Health inspection·December 16, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1 was rushed by Certified Nursing Assistant (CNA) F and spoken to with a demeaning tone and attitude.This failure resulted in Resident 1 feeling angry, helpless and emotionally stressed and had the potential to result in embarrassment and neglect which could result in negative clinical outcomes.Findings: The facility's policy revised 8/2025, titled, Residents' Rights, was reviewed and indicated employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. The facility's policy revised 3/2017, titled, Quality of Life-Dignity, was reviewed and indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. All residents shall be treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity is prohibited. The staff shall promote dignity and assist the residents as needed by promptly responding to the residents' request for activities of daily living (ADLs are activities related to personal care. ADLs include bathing, dressing, getting in and out of bed or a chair, walking, toileting, and feeding) assistance. During a review of Resident 1's record titled admission Record, indicated Resident 1 was admitted the facility on 11/12/25 with diagnoses that included cellulitis of perineum (area of the body located between and anus and private areas with infection of the skin causing redness, pain, and swelling), rectal abscess (painful pus filled pocket near your anus or rectum, like a deep pimple or boil), hyponatremia (low sodium level in the blood), dysphagia (difficulty swallowing), glaucoma (progressive eye disease caused by too much pressure that can lead to vision loss), bilateral osteoarthritis of knee and hip (the joints smooth cartilage wears down, causing stiffness, pain, swelling and decreased movement), bilateral hearing loss (hard of hearing in both ears), hypokalemia (low potassium level in the blood), high blood pressure, and a history of falling. During a review of Resident 1's record titled, Minimum Data Set, (MDS, a resident assessment), dated 11/19/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 9 of 15. This score indicated a mild cognitive (ability to think, reason and make decisions) impairment, but was her own responsible party (RP) and was capable to make her own decisions. MDS, section GG indicated Resident 1 was totally dependent on facility staff for toileting to complete this activity. During an interview on 12/16/25 at 9:02 am, Resident 1 stated, Yes, I remember the incident. I remember it was a long night, and I have requested [CNA F] does not come back in my room. [CNA F] did not physically hurt me, she just told me she could not keep coming in here, and I did need help that night. She acted like she was in a hurry and did not want to help me. You know, you can tell when someone doesn't want to help you. I reported [CNA F] for not being nice. I just felt helpless and I was kind of mad at the time, but not now. She just emotionally hurt me. During a interview on 12/16/25 at 12:30 pm, CNA F stated, I was in [Resident 1]'s room every 45 minutes to an hour. She had diarrhea that night, and I did help her. [Resident 1] is very hard Page 1 of 6 055656 055656 12/16/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of hearing and doesn't wear her hearing aids at night, so you do have to raise your voice, or she cannot hear you. During a concurrent interview and record review on 12/16/25 at 1:30 pm, the Director of Nursing (DON) confirmed she had verbally counseled CNA F on 11/28/25 related to resident rights, working too many hours, and on dignity and respect. DON stated, I confirm [CNA F] did not provide kindness during care for [Resident 1] which violated her rights for dignity and respect. During an interview on 12/16/25 at 1:45 pm, the administrator confirmed CNA F had no self-awareness of her attitude, she was very task focused and needed additional training on dignity and respect for resident care. 055656 Page 2 of 6 055656 12/16/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was free from physical and verbal abuse when Resident 2 yelled profanity and was swinging at Resident 3 in the hallway. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, anger, and the potential for negative clinical outcomes.Findings: The facility's policy revised 5/30/24, titled Abuse and Prevention Management, was reviewed and indicated the purpose of this policy is to address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect, misappropriation of resident property, exploitation, and mistreatment, including freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms. This facility's policy also indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the facility's abuse prevention, screening, and training program policies. The facility's policy revised 5/30/24, titled Abuse and Prevention Management, was reviewed and indicated Abuse is defined as the willful, deliberate infliction of injury.intimidation.resulting physical harm, pain or mental anguish. