Health inspection·December 23, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review, the facility failed to ensure that physician ordered wound care was provided as prescribed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 missed wound care for one day.Findings:Resident 1 was admitted in March 2025 with diagnoses including diabetes mellitus (difficulty in blood sugar control and poor wound healing), bullous pemphigoid (autoimmune skin disease causing large blisters), diabetic ulcer (open sore in people with diabetes), bipolar disorder (extreme mood swings) and obsessive compulsive disorder (general pattern of concern with orderliness, perfectionism, and control). Resident 1 had a history to refused wound care from other nurses unless it was provided by Treatment Nurse (TN) 2. A review of Resident 1's Order Summary Report (OSR) dated 3/7/25 indicated, Resident has capacity to make her decisionsA review of Resident 1's Discontinued Order Summary indicated, Order date: 12/3/25 Start date: 12/5/25 Discontinued date: 12/19/2025 for the following treatment order:1. Tx [Treatment] Order : Right lower legs chronic diabetic wounds: Cleanse wounds with n/s [normal saline], pat dry. Apply zinc oxide to open areas ,Cover with ABD pads [abdominal pad, a large, highly absorbent bandage], secure with roll gauze and ACE wrap [a stretchy, reusable bandage to provide compression and support] wrap. Change 3x a week and PRN [pro re nata means as needed] soiling. Notify Md [Medical Doctor] for any worsening or s/s [signs/symptoms] of infection. every (sic) day shift every Mon, Wed, Fri for treatment and moitoring (sic) for 14 Days2. Tx order: left dorsal foot/ toes- Cleanse wounds with n/s, pat dry. Apply zinc oxide, Apply Super absorbent pad. Gauze between the toes, secure with roll gauze and ACE wrap. Change 3x a week and PRN soiling. NOtify (sic) MD for any changes. every day shift every Mon, Wed, Fri for 14 Days.3. Tx order: Left lower legsCleanse wounds with n/s, pat dry. Apply zinc oxide, Apply Super absorbent pad. Gauze between the toes, secure with roll gauze and ACE wrap. Change 3x a week and PRN soiling. NOtify (sic) MD for any changes. every day shift every Mon, Wed, Fri for 14 Days4. Tx order: right dorsal foot/ toes- Cleanse wounds with n/s, pat dry. Apply zinc oxide, Apply Super absorbent pad. Gauze between the toes, secure with roll gauze and ACE wrap. Change 3x a week and PRN soiling. NOtify (sic) MD for any changes. every day shift every Mon, Wed, Fri for 14 DaysA review of Resident 1's Treatment Administration Record (TAR) for the above prescribed wound care orders included a blank space on 12/12/25 which indicated that the wound care treatment was not executed. During an interview with Licensed Nurse (LN) 1 on 12/23/25 at 10:21 a.m., LN 1 stated that Resident 1 often refused wound care if the treatment nurse was not TN 2. LN 1 stated she did not remember the exact date when Resident 1 missed a wound care treatment. LN 1 explained that she learned about the missed treatment when TN 2 told her that Resident 1 had missed wound care the previous week. LN 1 also indicated this was the only missed wound care treatment she knew about. During an interview with Resident 1 on 12/23/25 at 11:13 a.m., Resident 1 stated she was not sure if there had been a miscommunication, but no one came to provide her wound care treatment last week. During a concurrent interview and record review with the Director of Nursing (DON) on 12/23/25 at 1:30 p.m., the Residents Affected - Few Page 1 of 2 056410 056410 12/23/2025 Whitney Oaks Care Center 3529 Walnut Avenue Carmichael, CA 95608

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON stated that a blank space in the TAR for 12/12/25 meant the treatment was missed. The DON stated that on 12/12/25, one treatment nurse called off work, so the Charge Nurse gave the wound care instead. The DON further stated that treatment nurses usually document if Resident 1 refused wound care however there was no documentation on 12/12/25 that the resident refused. A review of the facility's policy and procedure (P&P) titled Dressings, Dry/Clean revised September 2013 indicated, 1. Notify the supervisor if the resident refuses the dressing change. 2. Report other information in accordance with facility policy and professional standards of practice. 056410 Page 2 of 2