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 facility was generally found to be clean and in good repair with required equipment and supplies. However, deficiencies were cited related to medication storage and documentation of PRN medication administration, with some deficiencies under appeal.

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 visit was triggered by an initial complaint. The report notes that citations on this visit report are under appeal but does not state substantiation status.

During the visit, a disposable razor was observed stored in an unlocked bathroom cabinet in Memory Care resident apartments, which was immediately removed. A deficiency was cited in the area of Care of Persons with Dementia.

The facility was generally found to be in good repair with proper furnishings, clean bathrooms, and appropriate storage of supplies. However, deficiencies were cited related to incidental medical and dental care services, medication storage, and storage space, including immediate health and safety risks such as missing medication and improper storage of medications and disinfectants.

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 related to resident falls due to staff neglect, failure to prevent wandering, and failure to report incidents. Other allegations such as questionable death, untimely notification to authorized representatives, and failure to provide basic activities of daily living were unsubstantiated.

The investigation substantiated that a resident's hospice care plan was not followed, resulting in a fall during a shower instead of a bed bath, and the facility failed to report the incident. Another resident was found wandering off the facility unassisted, posing a safety risk. Some allegations related to timely notification and provision of basic care were unsubstantiated due to insufficient evidence.

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 staff mismanagement of resident's medications due to inaccurate medication records. The allegation that incidents were not reported accurately was unsubstantiated.

The investigation substantiated that the facility failed to maintain accurate documentation and medication counts for centrally stored medications for Resident 1, posing a health and safety risk. Another allegation regarding inaccurate incident reporting was found to be unsubstantiated.

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 an incident where resident R1 went AWOL. The deficiency was substantiated and a Plan of Correction was developed and implemented.

The facility failed to 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 dementia. R1 was subsequently placed on the Wanderguard program and the deficiency was cleared during this visit.

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 10-Day complaint (Control Number 24-AS-20230911151045).

The inspection found deficiencies related to medication storage and storage of disinfectants and cleaning supplies accessible to residents, posing immediate health and safety risks. The facility was otherwise clean and well-maintained with proper safety measures observed.

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 complaint investigation was substantiated regarding the facility's failure to conduct an assessment prior to a resident's return from hospital after a fall and surgery. Other allegations about supervision, notification to responsible parties, and call system usage were unsubstantiated.

The investigation substantiated that the facility failed to conduct an assessment or obtain updated documentation for a resident (R1) who returned from the hospital with a significant change in condition, posing a potential health and safety risk. Other allegations related to supervision, notification of incidents, and use of call systems were unsubstantiated due to insufficient evidence.

The complaint was substantiated based on the preponderance of evidence standard. The allegation involved failure to assess a resident prior to returning from the hospital with a change of condition.

The investigation found that the facility did not conduct an assessment or obtain required updated documentation of the resident's changes in condition or care needs prior to the resident's return to the facility on 2023-05-06. The allegation was substantiated.

The complaint was substantiated based on the preponderance of evidence standard. The allegation involved failure to assess a resident after hospital discharge with a change in condition.

The investigation substantiated 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 on 2023-05-06. Deficiencies were cited accordingly.

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 was generally found to be in compliance with required standards including cleanliness, safety, and medication storage; 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 occurring on 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.

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.