24, and he had a past history with drug abuse. SSD indicated she had not had training on SUD or what to look for concerning illegal drugs. Residents Affected - Few

During an observation and interview on 4/22/25 at 3:19 pm, Resident 1 was observed sitting in his wheelchair in his private room. Resident 1 stated, I have anger issues. I am set in my ways and when they cannot get it right repeatedly, I tend to get upset.

During an interview on 4/24/25 at 8:45 am, Licensed Nurse (LN) B indicated that it would be helpful to have training concerning SUD and to know how to deal with Resident 1's behavior outbursts. LN B continued to say that training on the management of a resident with SUD had not happened.

During an interview with the Medical Director (MD) on 4/24/25 at 2:27 pm, MD confirmed that Resident 1 had

a SUD, and his admission record should have been updated to include a diagnosis of SUD and it was missed.

During an interview on 4/29/25 at 3:26 pm, LN A indicated that Resident 1 was verbally abusive to residents. LN A stated, I do not know what to do or where to go. I am not trained with behavioral issues such as this.

He snaps and the verbal and mental abuse is so profound. We do not know what to do it is so scary. LN A indicated she has not had training for the management of a resident with SUD.

During an interview on 4/24/25 at 12:33 pm, the Director of Nursing (DON) confirmed that Resident 1 was found to have illegal drugs in his possession and tested positive for drugs back in October 2024. DON confirmed that the Resident 1 had numerous physical and verbal altercations with other residents and staff and had had frequent outbursts of anger, using inappropriate language in and around facility. DON indicated

the facility had not done training on SUD but should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 055656

F-F741)

3. The facility failed to develop a SUD plan of care for Resident 1 with goals and interventions to mitigate potential accidents, hazards, and drug overdose. (Refer to