Inspection Reports for
Oakmont of Fresno

The complaint was substantiated. Resident R1 was restricted from leaving the facility without approval from the Public Guardian, which was not authorized by a court order.

The investigation found that Resident R1 was restricted from leaving the facility on 2025-06-29 due to restrictions placed by the resident's Public Guardian without a court order. The facility followed the Public Guardian's instructions, and the allegation was substantiated. A deficiency was cited for violating residents' personal rights to leave the facility at any time.

The facility was found generally clean and in good repair with required equipment and supplies. However, deficiencies were cited related to medication storage and documentation practices, with some deficiencies amended or dismissed during the visit. Plans of Correction were developed and submitted.

The visit was triggered by an initial complaint and conducted as a complaint investigation. The deficiency cited is under appeal.

During the visit, a disposable razor was found stored in an unlocked bathroom cabinet in Memory Care resident apartments, which was immediately removed. A deficiency was cited related to the care of persons with dementia.

The facility was generally found to be in good repair with clean and properly equipped resident apartments and common areas. However, deficiencies were cited related to incidental medical and dental care, residents with special health needs, and storage space. Civil penalties were assessed for repeat violations.

The complaint investigation was substantiated for allegations that a resident fell due to staff neglect, the facility failed to prevent a resident from wandering off the premises, and the facility did not report a resident fall. Other allegations including questionable death, failure to notify authorized representatives timely, and failure to provide basic activities of daily living were unsubstantiated.

The investigation substantiated that the facility failed to follow a resident's hospice care plan resulting in a fall, did not prevent a resident from wandering off the premises, and failed to report the fall to the licensing agency. Other allegations related to basic care and notification were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for the allegation that staff mismanaged resident's medications due to inaccurate medication records. The allegation that incidents were not reported accurately was unsubstantiated.

The investigation substantiated the allegation that the Centrally Stored Medication and Destruction Record (CSMDR) for Resident 1 was not maintained accurately, resulting in inaccurate documentation and medication counts. Another allegation regarding inaccurate incident reporting was unsubstantiated. A deficiency was cited related to medication record-keeping.

The visit was complaint-related, following up on an incident where resident R1 went absent without leave. The incident was substantiated by the finding that the facility failed to provide required supervision.

The inspection confirmed that the facility did not ensure adequate care and supervision for resident R1, who left the facility unassisted despite a physician's report stating R1 cannot leave unassisted due to a diagnosis of Dementia. A deficiency was cited related to this failure.

The visit was triggered by a complaint (Control Number 24-AS-20230911151045). The deficiencies cited pose immediate health, safety, or personal rights risks to persons in care.

The facility was generally clean and well-maintained with proper resident accommodations and safety measures observed. However, deficiencies were cited related to medication storage and accessibility of cleaning supplies posing immediate health and safety risks.

The complaint investigation was substantiated for failure to conduct an assessment or obtain updated documentation for a resident returning from the hospital with a significant change in condition. Other allegations regarding supervision, fall prevention, signal system, and notification of responsible party were unsubstantiated.

The investigation found that the facility did not conduct an assessment or obtain updated documentation of the resident's changes in condition or care needs prior to the resident's return from the hospital. Allegations related to lack of supervision, failure to address multiple falls, signal system issues, and notification of the resident's authorized representative were unsubstantiated due to insufficient evidence.

The facility was generally found to be in compliance with required standards including resident room furnishings, hygiene supplies, kitchen cleanliness, and safety equipment. However, a deficiency was cited related to medication administration where extra pills were found without documentation, posing an immediate health and safety risk.

The facility failed to submit complete Special Incident Reports to the licensing agency within seven days for incidents dated 11/12/21, 11/13/21, 11/15/21, 11/28/21, and 9/14/21, posing a potential health and safety risk to persons in care.