Oxnard Manor Healthcare Center
Oxnard Manor Healthcare Center in Oxnard, CA — inspection on January 29, 2026.
Found 6 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 review of Resident 1's admission Record (AR), dated 10/15/25, the AR indicated Resident 1 was initially admitted to the facility on [DATE], and then re-admitted on [DATE] with diagnoses that include hepatic encephalopathy (a decline in brain function occurring when a damaged liver cannot properly filter toxins), alcoholic cirrhosis of the liver without ascites (an advanced stage of alcohol-related liver disease where healthy liver tissue is replaced by scar tissue; the liver still performs basic functions without causing abdominal fluid buildup (ascites) or major complications), and acute respiratory failure with hypoxia (inability of the lungs to provide enough oxygen to the blood to preserve normal organ function).
During review of Resident 1's hospital Discharge Summary, dated 11/13/25, indicates the patient uses oxygen at care facility at 1 to 2 liters.
Review of Resident 1's Vitals and Pain Only progress note, dated 11/17/2025 at 22:59 p.m. indicates oxygen saturation was 95% at room air.
The admission Summary Assessment progress note dated 11/17/25 at 23:13 indicates the resident's breathing was even and unlabored on room air.
During a review of Resident 1's Weights and Vitals Summary (WVS) report for oxygen saturations, dated 1/20/26, the WVS indicate the oxygen saturation reading was obtained while the resident was on oxygen via nasal cannula on 11/19/25 through 11/24/25, 12/04/25, and 12/05/25.
Review of Resident 1's Order Summary (OS), dated 11/17/26, had no physician order for oxygen.
During an interview on 1/29/26 at 12:28 p.m. with Certified Nursing Assistant (NA 1), NA 1 stated that Resident 1 used oxygen via nasal cannula. In a separate interview on 1/29/26 at 1:28 p.m. with Certified Nursing Assistant (NA 2), NA 2 stated Resident 1 used oxygen via nasal cannula all the time.
During a concurrent interview and review on 2/19/26 at 10:21 a.m. with the Director of Nursing (DON), Resident 1's Order Summary (OS) and Weights and Vitals Summary (WVS) report for oxygen saturations (O2 sats) were reviewed. DON acknowledged the WVS report indicated oxygen saturation results were taken on numerous occasions while Resident 1 was on oxygen via nasal cannula and the OS did not indicate there was a physician order for oxygen administration.
During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 10/31/2025, indicates in part, .Purpose: To ensure the safe administration of oxygen in the Facility.Policy: Oxygen will be initiated with a provider order.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
056379 01/29/2026
Oxnard Manor Healthcare Center 1400 West Gonzales Road Oxnard, CA 93036
During review of Resident 1's admission Record (AR), dated 10/15/25, the AR indicated Resident 1 was initially admitted to the facility on [DATE], and then re-admitted on [DATE] with diagnoses that include hepatic encephalopathy (a decline in brain function occurring when a damaged liver cannot properly filter toxins), alcoholic cirrhosis of the liver without ascites (an advanced stage of alcohol-related liver disease where healthy liver tissue is replaced by scar tissue; the liver still performs basic functions without causing abdominal fluid buildup [ascites] or major complications), fluid overload (excessive water accumulates in the body's bloodstream and tissues), and acute respiratory failure with hypoxia (inability of the lungs to provide enough oxygen to the blood to preserve normal organ function).During review of Resident 1's weekly Advance Long Term Care Evaluations (ALTCE) dated 11/21/25, 12/3/25, 12/11/25, and 12/18/25 indicate the resident's abdomen was flat and non-tender.
The ALTCE dated 11/26/25 indicates the abdomen was non-tender.During a review of Resident 1's Changes in Condition (CIC), dated 12/22/25 at 6:55 a.m., the CIC indicated Resident 1 had a sudden onset of chest congestion and low oxygen saturation (O2 sat - the amount of oxygen being carried by red blood cells in the body with a normal range of 95%-100%) trending around 75%.
Question 4 of the CIC was marked yes on whether an abdominal/GI (gastrointestinal - relating to the stomach and the intestines).
The follow-up question (4a) had multiple boxes to choose from such as abdominal pain, distended abdomen, or abdominal tenderness to describe the abdominal/GI changes.
The only box selected was no changes observed.
