Health inspection·January 14, 2026

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure seven Nurse's Aides (NA, in training not certified by state) were state certified prior to hiring and were competent to provide direct resident care independently.This had the potential for all residents not to have their care needs met and at risk for injury and harm when seven uncertified Nurse's Aides provided direct resident care and were not deemed by the State of California to be competent to provide direct resident care. Refer to 837.Findings: A review of the Nursing Assistant Job Description (undated) indicated, uncertified Nursing Assistants are expected to provide routine daily nursing care and services in which the nursing assistant has received clinical instruction and demonstrated competence. Job description stated, General duties and responsibilities (Direct resident care) cannot be performed until theory and competency skills are accomplished. NA qualifications include currently enrolled in Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification approved by the California Department of Public Health (CDPH) and nursing assistants need to maintain clinical competency while enrolled in a NA certification class. A review of Facility 3's records indicated it did not have a CDPH approved NATP program. A record review of active Certified Nursing assistant (CNA)/NA list (undated), indicated Facility 3's Nurse's Aide Training Program (NATP) graduation list (undated), employee files, and the California State Board for Certified Nursing Assistants registry on 1/8/2025, indicated: NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 11/19/2025. On 10/21/2025 NA 1 was assigned to residents in Rooms 33-37 to orient with CNA 4 from 2:30 pm to 10:30 pm. On10/22/2025 NA 1 was assigned to residents in Rooms 38-41 to orient with CNA 5 from 2:30 pm to 10:30 pm. On 10/23/2025 NA 1 was assigned a resident assignment unpaired with a CNA from 2:30 pm to 10:30 pm. NA 2 was hired on 9/5/2025, graduated from NATP 10/17/2025, and became certified on 11/19/2025. On 10/22/2025 NA 2 was assigned to residents in Rooms 33-37 to orient with CNA 6 from 6:30 am to 2:30 pm. On 10/23/2025 NA 2 was assigned to residents in Rooms 42-45 to orient with CNA 7 from 6:30 am to 2:30 pm. On 10/26/2025 NA 2 was assigned to residents in Rooms 1-10 to orient with CNA from 6:30 am to 2:30 pm. NA 3 was hired on 9/5/2025, graduated from NATP 10/17/2025, and became certified on 11/19/2025. On 10/24/2025 NA 3 was assigned to residents in Rooms 46-50 to orient with CNA 4 from 2:30 to 10:30 pm. On 10/25/2025 NA 3 was assigned to residents in Rooms 1-9 to orient with CNA 8 from 2:30 pm to 10:30 pm. On 11/17/2025 NA 3 was assigned to provide 1:1 (direct resident observation) for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. On 1/18/2025 NA 3 was assigned to provide 1:1 care for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. NA 4 was hired on 6/13/2025 and remains uncertified to date (1/13/2026). On 11/17/2025 NA 4 was assigned to a unit to work independently unpaired with specific CNA from 2:30 pm to 10:30 pm. On 11/18/2025 NA 4 was assigned to a unit to work independently Page 1 of 5 055656 055656 01/14/2026 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/22/2025 NA 4 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. NA 5 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and remained uncertified until their resignation on 12/8/2025. On 11/18/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/19/2025 NA 5 was assigned to provide 1:1 for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. On 11/22/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/23/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. NA 6 was hired on 11/10/2025, graduated from NATP on 12/19/2025, and remains uncertified to date (1/13/2026). NA 7 was hired on 11/20/2025, graduated from NATP on 12/19/2025, and remains uncertified to date (1/13/2026). A record review of Facility 3's December 2025 Schedule for 2:30 pm to 10:30 pm, had no listing of NA 6 or NA 7, however NA 6 and NA 7 were observed on 12/29/2025 at 2:15 pm at Facility 1 and interviewed on 12/29/2025 at 2:23 pm. During interviews with NA 6 and NA 7 on 12/29/2025 at 2:23 pm, NA 6 and NA 7 both stated they had recently graduated NATP at Facility 2 and are working as NAs at Facility 3 until they become certified as CNAs. NA 6 and NA 7 both stated, today is my first day. During interview with Director of Staff Development (DSD 1) on 12/5/2025 at 11:40 am, DSD 1 (works at Facility 3) stated Facility 2 interviews and hires 5 NA students per Nurse's Aide Training Program (NATP) cycle during the application process at Facility 2. DSD 1 explained the NATP was conducted through Facility 3 off campus. DSD 1 stated Facility 3 does not have an approved NATP and was not a clinical training site. DSD stated their