Oakmont of Valencia

Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.

Based on observation and medication record review, the licensee did not comply with the section cited above in [14] out of [101] medication record review, (6) records showed the initial dates of medication administration did not align with the actual medication counts, resulting in off-count errors, which poses an immediate health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving inhaler according to doctor's orders. This is an immediate health and safety risk to residents in care.

Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.

Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist... following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR was submitted: (8) residents were not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...Knowledge required to safely assist with prescribed medications which are self-administered... This requirement was not met as evidence by: based on a SIR submitted to Licensing, it was reported (8) residents missed their daily medication. This poses as an immediate health and safety risk to residents in care.

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...Knowledge required to safely assist with prescribed medications which are self-administered... This requirement was not met as evidence by: It was reported to Licensing staff #1 administered the wrong medication to resident #1. This poses as an immediate health and safety risk to residents in care.

Personal Rights of Residents in All Facilities: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings...This requirement is not met as evidenced by: Based on LPA Ruiz inspection, during the initial visit, the licensee did not comply with the section cited above. Staff failed to clean R1’s shoes, saturated with diarrhea, which was found in the cabinet with R1’s toothbrush This poses/posed a potential health and safety risk to persons in care.

Managed Incontinence: (b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.This requirement is not met as evidenced by: Based on LPA Ruiz inspection/observation, during the initial visit, licensee did not comply with the section cited above by having a strong odor of feces/urine in room #122B and Memory Care Unit. This poses/posed a potential health and safety risk to persons in care.

Personal Accommodations & Services:(a) Living accommodations and grounds shall be... Equipment and supplies necessary for personal care and maintenance of adequate hygiene... (C) Clean linen… shall be in good repair.This requirement is not met as evidenced by: Based on interview/observation conducted by LPA Ruiz, licensee did't comply with the section cited above by purchasing a laundry detergent that damaged residents personal items; clothing, bedsheets, which posed a potential health and safety risk to persons in care.

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 ...and disposition of the case. This requirement was not met evidenced; based on documentation and interviews, facility submited one SIR for R1 when there were multiple falls. This is a potential health and safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on records reviewed and interviews, it was determined that R2 choked or physically grabbed R1 by the neck. Additionally, there was a previous incident report that stated on 2/10/23, R2 was caught in R1's bedroom. The behavior issues exhibited by R2 towards R1 posess an immediate health and safety risk or personal rights risk to residents in care.

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...This requirement was not met as evidence by: (4) Knowledge required to safely assist with prescribed medications...Staff #1 administered the wrong medication to resident #1. This poses as an immediate health and safety risk to residents in care.

Care of Persons with Dementia(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.This requirement is not met as evidenced by: Based on the information obtained, by the Investigator, Licensee/Administrator did not comply with the section cited above by knowing that R1 needed 1:1 staffing and did not put into current appraisal as the appraisal was never updated, which poses/posed an immediate health and safety risk to residents is care.

Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia... (5) Each resident with dementia... A) When any medical assessment... ...corresponding changes shall be made...This requirement is not met as evidenced by: Based on the information obtained, by the Investigator, licensee did not comply with the section cited above by failing to provide an updated care plan to address R1's chronic falls, which poses/posed an immediate health and safety risk to residents in care.

87405 Administrator - Qualifications and Duties(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. Based on the investigation, the Administrator/Executive Director did not comply with the section cited above, failing to follow and carry out medication policy, which poses/posed an immediate health and safety risk to residents in care.

87411 Personnel Requirements-General(d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following... (4) Knowledge required to safely assist with prescribed medications...This requirement was not met as evidence by: Based on the investigation, the licensee did not comply with the section cited above, for Staff #1 (S1), which poses/posed an immediate health and safety risk to residents in care.

87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. Based on review of documentation during investigation, the licensee did not comply with the section cited above by not completing a resident appraisal due to changes in R1’s medical condition that required the assistance with medications management, which poses/posed a potential health and safety risk to residents in care.

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health....This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses/posed an immediate health and safety risk to residents in care.

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above by not having a staff regularly check on or document any changes as agreed upon, which poses an immediate health and safety risk to residents in care.

Basic Services: (b)(2) "Basic Services," as defined in Health and Safety Code section 1569.312, means those services required to be provided by the facility in order to obtain and maintain a license and in such combinations as may meet the needs...This requirement was not met as evidenced by: Based on information obtained during the course of the investigation licensee failed to protect R2 from being assaulted by R1 which poses an immediate health, safety and personal risk to persons in care.

87211(a)(1) A,B & D Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by failing to notify CCLD regarding the incident that occured on 11/06/22 which poses a potential health and safety risk to persons in care.

Basic Services: (3) "Care and Supervision" means those activities which if provided shall require the facility… It involves assistance as needed with activities of daily living… (F) Supervision of resident schedules and activities;This requirement was not met as evidenced by: Based on information obtained during the course of the investigation S1 did not comply with the cited section by neglecting and leaving demetia residents unsupervised which led R1 to fall and sustain severe hip fracture that resulted in surgery.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions...This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses an immediate health and safety risk to residents in care.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions...This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses a potential health and safety rist to residents in care.

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on LPAs observation during the visit made on 07/27/22 the licensee did not comply with the section cited above. Resident’s pendant and/or emergency cord devices in both Memory Care Units were in poor repair and non-operational, which poses a potential health and safety risk to persons in care.

87211(a)(1) Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (D)...This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA during the visit made on 09/01/22, the licensee did not comply with the section cited above by failing to notify residents responsible party (in writing) about the incident within seven (7) days of the occurence, which poses a potential health and safety risk to persons in care.

87211(a)(1) A,B & D Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA during the visit made on 09/01/22, the licensee did not comply with the section cited above by failing to notify CCLD regarding the twelve incidents that occured between 08/03/22 -08/22/22, which poses a potential health and safety risk to persons in care.

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors... (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by failing to ensure the safety of resident who wondered away from the facility, which poses an immediate health, safety and personal risk to persons in care.

Specifically for a terminally ill resident that is receiving hospice services… For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met as evidenced by: Based on the information obtained during the course of the investigation the licensee/Administrator did not comply with the section cited by failing to call 911 when R1 was experiencing severe pain resulting from an unexplained injury which posed an immediate health and safety and personal rights risk to R1.

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457....... This requirement was not met as evidenced by: Based on information obtained during the course of the investigation the staff did not comply with the cited section by neglecting to put the footrests on R1’s wheelchair causing R1 to reportedly put foot down, fall forward and sustain severe facial injuries which posed an immediate health and safety and personal rights risk to R1.

Posting requirements 1569.33(h)(2)(2) Each residential care facility for the elderly shall post this poster in the main entryway of its facility.This requirement was not met as evidenced by Based on observations made by LPA on 1/11/22 at 11:09am, the licensee did not comply with the section cited above, in posting the Ombudsman’s poster in the main entryway, which posed a potential health, safety risk to persons in care.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions...This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses a potential health and safety rist to residents in care.

§1569.69 Employees assisting residents with self-administration of medication; training requirements (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training....This requirement is not met as evidenced by: Based on record review and interviews, licensee failed to ensure staff were provided the required 24 hours of initial training, which poses a potential health and safety risk to residents in care.

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors... (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by failing to ensure the safety of resident who wondered away from the facility, which poses an immediate health, safety and personal risk to persons in care.