Inspection Reports for Oakmont of Lodi

The visit was an unannounced Plan of Correction (POC) follow-up conducted to verify correction of deficiencies cited from a prior complaint investigation on 2025-09-25.

No further deficiencies were observed or cited during this Plan of Correction visit. The facility provided a Plan of Correction clearance letter to the designated administrator.

The visit was a follow-up on deficiencies cited from a prior complaint conducted on 2025-09-25.

The visit was an unannounced case management visit conducted as a quarterly follow-up to increased monitoring requirements from a Non Compliance Conference held on 03/25/2024, focusing on medication errors, staffing concerns, reporting requirements, and medication training.

The inspection found that the facility had ongoing issues related to medication management, including missed medications and incomplete centrally stored medication logs. Staffing levels were generally adequate but with some concerns about care assistance coverage. Several resident incident reports related to falls were reviewed, with care plans updated accordingly. Citations were issued related to a complaint about medication mismanagement, but no citations resulted directly from this visit.

The visit was related to a complaint regarding mismanagement of medications. Citations were issued in relation to this complaint, and findings from the visit were incorporated into that complaint. No citations were issued solely as a result of this visit.

Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior case management visit/Legal Non Compliance conducted on 2025-06-19 and to verify the Plan of Correction that was due.

The Plan of Correction visit found no further deficiencies; the previously cited deficiency regarding the lack of a plan for incidental medical and dental care and assistance with self-administered medications was addressed and cleared.

Unannounced case management visit conducted as a quarterly visit following a Non Compliance Conference on 03/25/2024, with increased monitoring required. The visit focused on medication errors, staffing concerns, reporting requirements, medication training, and facility policies regarding assessments, monitoring of residents, change in condition, and medication errors.

The inspection found deficiencies related to medication administration, including missing or incorrect narcotics count entries, incomplete documentation, and medications not dispensed as prescribed, posing an immediate risk to resident health and safety. Caregiver task documentation was also incomplete or improperly filled out. A civil penalty of $1000 was assessed for a repeat violation.

Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior complaint visit conducted on 2025-04-28 and to verify the Plan of Correction that was due.

No further deficiencies were observed or cited during the Plan of Correction visit. The prior deficiencies related to ensuring incontinent residents are checked during known incontinent periods, including night time.

Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior complaint visit conducted on 2025-02-21 and to verify the Plan of Correction that was due.

The prior deficiencies related to the lack of a plan for incidental medical and dental care and assistance with self-administered medications were addressed. No further deficiencies were observed during this Plan of Correction visit.

The visit was a follow-up on deficiencies cited from a prior complaint visit conducted on 2025-02-21.

The visit was an unannounced Case Management follow-up to a report concerning a facility resident requiring care and supervision related to a Restricted Health Condition.

The review confirmed that the facility had an appropriate care plan in place with trained individuals involved, and no deficiencies were observed or cited during this visit.

The visit was an unannounced case management visit conducted as a quarterly monitoring visit following a Non Compliance Conference held on 2024-03-25, with a focus on medication errors, staffing concerns, reporting requirements, medication training, and facility policies regarding assessments, monitoring of residents, change in condition, and medication errors.

The inspection found deficiencies related to medication administration, including missing required names/initials for narcotics counts, omitted or incorrect dates, and medications not dispensed as prescribed, posing an immediate risk to residents. A civil penalty of $250 was assessed for a repeat violation.

Unannounced case management visit conducted to follow up on a substantiated allegation from a prior complaint investigation regarding failure to provide care and supervision.

The Department determined that the facility failed to monitor a resident (R1), resulting in serious bodily injury requiring hospitalization and rehabilitation. A civil penalty of $9,500 was issued in addition to a prior immediate penalty of $500.

The visit was a follow-up to a substantiated complaint investigation concluded on January 17, 2024, which found the facility failed to provide care and supervision to Resident (R1). The complaint was substantiated and resulted in an immediate civil penalty and further penalties for serious bodily injury.

Unannounced Plan of Correction visit conducted to follow up on deficiencies cited from a prior complaint visit on 2024-12-12 and to verify the Plan of Correction that was due.

No further deficiencies were observed or cited during this Plan of Correction visit. The previously cited deficiency related to staffing sufficiency and competency was addressed and cleared.

The visit was a follow-up on deficiencies cited from a prior complaint visit conducted on 2024-12-12.

The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that the licensee does not ensure enough staff are present to prevent inappropriate interaction between residents.

The investigation found that residents R1 and R2, both with cognitive impairments, had a mutual, non-forced relationship seeking comfort from each other. The allegation was found to be unsubstantiated with no deficiencies observed or cited.

The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.

Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior annual visit conducted on 2024-10-17 and to verify the Plan of Correction that was due.

No further deficiencies were observed or cited during the Plan of Correction visit. The previously cited deficiencies related to staffing with CPR training, medication administration per physician orders, and resident record documentation were addressed.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding improper isolation of residents, lack of toiletries in restrooms, and inadequate facility cleanliness and sanitation.

The investigation found the allegations to be unsubstantiated with no deficiencies observed or cited. The facility had adequate supplies in restrooms and appropriate infection control policies and staff training were in place.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding staff training, medication administration, timely medication ordering, and staff retaliation against residents.

The investigation found the allegations of inadequate staff training, medication administration errors, untimely medication ordering, and staff retaliation to be unsubstantiated except for the allegation that there were not enough staff to provide care and supervision, which was substantiated. The facility was found deficient in staffing levels posing an immediate threat to resident health and safety.

The complaint investigation was triggered by allegations received on 09/25/2024 concerning inadequate staff training, medication administration errors, untimely medication ordering, staff retaliation, and insufficient staffing. The allegation of insufficient staffing was substantiated, while the others were unsubstantiated.

