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Complaint Investigation

Oxnard Manor Healthcare Center

January 29, 2026 · Oxnard, CA · 1400 West Gonzales Road
Citations 2
CMS Rating 4/5
Beds 82
Provider ID 056379
Healthcare Facility
Oxnard Manor Healthcare Center
Oxnard, CA  ·  View full profile →
Inspection Summary

Oxnard Manor Healthcare Center in Oxnard, CA — inspection on January 29, 2026.

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.

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Inspection Findings

FF0698
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

the risks it can cause to the AVF site.During a review of the facility's policies and procedures (P&P) titled, Dialysis Management, dated 3/24, the P&P indicated, The facility should assure that each resident receives care and services consistent with professional standards of practice. 3. A pre and post dialysis evaluation will be completed by the licensed nurse. 4.

Vascular Access Site.b.

Assessing, observing and documenting care of access sites daily, as applicable, such as.iii.

Skin integrity (waxy skin, ulcerations, drainage from incisions) .vii.

Evidence of infection at the surgical site, such as drainage, redness, tenderness at incision site, fever.During a review of the facility's P&P titled Arteriovenous Shunt Care, revised 01/12, indicated, . I.

Observe for signs of inflammation, infection and obstruction.Inspect total shunt site area for color, warmth, redness, edema and drainage, once per shift

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Oxnard Manor Healthcare Center

1400 West Gonzales Road Oxnard, CA 93036

SUMMARY STATEMENT OF DEFICIENCIES

During a review of Resident 1's admission Record (AR), dated 1/29/26 the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD - final stage of permanent kidney failure whereby requiring regular dialysis or a transplant for survival) and dependence on renal dialysis (procedure done by a trained professional to remove waste and excess fluids from the body when the kidneys stop working properly).

During a review of Resident 1's Order Summary (OS) dated 2/12/25, the OS indicated Resident 1 had hemodialysis on Mondays, Wednesdays, and Fridays.

During a review of Resident 1's OS dated 3/24/24, the OS indicated, If bleeding occurs at AV shunt arteriovenous fistula (AVF- a surgical connection between an artery and a vein used for dialysis) RUA (Right Upper Arm) any time after dialysis, apply pressure with clean gauze for 5-10 minutes.repeat until bleeding stops. If this intervention does not control the bleeding, notify MD.During a review of Resident 1's medical record titled Microbiology Report (a report that help identify bacteria, fungi, or viruses from clinical specimens to diagnose infections and guide treatment) result date of 1/24/26 indicated, Culture Wound.Access Site.Collected 1/19/26.Organism Pseudomonas aeruginosa (a major opportunistic pathogen, frequently causing severe, antibiotic-resistant), heavy growth and Staphylococcus aureus (a germ found on people's skin), moderate growth. In addition, the physician ordered Vancomycin and Ceftazidime (both antibiotics).

During a review of Resident 1's medical record, there was no documentation to show a comprehensive assessment and an individualized care plan with interventions was done for Resident 1's new onset of infection on the dialysis access site and that it had been monitored for signs and symptoms of infection/complication since the start of a new antibiotic therapy.

In addition, there was no documentation on Resident 1's change of condition related to the infection.

During a concurrent phone interview and record review on 2/3/26 at 2:19 p.m. with Licensed Nurse (LN 2), LN 2 confirmed there was no change of condition in the Resident 1's medical record for the positive growth result and antibiotic therapy. LN 2 stated a change of condition should have been initiated but was not.

During a concurrent phone interview and record review on 2/3/26 at 3:34 p.m. with Licensed Nurse (LN 3), LN 3 confirmed to have been assigned and was familiar with Resident 1. LN 3 acknowledged that the receiving nurse did not initiate a change of condition when dialysis staff communicated that the resident had positive bacterial cultures and was receiving antibiotics.

During a review of the facility's policy and procedure titled, Change in Condition, dated 08/22, indicated, .2.

The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate. a.i Notification to the Physician/APP will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required utilizing a SBAR format (situation, background, assessment, recommendation) .4.

Reporting Information to the Physician/APP.b.

Reporting Laboratory and Diagnostic results .

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Oxnard, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Oxnard Manor Healthcare Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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