Oakmont of North Fresno

Freedom to leave and not be locked in

87468.1 Personal Rights of Residents in All Facilities (a) Residents... (6) to leave or depart the facility at any time… This does not prohibit a licensee from establishing house rules..., This requirement was not met as evidenced by: Licensee did not ensure all residents could leave the facility at any time. On 6/29/25, R1 was restricted from leaving the facility to attend church per a restriction placed without a court order by the Public Guardian. This poses a potential health & safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. R1 Docusate 100mg caps - start date noted as 4/16/25. 7 had beed given. Only 1 cap had been documented on 4/29/25 PRN MAR. Unknown when the other 6 were given. Start date confirmed on centrally stored log with MT.

Store toxic and hazardous substances safely

THIS DEFICIENCY HAS BEEN AMENDED FROM TYPE A TO TYPE BBased on observation and record review, the licensee did not comply with the section cited above which poses/posed a POTENTIAL health, safety or personal rights risk to persons in care. LPA observed Gummy vitamins and medicated creams in R3's bathroom cabinet. Physician Report dated 6/6/24: Able to store own medications - No.

THIS DEFICIENCY HAS BEEN DISMISSED

Assist residents with self-administered medication

Based on interview and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. R5's Spiriva Respimat inhaler was not able to be located. Based on the MAR, it has been given as ordered, Centrally stored log start date is 1/29/24. The inhaler has 60 doses which means it would have run out in approximately a month. Today AM Med Tech did not assist R5 with the inhaler.

Store centrally held medications in locked secure place

Based on observation and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Over the counter medications were stored in the apartment shared by R1 and R2. R2 is current in the hospital. R1 receives medication assistance by the facility, has a diagnosis of Dementia and Physician Report states R1 cannot store own medication. R4 also had medications stored in bathroom cabinets.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. Mold was observed in the upper portion of the ice machine. A chefs knife was observed in the prep area of the dining room with no staff member present. Disinfecting supplies were located in the bathroom cabinet of R3, who has a diagnosis of Dementia.

Each terminal resident needs a written hospice care plan

87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted... receive hospice services from a hospice agency in the facility…(4) A written hospice care plan which specifies the care, services... all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by: Licensee did not ensure R1's hospice care plan was implemented. R1 received a shower by staff and hospice aid of the wrong agency. R1's careplan specifies a bed bath to be given. R1 sustained a fall during this shower.This poses an immediate health & safety risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports… (1) A written report shall be submitted… (D) Any incident which threatens the welfare, safety or health of any resident…This requirement was not met as evidenced by: Licensee did not ensure an Incident Report was submitted to CCLD when R1 fell and hit head while receiving a shower by the wrong hospice agency and facility staff member.This poses a potential health & safety risk to persons in care

Resident care and supervision skills

87411 Personnel Requirements – General(d) All personnel shall be given on the job training…training shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision..., This requirement was not met as evidenced by: Licensee did not ensure supervision of R2 who exited the Dementia wing and walked out of the facility on 3/10/23. R1's whereabouts were unknown by the facility. This poses an immediate health & safety risk to persons in care.

Maintain records of centrally stored medication dosages

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… by compliance with the following: (6) When requested... or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by: Licensee did not ensure that a record was maintained of medications that were centrally stored for R1. Multiple medications were accepted and stored by the facility but an accurate/up to date Centrally Stored Medication and Destruction Record (CSMDR) was not maintained. Received and start dates are not recorded for multiple medications from April-August 2023. This poses a potential health & safety risk to persons in care.

§1569.312 Basic services requirementsEvery facility required to be licensed under this chapter shall provide at least the following basic services:(a) Care and supervision as defined in Section 1569.2.*This requirement was not met as evidenced by: Licensee did not ensure the care and supervision to R1. R1 AWOL the facility 10/12/23. R1's Physician's Report (PR) states R1 cannot leave the facility unassisted. Per PR, R1 has diagnosis of Dementia. This poses a potential health and safety risk to residents in care

Ensure hazardous items are locked and not unattended

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidenced by: Licensee did not ensure that disinfectants, cleaning supplies and poisons… were inaccessible to residents in Memory Care. Cleaning supplies and laundry detergent were observed in 116.This poses an immediate health, safety or personal rights risk to residents in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible...The requirement was not met as evidenced by: Licensee did not ensure that medications were centrally stored and locked. Over the counter medications were observed accessible to R1 and R2. Required documentation and assessments were not maintained in resident files.This poses an immediate health, safety or personal rights risk to persons in care.

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ... The reappraisals shall document changes in the resident's physical, medical,(3) Any illness, injury, trauma, or change in the health care needs… This requirement was not met as evidenced by: R1 was accepted back to the facility with a significant change prior to the facility conducting an assessment or Home Health plan of care in place. This poses a potential health & safety risk to persons in care.

Give PRN medication by physician order

Based on record review of 2 resident Centrally Stored Medication Log and Medication Administration Record (MAR) the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Additionally, LPA Kaur conducted a pill count which identified that there were extra pills that had not been given with no documentation as to why. MAR indicated that all meds were given on time.

Report specified resident events within seven days

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.The requirement was not met as evidenced by Licensee did not submit complete Special Incident Reports to to CCLD within 7 days. Incident dates include 11/12/21, 11/13/21, 11/15/21, 11/28/21 and 9/14/21.This poses a potential health & safety risk to persons in care.