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability. Mental abuse, emotional abuse, and psychological abuse, are defined as, but not limited to, verbal or non-verbal conduct that causes humiliation, intimidation, fear, shame, agitation, or degradation. During a review of Resident 2's record titled, admission Record, indicated Resident 2 was admitted the facility on 1/12/21 with diagnoses that included vascular dementia, (a decline in thinking, memory and daily function) with agitation (restless, upset or irritable), chronic obstructive pulmonary disease (COPD, a progressive lung condition), heart failure (the heart cannot pump enough blood to meet the body's needs), dysphagia (difficulty swallowing), anxiety (a feeling of worry, fear, unease and dread), glaucoma (progressive eye disease caused by too much pressure that can lead to vision loss), major depressive disorder (persistent feelings of sadness, hopelessness and loss of interest), and polyneuropathy (many damaged nerves causing tingling, numbness, weakness and pain). During a review of Resident 2's record titled, Minimum Data Set, (MDS, a resident assessment), dated 10/3/25, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 3 of 15. This score indicated a severe cognitive (ability to think, reason and make decisions) impairment. During an interview on 12/16/25 at 9:40 am, Resident 2 shouted, I don't remember, get out of here. Just pick up the covers and then you can leave. During an interview on 12/16/25 at 9:42 am, Certified Nurse Assistant (CNA) E stated, I heard [Resident 2] did not sleep much last night. [Resident 2] does have behaviors; we all check on her a lot. During an interview on 12/16/25 at 10:03 am, Activity Assistant (AA) stated, I know [Resident 2] very well. I think she has a great spirit, and she can be loving and funny. [Resident 2] does get aggressive; I can tell a difference in her behaviors lately. She is more confused. During an interview on 12/16/25 at 10:15 am, Activity Director (AD) stated, Oh, I know [Resident 2]. She is having a lot of behaviors lately. I heard she is not taking her medicine, she thinks it is for someone else. I did hear [Resident 2] waved her hands at [Resident 3], but I don't know if she hit her. During a review of Resident 3's record titled, admission Record, 055656 Page 3 of 6 055656 12/16/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 3 was admitted the facility on 1/12/21 with diagnoses that included diabetes (too much sugar in the blood), anxiety, heart disease, Bi-polar disorder (a mental health condition causing severe mood swings), depression, high blood pressure, stage 4 chronic kidney disease (severe damage to the kidneys when they can no longer filter blood effectively), Nicotine use (smoking tobacco or cigarettes), and neuralgia (severe burning, stabbing, and shocks of pain from damaged nerves.) During a review of Resident 3's MDS, dated [DATE], indicated Resident 3 had a BIMS score of 15 of 15. This score indicated Resident 3 has no cognitive impairments and could make her own decisions. During an interview on 12/16/25 at 9:25 am, Licensed Nurse (LN) H stated, I know about the incident with [Resident 2]. She is confused, and she has behaviors, and just yells at times. She likes to block the hallways. She will not always take her medicine. [Resident 2] gets very defensive. [Resident 3] said [Resident 2] hit her. From what I understand [Resident 3] had no red marks or bruising on her mouth, and the video showed [Resident 2] waving her hands at her. During an interview on 12/16/25 at 9:30 am, LN C stated, I was here that day and I am the one who reported it immediately. I was at the cart in front of the nurses' station, and [Resident 3] came to see me, she was by room [ROOM NUMBER], and [Resident 2] was headed to the therapy room. I would say they just crossed paths. [Resident 3] said that [Resident 2] hit her in the face, but I did not see that. I wrote it down and I reported it. [Resident 3] is alert and oriented, but she also exaggerates. I know they don't like each other. She also said [Resident 2] called her a name. I don't doubt that because she does have behaviors. [Resident 3] was really mad because she called her a bad name. I reported it to the administrator. I think [Resident 3] was more mad than upset. I don't know for sure if it happened, but I report what I'm told. [Resident 2] can be very intimidating because she's unpredictable and she's very strong. This just all happened so fast, they have a history of arguing. During an interview on 12/16/25 at 9:42 am, Resident 3 stated, Yes, I remember the incident with [Resident 2]. I asked her nicely if she could move so I could get by. She called me a profanity name and hit me in the mouth. She did not hit me hard, but it is on video. She was waving and swinging her hands all around. I was in the hall; it was very embarrassing. No, I am not scared of her, I knew not to hit her back, but they need to keep her out of the halls where it is crowded. [Resident 2] has cussed at me before but never hit me. They say she is confused, but I think she knows what she is doing. I am not as mad as I was, it just gets frustrating. During an interview on 12/16/25 at 10:05 am, AA stated, I would describe [Resident 3] as sticking to herself, she likes to keep to herself. She can get inpatient waiting on staff to go smoke, but other than that, she is very friendly. During an interview on 12/16/25 at 10:18 am, AD stated, [Resident 3] likes to stay to herself and near the nurse's station, she enjoys the gossip from the staff. During an interview on 12/16/25 at 10:45 with the Director of Nursing (DON), DON stated, The problem is we could not see a clear view on the video of [Resident 2] hitting [Resident 3]. We could see [Resident 2] waving her hands close to [Resident 3]'s face and all around but if she did hit her it was not hard, maybe a light swat. During an interview on 12/16/25 at 10:50 am, the Admin stated, I was told [Resident 2] did not hit [Resident 3]. I confirm if [Resident 2] called [Resident 3] a profanity that is a type of verbal abuse. 