knowledge of the NATP was very minimal. DSD 1 stated graduated Nurse's Aides can do everything a CNA can do except operate machinery like the Hoyer lift. DSD 1 stated the NAs can do one on one care, go to appointments with residents, and pretty much everything a CNA can do. During an interview with the Scheduler on 12/5/2025 at 11:46 am, Scheduler stated, NAs are scheduled to work full time and are filled into a CNA rotation slot in advance so they can transition into the CNA position already with their schedule.During an interview with Account Payable/Payroll Clerk (AP, time sheet verification technician) on 12/5/2025 at 12:08 pm, AP stated NAs in training (recently graduated NAs) are employees at Facility 3. During an interview with NA 4 on 12/8/2025 at 10:15 am, NA 4 stated their role as an NA was to assist CNAs with tasks such as transferring (mobilizing) and providing one-on-one care to residents. During an concurrent interview with NATP Instructor (NATP-I from Facility 2) and DSD 2 from Facility 2 on 12/23/2025 at 2 pm, NATP-I stated, uncertified NAs are not supposed to do direct resident care (hands on care) without the supervision of a CNA or licensed nurse until they are certified. NATP-I stated NAs are allowed to do direct resident care with a CNA present and are deemed NAs in training until they are certified at Facility 2. NATP-I and DSD 2 stated they were unaware that NA graduates were not permitted to work at Facility 1 or Facility 3 prior to becoming state certified. During an interview with CNA 3 on 12/29/2025 at 1:35 pm, CNA 3 stated NAs are allowed to feed residents. During an interview with NA 6 on 12/29/2025 at 2:20 pm, NA 6 stated they just graduated from NATP class at Facility 2 and it was their first day working at Facility 3. NA 6 was scheduled for the 2:30 pm to 10:30 pm shift. Assignments sheets requested from the Scheduler and were not provided for this date. During an interview with NA 7 on 12/29/2025 at 2:23 pm, NA 7 stated they recently graduated from the NATP through Facility 2 and were picked to work at Facility 3. A record review of Facility 2's December 2025 Schedule for 2:30 pm to 10:30 pm had no listing of NA 6 or NA 7. During an interview with NA 3 on 12/30/2025 at 11:09 am, NA 3 stated they performed direct resident care including touching and changing residents with CNA supervision. They stated their job duties changed following an incident in which a resident fell because of an NA using a Hoyer lift 055656 Page 2 of 5 055656 01/14/2026 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unsupervised by certified or licensed staff. They stated NAs are no longer allowed to provide direct resident care touching residents. NA 3 stated at first things got confusing, we were not sure what we could and couldn't do. NA 3 stated at that time they were unaware of who the DSD was.NA 3 stated the facility has not assessed skill competencies or provided orientation during their work as an NA. During an interview with Interim Administrator (IA) on 12/30/2025 at 12 pm, IA stated they have been working at Facility 3 since 11/11/2025 and they have recently ceased using uncertified NAs at the Facility 3 until the matter of training and competence is resolved. During an interview with the Governing Body (GB), with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, 2 and 3, Facility 2 was the only site that had an approved NATP program. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 1 and 3 was not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations. 055656 Page 3 of 5 055656 01/14/2026 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Governing Body (GB) failed to provide oversight for the Administrator to ensure seven Nurse's Aides (NA, in training not certified by state) were state certified and had the competencies required prior to providing care to residents independently.This had the potential to put all residents at risk of injury and harm and to not receive quality of care when seven NAs were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to

F728.Findings: A record review of the Operations Manual Administrative Policies dated 6/4/24, indicated the purpose was to ensure proper and lawful oversight of the facility. GB was responsible for appointing a facility administrator. GB was legally responsible for establishing and implementing policies and procedures regarding the management and operation of facility. The GB was responsible for providing Administrative Services who develop policies and procedures for the management and operation of the facility. A review of the Nursing Assistant Job Description (undated) indicated, uncertified Nursing Assistants are expected to provide routine daily nursing care and services in which the nursing assistant has received clinical instruction and demonstrated competence. Job description stated, General duties and responsibilities (Direct resident care) cannot be performed until theory and competency skills are accomplished. NA qualifications include currently enrolled in Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification approved by the California Department of Public Health (CDPH) and nursing assistants need to maintain clinical competency while enrolled in a NA certification class. A review of Facility 3's records indicated it did not have a CDPH approved NATP program. A record review of active Certified Nursing assistant (CNA)/NA list (undated), indicated Facility 3's Nurse's Aide Training Program (NATP) graduation list (undated), employee files, and the California State Board for Certified Nursing Assistants registry on 1/8/2025, indicated: NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 11/19/2025. On10/21/2025 NA 1 was assigned to residents in Rooms 33-37 to orient with CNA 4 from 2:30 pm to 10:30 pm. On10/22/2025 NA 1 was assigned to residents in Rooms 38-41 to orient with CNA 5 from 2:30 pm to 10:30 pm. On 10/23/2025 NA 1 was assigned a resident assignment unpaired with a CNA from 2:30 pm to 10:30 pm. NA 2 was hired on 9/5/2025, graduated from NATP 10/17/2025, and became certified on 11/19/2025. On 10/22/2025 NA 2 was assigned to residents in Rooms 33-37 to orient with CNA 6 from 6:30 am to 2:30 pm. On 10/23/2025 NA 2 was assigned to residents in Rooms 42-45 to orient with CNA 7 from 6:30 am to 2:30 pm. On 10/26/2025 NA 2 was assigned to residents in Rooms 1-10 to orient with CNA from 6:30 am to 2:30 pm. NA 3 was hired on 9/5/2025, graduated from NATP 10/17/2025, and became certified on 11/19/2025. On 10/24/2025 NA 3 was assigned to residents in Rooms 46-50 to orient with CNA 4 from 2:30 to 10:30 pm. On 10/25/2025 NA 3 was assigned to residents in rooms 1-9 to orient with CNA 8 from 2:30 pm to 10:30 pm. On 11/17/2025 NA 3 was assigned to provide 1:1 (direct resident observation) for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. On 1/18/2025 NA 3 was assigned to provide 1:1 care for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. NA 4 was hired on 6/13/2025 and remains uncertified to date (1/13/2026). On 11/17/2025 NA 4 was assigned to a unit to work independently unpaired with specific CNA from 2:30 pm to 10:30 pm. On 11/18/2025 NA 4 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/22/2025 NA 4 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. NA 5 was hired on 9/5/2025, graduated from NATP on 10/17/2025, 055656 Page 4 of 5 055656 01/14/2026 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and remained uncertified until their resignation on 12/8/2025. On 11/18/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/19/2025 NA 5 was assigned to provide 1:1 for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. On 11/22/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/23/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. NA 6 was hired on 11/10/2025, graduated from NATP on 12/19/2025, and remains uncertified to date (1/13/2026). NA 7 was hired on 11/20/2025, graduated from NATP on 12/19/2025, and remains uncertified to date (1/13/2026).During interview with Director of Staff Development (DSD 1) on 12/5/2025 at 11:40 am, DSD 1 (works at Facility 3) stated Facility 2 interviews and hires 5 NA students per Nurse's Aide Training Program (NATP) cycle during the application process at Facility 2. DSD 1 explained that the NATP was conducted through Facility 2 (had an approved CDPH NATP) off campus. DSD 1 stated Facility 3 does not have an approved NATP and was not a clinical training site. DSD stated their knowledge of the NATP was very minimal. DSD 1 stated graduated Nurse's Aides can do everything a CNA can do except operate machinery like the Hoyer lift. DSD 1 stated the NAs can do one on one care, go to appointments with residents, and pretty much everything a CNA can do. During an interview with the Scheduler on 12/5/2025 at 11:46 am, Scheduler stated, NAs are scheduled to work full time and are filled into a CNA rotation slot in advance so they can transition into the CNA position already with their schedule.During an interview with Account Payable/Payroll Clerk (AP, time sheet verification technician) on 12/5/2025 at 12:08 pm, AP stated NAs in training (recently graduated NAs) are employees at Facility 3. During an interview with Interim Administrator (IA) on 12/30/2025 at 1:35 pm, IA stated they have been working at Facility 3 since 11/11/2025. IA stated Facility 3 has stopped NAs working at the facility until the matter of training and competence was resolved. During an interview with the Governing Body (GB), with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, 2 and 3, Facility 2 was the only site that had an approved NATP program. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 1 and 3 was not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations. 055656 Page 5 of 5