Review of records titled Progress Notes (PN) dated 12/22/26 indicated, the nursing observations, evaluation, and recommendations made were at around 6:45 a.m., resident had sudden onset of low O2 (Oxygen) trending around 75% and noted with chest congestion.
Resident appearing anxious and having and dyspnea And further reviews did not show Resident 1's abdomen was assessed for change in condition prior to sending Resident 1 out to the ER (emergency) per resident request and recommendation by MD (physician).During review of Resident 1's hospital record, dated 12/23/25, the record indicates the resident was admitted to the hospital on [DATE] at 7:20 a.m., for acute shortness of breath.
The hospital staff's physical examination revealed the resident had a painful abdomen and significant abdominal distention.
Diagnostic imaging confirmed the resident had large volume ascites and laboratory results indicate 4600 mL (milliliters- measurement of volume) of ascites was removed via paracentesis (procedure where a needle is inserted through the abdominal wall into the space between the abdominal wall and organs to remove ascites).During a concurrent phone interview and record review on 2/4/26 at11:51 a.m. with Licensed Nurse (LN 2), Resident 1's CIC dated 12/22/25 was reviewed. LN 2 acknowledged Resident 1's abdomen was not assessed or evaluated for abdominal pain or distention.During a review of the facility's policies and procedures (P&P) titled, Change in Condition, dated 08/25/2022, the P&P indicates in part, The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate. a.
Before notifying the Physician/ APP (attending primary physician), the Licensed Nurse must observe and assess the overall condition utilizing a physical assessment and chart review.
056379 01/29/2026
Oxnard Manor Healthcare Center 1400 West Gonzales Road Oxnard, CA 93036
infection since a growth result of bacteria was detected and was started on new antibiotic
included entering notes in the medical record, if there were any, and to remove the dialysis dressing 1
1/7/26, 1/19/26, and 1/26/26 were signed by LN 1 and that there was no documentation to show the dressings applied at the dialysis center after Resident 1's treatments were removed.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 being familiar with Resident 1. Resident 1's pre-dialysis assessments dated 1/5/26, 1/19/26, and 1/26/26 were reviewed. LN 3 acknowledged the access site assessments performed by staff were discrepant from the dialysis center and that the resident's access site could not change so drastically during transport from the facility to dialysis. LN 3 stated the access site was assessed as being within normal limits (WNL) when there were other options in the electronic health record to better describe Resident 1's AVF site such as redness, swelling, pain, bleeding, or skin discoloration but those options were not selected.
And LN 3 acknowledged, not to be aware the dressing on Resident 1's AVF site was the dressing from the previous dialysis session and confirmed there were no observations done to monitor for signs of inflammation, infection and or inspection of the shunt site area for color, warmth, redness, edema, and drainage.During a concurrent phone interview and record review on 2/3/26 at 4:03 p.m. with Licensed Nurse (LN 4), Resident 1's Pre-dialysis records dated 12/25 through 01/26 were reviewed. LN 4 confirmed to have been assigned and involved in the care of Resident 1 during when the resident had pre and post dialysis appointments.
However, pre or post dialysis assessments were not performed on the days she was assigned to Resident 1 on 12/21/25, 12/28/25, 1/7/26, and 1/16/26, and 1/23/26 for Resident 1.
Further interview with LN 4 revealed that dialysis dressing must be removed by the receiving nurse after 2 hours from arrival and LN 4 claimed to have assumed the dressings found on Resident 1's AVF site were for treatment provided by the facility. LN 4 state she was not aware the dressing on Resident 1's AVF site was the dressing from the previous dialysis session and acknowledged, there were no observations done to monitor for signs of inflammation, infection and or inspection of the shunt site area for color, warmth, redness, edema, and drainage,During a concurrent interview and record review on 2/19/26 at 10:21 a.m. with Director of Nursing (DON), Resident 1's Pre-dialysis records dated 12/25 through 01/26 were reviewed. DON confirmed the post dialysis dressing should be removed 4 - 6 hours after dialysis. DON confirmed dialysis center communicated to the facility on multiple occasions when Resident 1 had returned to dialysis with the dressing from the previous dialysis treatment and 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
056379 01/29/2026
Oxnard Manor Healthcare Center 1400 West Gonzales Road Oxnard, CA 93036
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 .
