Inspection Reports for
Oakmont Gardens

The inspection found ongoing deficiencies including medication room left unattended and unlocked with medications accessible to residents, pre-pouring of medications despite facility claims to have stopped, exposed walls with mildew odor posing health risks, and failure to document resident refusals of emergency medical services. Multiple Type A deficiencies were cited related to medication errors, resident rights, and facility safety.

The visit was complaint-related due to incident reports of medication errors affecting multiple residents. The facility was found to have substantiated medication errors caused by pre-pouring practices. Staff involved were disciplined, and corrective measures were planned and implemented.

The investigation found that medication errors occurred due to staff pre-pouring medications, resulting in seven residents receiving the wrong medications and one resident receiving medications late. The facility acknowledged ongoing issues with pre-pouring and has taken corrective actions including suspension of involved staff, planned additional training, staff meetings, audits, and elimination of pre-pouring medication boxes.

The complaint alleged staff did not respond to resident's request for assistance in a timely manner. The allegation was substantiated based on evidence including pendant call logs and interviews. The facility was cited under California Code of Regulations, Title 22, Division 6, and the Health and Safety Code.

The investigation found that resident R1 waited between 15 and 33 minutes for staff response after activating their pendant call, exceeding the facility's policy of responding within 10 minutes. The allegation was substantiated based on interviews and record reviews.

Complaint was substantiated. The facility water was turned off starting 5/11/25 and remained off for more than 24 hours. The facility did not notify the licensing agency as required and failed to fully implement their emergency disaster plan initially. Interim measures such as bottled water delivery and port-a-potties were provided. Water was restored on 5/12/25 at 8:30pm. The licensing analyst conducted a health and wellness check on 5/13/25 and found water fully operational.

The investigation substantiated the complaint that the facility water was shut off for more than 24 hours without immediately providing for residents' needs such as bathing and flushing toilets, posing an immediate health, safety, and personal rights risk. The facility did not notify the licensing agency of the water shut off and failed to fully engage their emergency disaster plan initially. Water service was restored on 5/12/25 at 8:30pm after delivery of bottled water, port-a-potties, and other interim measures.

The visit was complaint-related due to an incident report of resident R1 eloping from the facility and being found alone outside the facility property. The complaint was substantiated as the facility was found deficient in monitoring exits for residents at risk of elopement.

The facility was found to have failed to meet the requirement to have an auditory device or staff alert feature to monitor exits accessible to residents at risk for elopement, as evidenced by resident R1 eloping and being found outside the facility. The facility provided 1:1 care for R1 after the incident until the resident was no longer at the facility.

The facility was generally found to be clean and well-maintained with appropriate food storage and safety measures. However, several deficiencies were cited related to unlocked storage of disinfectants, incomplete staff training hours, missing fingerprint clearances for two staff members, and lack of required CPR/First Aid certification for some staff.

The visit was triggered by a complaint/incident report of a medication error submitted on 2024-07-19. The medication error was substantiated as the facility confirmed the incident and took corrective actions including staff termination and policy changes.

The investigation confirmed a medication error involving a resident receiving PRN Tramadol and scheduled Gabapentin without proper medication technician oversight. The resident did not exhibit adverse reactions. The facility terminated the involved staff, adjusted medication technician scheduling to cover all shifts, conducted staff training on medication administration policies, and is redesigning the medication room to improve safety.

The inspection identified multiple deficiencies including failure to assist residents with self-administered medications, incomplete staff training documentation, improper medication storage practices, lack of a hospice care plan for a resident on hospice, and outdated medical assessment for a resident with dementia.

The inspection found two deficiencies posing immediate health and safety risks: the facility lacked a qualified and currently certified administrator, and toxins were stored in an unlocked cabinet accessible to residents. Additionally, the facility retained a resident with dementia without a current exception on file.

The complaint investigation was initiated based on allegations that staff mismanaged resident R1's medications and failed to provide timely medical attention after a fall on 10/31/2023. Additional allegations included failure to respond timely to call bells and failure to meet reporting requirements. The medication and medical attention allegations were unsubstantiated, but the call bell response delays and reporting failures were substantiated.

The investigation found insufficient evidence to substantiate the medication mismanagement and delayed medical attention allegations, but substantiated that staff responses to call bells were often delayed and that the facility failed to provide required written incident reports to the resident's responsible person. Deficiencies related to personnel sufficiency and reporting requirements were cited.

The complaint alleged that staff did not respond to a resident's call button in a timely manner after the resident fell. The allegation was substantiated.

The investigation found that staff failed to respond timely to a resident's call button after a fall, with at least one incident showing a 94-minute delay. The allegation was substantiated based on the preponderance of evidence.

The visit was triggered by a complaint incident report regarding a resident (R1) who eloped from the facility on 10/22/2023 and was found with bruises and a scraped leg. The complaint was substantiated by findings of inadequate supervision and administrative deficiencies.

The investigation found that the resident left the facility unassisted during a period when caregivers were canceled without notifying staff, resulting in the resident's elopement and injury. The facility lacked a qualified and certified administrator, and the Executive Director did not have required fingerprint clearance. The facility updated the resident's care plan to include hourly checks to monitor wandering behavior.

The visit was complaint-related, investigating missing resident records. The deficiency was substantiated as the facility did not retain the required updated LIC 602 for Resident #1.

The inspection found that Resident #1 was missing the most recent LIC 602/Physician Assessment, which the facility failed to retain. This deficiency poses a potential health, safety, and personal rights risk to residents.

The complaint investigation was triggered by allegations that staff failed to meet residents' care needs and mismanaged a resident's medication. The medication mismanagement was substantiated, confirming that a resident was administered discontinued medications causing hospitalization. The care needs allegations were unsubstantiated.

The investigation found the first set of allegations regarding failure to meet care needs unsubstantiated due to insufficient evidence. However, the medication mismanagement allegations were substantiated, confirming that a resident was administered discontinued medications resulting in hospitalization. Deficiencies were cited and corrective actions were implemented.