Health inspection·December 1, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that staff consistently implemented the physical mobility care plan for one of three sampled residents (Resident 1) when Resident 1's care plan indicated that she would be transferred using a Hoyer lift (a mechanical lifting device), and staff were not consistently using the Hoyer lift and transferring her with two people lifting her up by her arms. This had the potential for Resident 1 to sustain injuries from staff not using the Hoyer lift and negatively impact her ability to attain or maintain her highest practicable level of emotional and physical well-being. Findings:A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 9/7/23, indicated a care plan would be developed for each resident that included standards for meeting safety and health care needs.During a review of Resident 1's medical record indicated that Resident 1 was admitted to the facility on [DATE] with a diagnoses that included Parkinson's disease (a neurological disorder leading to movement issues like tremors, stiffness, and balance problems), schizophrenia (a brain disorder that disrupts how people interpret reality) and dementia (a decline in mental ability, including memory, thinking and behavior that is sever enough to interfere with daily life). Resident 1 has a Responsible Party (RP decision maker) who makes decisions for them. On 10/10/25 the facility reported to the California Department of Public Health (CDPH) that Resident 1 was found to have a broken left pinky toe and they were unsure how it occurred. During a review of Resident 1's Physical Mobility care plan dated 12/13/22, indicated Resident 1 had limited physical mobility and was dependent on staff for care. An update to the care plan was added on 10/10/25 and reflected that Resident 1 was non-ambulatory (unable to walk or stand) and dependent on a Hoyer lift for transfers. During a review of Resident 1's most recent Minimum Data Set (MDS, a resident assessment) dated 9/26/25, Resident 1 was dependent (helper does all of the effort) for showering/bathing and for chair to bed transfers. A review of a handwritten note by CNA A dated 12/1/25, was provided by Medical Records. CNA A had written that on 10/6/25 Resident 1 had been transferred with two staff members and had not included that the Hoyer lift had been used. During a review of a health status note dated 10/10/25 at 11:09 am, Registered Nurse (RN) A documented that there was a bruise discovered on Resident 1's left top of the foot that was yellow in color with blotchy red and purple bruising. Resident 1 stated someone stepped on my foot and that it was painful. RN A documented that Resident 1 was non-ambulatory and had foot drop (where the feet point downward from contracted muscles). An x-ray was ordered. During a review of a health status note dated 10/10/25 at 2:34 pm, RN A documented that the x-ray results for Resident 1 had been received and Resident 1 had an acute fracture on the left pinky toe. During an observation and interview on 11/6/25 at 10:02am, with Resident 1, Resident 1 was lying in bed with foot board (a device that keeps blankets from touching the feet) in place. When Resident 1 was asked how she broke her pinky toe, Resident 1 stated that her sister stepped on her toe.During an Page 1 of 2 055656 055656 12/01/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview on 11/6/25 at 2:22 pm, with the Director of Nursing (DON), the DON confirmed that Resident 1 was found with a bruise and fractured left pinky toe on 10/10/25 and the facility had not known how that happened. The DON confirmed that Resident 1 required a Hoyer lift to transfer from bed to chair. During an interview on 11/12/25 at 11:06 am, with CNA B, CNA B stated that sometimes they will transfer Resident 1 with just two people by lifting Resident 1 under the arms instead of using a Hoyer lift, it just depends on how the resident is feeling. During an interview and concurrent care plan review on 11/13/25 at 3:25 pm, with Licensed Nurse (LN), the LN confirmed Resident 1 is a Hoyer lift. During an interview on 11/13/25 at 3:32 pm, with CNA C, CNA C stated that Resident 1 is a 2-person transfer (where 2 staff lift her under her arms) but they will use a Hoyer lift if Resident 1 is really struggling to get up. During an interview on 11/13/25 at 3:37 pm, with CNA A, CNA A stated that she got Resident 1 up and out of bed for a shower on 10/6/25, using another CNA to help lift her and had not used the Hoyer lift. 055656 Page 2 of 2