055656 Page 4 of 6 055656 12/16/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record reviews, the facility failed to ensure the environment was free from hazards when they did not follow their laundry policies and procedures (P&P) and did not provide Laundry Tech (LT) A with required competencies (training and education). This had the potential to contribute to smoldering (burn slowly with smoke but no flames) laundry that was discovered in a laundry bag.Findings: A review of the facility's P&P titled, Laundry-Sorting, Washing and Drying, revised 1/1/12, indicated, dryers would be unloaded after the drying cycle was complete. The P&P indicated, to remove grease and stains, when needed, kitchen and housekeeping laundry would be pre-soaked in degreaser (a chemical that broke down grease and oil) or detergent, prior to washing. A review of the undated Laundry Tech, job description, indicated the LT would maintain a safe working environment. A review of the Full NFIRS v1.0 (fire department report), dated 12/1/25, indicated, the fire department arrived at the facility on 12/1/25 at 2:54 am due to facility staff smelling smoke in the laundry room. The fire department report indicated that the fire department captain felt heat coming from a laundry bag and relocated the laundry bag to the parking lot. The fire department report indicated that when the fire captain opened the laundry bag, the smoldering laundry ignited with flames, and the fire was immediately put out. During an interview on 12/12/25 at 11:32 am, the facility's previous Environmental Services Manager (PEVSM) stated, the drying cycle had a cooling period (switching from hot air to cool air) and when I came in the next day [12/2/25], the dryers didn't work. I found out the fire department had turned the breakers [an automatic safety switch] off. Once the dryers were turned back on, I had to reach out to [LT A] because the dryer timer indicated there was 20 minutes left on the [dryer] cycle. [LT A] told me she took the laundry out before the dryer was done and I educated her that you can't do that, it's too hot, and when you put it in a bag it could smolder. During an interview on 12/12/25 at 12:14 pm, LT B described the different washing machine cycles and stated that the washing machine chemicals were preset and dispensed for each cycle. Kitchen rags with grease, we pre-wash. LT B could not verbalize if the prewash cycle contained a degreaser or detergent and stated, we haven't been pre-soaking kitchen laundry, there is a pre-rinse cycle [prewash] built into the laundry cycle. During an interview on 12/12/25 at 2:13 pm, the Regional Operations Manager (ROM, oversaw the company that supplied the facility's washing machines) stated that all washing machine cycles start with a pre-wash. It's just warm water to remove chunky [food particles or residue from bowel movements] things that might come from patients. ROM confirmed, no detergent or degreaser was utilized during the washing machine's pre-wash cycle. During a concurrent observation and interview on 12/12/25 at 2:58 pm, located in the facility's laundry room, LT A was observed removing laundry from plastic bags and placing the laundry directly into the washing machine. LT A confirmed the laundry was housekeeping's, LT A had not performed a pre-soak per the facility's P&P, and was not aware of the P&P regarding washing kitchen and housekeeping's laundry. LT A stated no training had been provided. I was hired in August as a housekeeper and moved to laundry. LT A indicated, on 11/30/25, at the end of the shift (approximately 7:00 pm), prior to the dryer completing its entire cycle, LT A had removed the kitchen laundry from the dryer, immediately put the hot laundry in a laundry bag, and placed it near the door inside of the laundry room. LN A confirmed, having knowledge that the fire department had discovered a laundry bag that contained smoldering laundry and stated, I was thrown in, not aware of drying and cooling times until it happened. LT A could not verbalize when they transitioned from being a housekeeper to an LT and stated, We never do whole [drying] cycle and cool down. It went straight from the dryer to the plastic bag. I don't ever remember doing or signing competency forms, I was just thrown in. A review of LT's 055656 Page 5 of 6 055656 12/16/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few employee file indicated LT's hire date was 8/19/25. There was no documentation that indicated when LT A transitioned from housekeeper to LT. During a concurrent interview and record review on 12/12/25 at 3:19 pm, with Maintenance Supervisor (MS), LT A's Laundry Competency check list, dated 8/20/25 was reviewed. MS stated, I went down the [competency] list with her today. MS confirmed, the date on LT A's competency form indicated LT A's competency checklist was performed on 8/20/25 not 12/12/25. During a concurrent interview and record review on 12/12/25 at 3:35 pm, with Payroll (PR), LT A's Laundry Competency check list, dated 8/20/25 was reviewed. PR stated, it was given to me today. PR confirmed, PR placed the competency form into LT A's employee file on 12/12/25. During an interview on 12/16/25 at 9:55 am, PEVSM stated, [LT A] transitioned from housekeeping to laundry in September. I don't remember doing competencies with [LT A], if I did, I would have given it to PR. During an interview on 12/16/25 at 10:06 am, Administrator stated, [LT A's] competency was done Friday, 12/12/25, not 8/20/25. 055656 Page 6 of 6