056379 01/29/2026
Oxnard Manor Healthcare Center 1400 West Gonzales Road Oxnard, CA 93036
Review of PN's showed no evidence the attending physician was notified or had reviewed the hemoglobin and hematocrit results which indicated the hematocrit level was 24.9 (normal range is 42.0 - 52.0) and a hemoglobin was 8.0 (normal range is 12.0 - 18.0).
During review of Resident 1's PN dated 12/15/25, the PN indicates an order was placed to repeat the CRP and ESR.
Further review of the PN's showed no evidence that the attending physician was notified or had reviewed the laboratory test results.
The results indicated the CRP was abnormal at 12.05 with a reference range of 0.00-0.80.
During a concurrent interview and review on 1/29/26 at 4:30 p.m. with the Director of Nursing (DON), Resident 1's laboratory results dated [DATE] were reviewed.
The DON was asked for evidence indicating the physician had been notified of the test results.
The DON provided a faxed coversheet with attached laboratory results of several residents at the facility.
One of the laboratory results included the hemoglobin and hematocrit ordered on 12/10/25 for Resident 1. DON stated the fax was the only record available to show the physician had been notified of the lab results.
The faxed cover sheet document has the date and time stamped indicating the time the records were faxed but it does not indicate or show the physician received the fax and reviewed the results. DON acknowledged there was no record to show receipt confirmation, or any follow-up with the physician to verify if there were any new orders.During a follow up interview on 1/29/26 at 4:59 p.m. with the DON, the DON was asked for physician notification of Resident 1's abdominal radiology report dated 11/26/25.
DON stated that there were no records to show the physician was notified.
During an interview on 2/12/26 at 3:42 p.m. with Medical Director (MD), MD acknowledged not recalling being informed about Resident 1's abnormal radiology and laboratory results.
During review of the facility's policy and procedure (P&P) titled, Physician Services and Visits, dated 8/28/25, indicates Policy: The physician is responsible for evaluating, managing, and coordinating the resident's overall care in accordance with the resident's condition, applicable laws, and this facility's interdisciplinary approach to care.
Purpose: To ensure that residents receive timely and appropriate medical care under the supervision of a licensed physician, in compliance with federal and state regulations.
056379 01/29/2026
Oxnard Manor Healthcare Center 1400 West Gonzales Road Oxnard, CA 93036
During review of Resident 1's admission Record (AR), dated 10/15/25, the AR indicated Resident 1 was initially admitted to the facility on [DATE], and then re-admitted on [DATE] with diagnoses that include hepatic encephalopathy (a decline in brain function occurring when a damaged liver cannot properly filter toxins) and alcoholic cirrhosis of the liver without ascites (an advanced stage of alcohol-related liver disease where healthy liver tissue is replaced by scar tissue; the liver still performs basic functions without causing abdominal fluid buildup (ascites) or major complications.
During review of Resident 1's Hospital Discharge (HD), record dated 10/27/25, indicates Resident 1 had a past medical history of decompensated liver cirrhosis with ascites and fluid volume overload.
Review of the AR dated 10/15/25 does not list the diagnosis of decompensated liver cirrhosis with ascites.
Review of Resident 1's care plan also did not contain any nursing interventions for decompensated liver cirrhosis with ascites.
During a concurrent interview and record review on 1/29/26 at 2:00 p.m. with Licensed Nurse 1 (LN 1), Resident 1's AR and HD records were reviewed. LN 1 acknowledged the diagnosis on the AR indicates alcoholic cirrhosis of liver without ascites and the HD record lists the diagnosis as decompensated cirrhosis with ascites. LN 1 stated that both diagnoses should be aligned to ensure appropriate care.
During a concurrent interview and record review on 1/29/26 at 4:34 p.m. with Minimum Data Set Coordinator (MDS), Resident 1's AR was reviewed. MDS stated not knowing where the term without ascites was obtained that was entered in Resident 1's medical record for liver cirrhosis. MDS acknowledged the diagnosis of alcoholic cirrhosis of liver without ascites on the AR was incorrect.
During an interview on 2/19/26 at 10:21 with DON, the DON acknowledged Resident 1's AR did not list the diagnosis of decompensated liver cirrhosis with ascites included in the medical records the facility received from the hospital prior to the resident's re-admission on [DATE].