Ojai Health & Rehabilitation
Ojai Health & Rehabilitation in Ojai, CA — inspection on November 18, 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
During an interview on 9/25/25 at approx. 1:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 verbalized, heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was a false alarm and did not realize a resident was missing until the fire department showed up.
During an interview on 10/8/25 at 8 a.m. with [NAME] County Fire Captain (FC), the FC stated, When we arrived on scene there was a gentleman lying just off the ramp into the road in front of a home approximately a block from the facility. He had a hospital bracelet on that had the name of the facility and another bracelet on one of his legs (wander guard).
After doing an assessment we helped him up, he was not talking, his blood pressure was pretty low. We stopped at the facility first.quickly ran inside and the staff did not know he was missing.
The facility was able to pull up that he had medication around 9 a.m., the call went out about 10 a.m., so sometime in between he left the facility. He could have been missing from the facility for an hour and nobody would have noticed.During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated, Resident 1 was given medication at approximately 9 a.m. and that was the time the resident was last noted in the facility.During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment tool used in nursing homes to evaluate residents' health and functional status, dated 7/15/25, the MDS indicated, a Brief Interview for Mental Status (BIMS) score of 5 on admission (Scores of 0-7: indicate severe cognitive impairment).
During a review of Resident 1's Care Plan (CP), dated 7/8/25, the CP indicated, Resident is at risk for elopement, exit seeking/wandering related to communication deficits, difficult to redirect, exit seeking behaviors.During a review of Resident 1's Order Summary Report (OSR), dated 11/10/25, the OSR indicated, Resident 1 was to wear a Wander Guard, a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area.
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
11/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ojai Health & Rehabilitation
601 North Montgomery Street Ojai, CA 93023
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 9/25/25 at approx. 1:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA verbalized, they heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was a false alarm and did not realize a resident was missing until the fire department showed up.During an interview on 10/8/25 at 8 a.m. with [NAME] County Fire Captain (FC), the FC stated, When we arrived on scene there was a gentleman lying just off the ramp into the road in front of a home approximately a block from the facility. He had a hospital bracelet on that had the name of the facility and another bracelet on one of his legs (wander guard).
After doing an assessment we helped him up, he was not talking, his blood pressure was pretty low. We stopped at the facility first.quickly ran inside and the staff did not know he was missing.
The facility was able to pull up that he had medication around 9 a.m., the call went out about 10 a.m., so sometime in between he left the facility. He could have been missing from the facility for an hour and nobody would have noticed.During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated, Resident 1 was given medication at approximately 9 a.m. and that was the time the resident was last noted in the facility.During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment tool used in nursing homes to evaluate residents' health and functional status, dated 7/15/25, the MDS indicated, a Brief Interview for Mental Status (BIMS) score of 5 on admission (Scores of 0-7: indicate severe cognitive impairment).
During a review of Resident 1's Care Plan (CP), dated 7/8/25, the CP indicated, Resident is at risk for elopement, exit seeking/wandering related to communication deficits, difficult to redirect, exit seeking behaviors.During a review of Resident 1's Order Summary Report (OSR), dated 11/10/25, the OSR indicated, Resident 1 was to wear a Wander Guard, a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated December 2007, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.
Facility ID:
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.