Oakmont Gardens

§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs...This requirement not met by licensee as evidenced by: Based on LPA record review of facility's pendant/call button system log, the licensee did not comply with the section cited above in that between 12/14/25 and 1/15/26 residents pushed their pendant call button at least 1541 times. Of those 1541 times, residents waited over 50 minutes at least 114 times, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in that S5 and S6 did not have 1st Aid certificates on file, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in that all seven (7) staff did not have Health Screens on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in that R1, R2, R3, and R4 do not have current physician's reports on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that disinfectants and cleaning solutions were observed in unlocked cabinet in ancillary Assisted Living Dining room, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that Main kitchen disposal sink has an active leak and hot box door does not properly latch or seal shut, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that food items such as ice cream, bread, rice, tortillas, chopped onions, chopped tomatoes, prepared steaks, and chopped greens were all found uncovered and/or in open unsealed bags/bins, which poses a potential health, safety or personal rights risk to persons in 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 to persons other than employees responsible for the supervision of the centrally stored medication This requirement not met by licensee as evidenced by: based on LPA observation medication room left unattended, door unlocked, and with medications accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement not met by licensee as evidenced by: Based on LPA and HWD interview, staff are pre-pouring medications, resulting in medication errors, which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: residents R1, R2, R3, R4, R5, R6, and R7 were each administered the wrong medication, which poses an immediate health, safety or personal rights risk to persons in care

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs...This requirement not met by licensee as evidenced by: R1 waited in excess of 33 minutes for staff response after activating pendant alert for assistance, which poses an immediate health, safety or personal rights risk to persons in care.

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement not met by licensee as evidenced by: Based on LPA observation, black and white fuzzy substance that appears wet and dark in color and has the odor of mildew, found inside exposed walls in hallway by rooms #113-#116, which poses an immediate health, safety or personal rights risk to persons in care.

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs...This requirement not met by licensee as evidenced by: R1 waited in excess of 33 minutes for staff response after activating pendant alert for assistance, which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: residents R1, R2, R3, R4, R5, R6, and R7 were each administered the wrong medication, which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement not met by licensee as evidenced by: Based on LPA and HWD interview, staff are pre-pouring medications, resulting in medication errors, which poses an immediate health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... This requriement not met by licensee as evidenced by: R1 eloped from facility and was found alone outside of facility property, which poses an immediate health, safety or personal rights risk to persons 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 was not met by licensee as evidenced by: facility water shut off for more than 24hrs without immediately providing for residents needs that require access to running water like bathing and flushing toilets, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, S5, S6, and S7 did not have the required hours of training completed, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation, the licensee did not comply with the section cited above in that disinfectants and cleaning solutions were observed in unlocked cabinet in ancillary Assisted Living Dining room, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, S5, and S6 did not have 1st Aid/CPR on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1 and S2 did not have fingerprint clearance on file and were not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed.This requirement not met by licensee as evidenced by: Based on facility's submitted incident report reporting medication error, which poses an immediate health, safety or personal rights risk to persons in care

Based on LPA, HWD, and Med Tech observation and record review, resident R2 missed two [2] doses of Acetaminophen 325mg, Amlodipine 2.5 mg, and Furosemide 20 mg, respectively. Doses present in bubble packs, but documented as given to R2. Therefore, the licensee did not comply with the section cited above in [1] out of [5] residents reviewed which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observation and record review, as well as interview with ED, the licensee did not comply with the section cited above in [5] out of [5] staff files reviewed. Five [5] out of five [5] staff files either were missing the training log entirely, or the training log present did not show the number of training hours completed, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA interview with HWD and Med Tech, the licensee did not comply with the section cited above as facility is currently pre-pouring medications, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA observation and record review, as well as interview with HWD, the licensee did not comply with the section cited above in [1] out of [1] resident (R1) on hospice. R1 has been on hospice beginning 11/20/2023 but did not have a Hospice care plan on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA observation and record review, the licensee did not comply with the section cited above in [1] out of [1] resident (R4) with a diagnosis of dementia, LIC602 Physican's Report for R4 dated 2021,which poses a potential health, safety or personal rights risk to person in care.

Based on LPA observation, 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.

Based on LPA observation, the licensee did not comply with the section cited above as toxins accessible to residents in Ancillary Assisted Living Dining Area. Toxins stored in cabinet under/around sink area was not locked. which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [1] residents. R4 has DX of dementia but facility does not retain residents with dementia and facility does not have a current exception on file to retain resident with DX of demntia, which poses/posed a potential health, safety or personal rights risk to persons in care.

Reporting Requirements…. A written report shall be submitted.. to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D…***Based upon statements made and documents reviewed, this requirement has not been met as evidenced by: R1’s Responsible Person states RP did not receive a copy of the Incident Report for 10/31 and the Report does not indicate a copy was provided to the Responsible Person. This posed a potential risk to the personal rights of R1.

Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ***This requirement has not been met as evidenced by: Based upon review of call log records, out of 22 responses for calls to R1’s room in October, 2023, six exceeded 25 minutes and one was 126 minutes. This posed an immediate risk to the health and safety of residents in care.

87411(a)Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....Licensee did not meet this requirement as evidenced by: Based on interview staff did not respond to a resident's call button in a timely manner.

Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator. Licensee did not meet this requirement as evidenced by; LPA interview with ED and record review, facility does not have a currently qualified and certified administrator. This poses an immediate Health, Safety or Personal rights risk to residents.

Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted. Licensee did not meet this requirement as evidenced by; based on DOJ database report, Executive Director does not have fingerprint clearance.

Personnel Requirements – General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not meet this requirement as evidenced by; elopement of resident. This poses an immediate Health, Safety or Personal rights risk to residents.

87506(a)(10) Resident Records:(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.(10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. This requirement was not met as evidenced by:During the course of the complaint investigation, LPA reviewed documents and determined that Resident #1 was missing the most recent LIC 602/Physician Assessment. During the delivery of complaint findings on July 31, 2023, LPA requested to review the most recent LIC 602 for Resident #1. The Administrator disclosed to the LPA that the LIC 602 was unavailable for viewing due to the facility not retaining the updated LIC 602. This is a potential Health, Safety and Personal Rights risk to the residents in care.

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. ***Based on statements and records, this requirement has not been met as evidenced by:R1 was given medications that had been ordered discontinued by physician. This posed an immediate risk to the health of R1

87464(f)(1)(c) Basic Services. "Care and supervision" means the facility assumes responsibility for...Assistance includes assistance with taking medications, money management, or personal care. ***Based on statements and records, this requirement has not been met as evidenced by: R1 was given medications that had been discontinued by physician. This posed an immediate risk to the health of R1.