Unannounced annual visit conducted on 10/17/2024 to evaluate compliance with licensing requirements and facility operations.

The inspection found deficiencies related to staff training in First Aid, incomplete narcotic medication documentation, and missing required forms in resident files. Plans of correction were submitted with due dates for compliance.

Unannounced case management visit conducted to follow up on quarterly visits required since the last visit on 2024-07-25, monitoring compliance with staffing, medication errors, audits, reporting, training, and facility policies.

The visit found that all required items were monitored and maintained in compliance. A medication error was reported by the facility, a medication audit was completed, incident reports were received, and facility policies were provided. The case management visit was conducted in conjunction with the required annual visit, with all deficiencies addressed and cited on the annual LIC 809-D.

The visit was an unannounced case management quarterly visit to follow up on staffing concerns, medication errors, medication audit, reporting requirements, medication training, and facility policies regarding assessments, monitoring of residents, change in condition, and medication errors.

The inspection found that Resident 1 was administered the wrong dosage of Metoprolol from June 6, 2024, to July 9, 2024, with missing medication administration record signatures and no caregiver notes. Resident 2's assessments were not updated to reflect significant health changes, including wound care needs. Deficiencies were cited related to medication administration and assessment documentation, posing immediate and potential health and safety risks.

The visit was an unannounced case management quarterly visit to follow up on staffing concerns, medication errors, medication audit, reporting requirements, medication training, and facility policies regarding assessments and monitoring of residents.

No deficiencies were cited at the time of the visit. The Licensing Program Analyst reviewed seven resident files and conducted interviews related to medication errors and will follow up on these files at a later time.

An unannounced post continuation required inspection was conducted to ensure compliance with Title 22 regulations.

The Licensing Program Analyst inspected the physical plant and conducted staff interviews. No deficiencies were cited during this continuation post licensing visit.

An unannounced post licensing inspection visit was conducted to ensure compliance with Title 22 regulations and to complete the post licensing visit process.

The facility was found not in compliance with Title 22 regulations due to deficiencies including lack of first aid training for staff, failure to conduct required fire drills, and medication administration errors involving morphine sulfate. Plans of correction were required for these deficiencies.

The visit was an unannounced case management follow-up to review incident reports involving falls with injuries received on February 7, 2024 and February 24, 2024.

No deficiencies were cited during this visit. The Licensing Program Analyst requested documentation related to the incidents for further review and will follow up at a later date.

The visit was an Informal Non-Compliance Conference (NCC) conducted due to legal/non-compliance issues including complaint investigations, medication errors, staffing concerns, and reporting requirements.

No deficiencies were cited at this visit. The facility has been cited six times in the past year with four A citations and two B citations related to care and supervision, incidental reporting, and medical issues. The facility agreed to submit documentation and updated policies by 03/29/2024 to achieve continued compliance.

Complaint Number 27-AS-20231107162650 regarding Lack of Care and Supervision was discussed during the Non-Compliance Conference.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-12-15 regarding medication administration, care and supervision, and adherence to resident's signed admission agreement.

The investigation substantiated that the facility failed to administer medications to resident 1 (R1), posing an immediate health and safety risk, resulting in a $1,000 civil penalty. The allegation that the facility failed to provide care and supervision was unsubstantiated due to lack of evidence. The complaint that the facility did not adhere to the resident's signed admission agreement was found to be unfounded.

The complaint investigation was substantiated for failure to administer medications to resident 1, resulting in a civil penalty of $1,000. The allegation of failure to provide care and supervision was unsubstantiated. The allegation regarding non-adherence to the signed admission agreement was unfounded.

The visit was an unannounced case management follow-up to address deficiencies learned during a prior complaint investigation related to medication administration and reporting requirements.

The facility failed to properly administer medications to residents R1, R2, and R3, including missed doses and administration of wrong medications. Additionally, the facility did not submit required incident reports related to medication errors and did not maintain medication administration records (MARs) properly, posing immediate and potential health and safety risks.

The follow-up visit was triggered by a complaint investigation (27-AS-20231114094113) which revealed missing Hydrocodone tablets for resident R1, missed medication doses in November 2023, and administration of wrong medications to residents R2 and R3. The complaint investigation substantiated deficiencies in medication administration and reporting.

An unannounced complaint investigation was conducted following a complaint received on 2023-11-07 regarding alleged failure to provide care and supervision and failure to seek timely medical care for a resident.

The investigation substantiated that Resident 1 (R1) was found on the floor for an undetermined amount of time with injuries due to lack of monitoring and timely medical attention. The facility was short staffed during the AM shift and failed to provide basic care services, posing an immediate health and safety risk to R1. Another allegation regarding failure to provide care as identified on the care plan was unsubstantiated.

The complaint was substantiated based on evidence that the facility failed to provide care and supervision and failed to seek timely medical care for Resident 1, who was found on the floor with injuries after being unmonitored for hours. The allegation that the facility failed to provide care as identified on the care plan was unsubstantiated.

Unannounced complaint investigation visit conducted in response to allegations including staff stealing resident's medication and the facility charging visitors for liquor.

The investigation found no missing controlled medication during the audit and no evidence that staff were stealing medication. The facility was incorrectly charging a resident for a meal not ordered but was reviewing and would reimburse if needed. There was no evidence that the resident was charged for alcoholic beverages, and the admission agreement allowed alcohol purchase. The allegations were unsubstantiated due to insufficient evidence.

Complaint investigation was unsubstantiated. Allegations included staff stealing medication and improper charges for liquor. Evidence did not support the allegations.

An announced pre-licensing visit was conducted to evaluate the facility for licensure.

The facility was found to be in good condition with no objections to licensure at this time. Observations included proper medication storage, no obstruction of emergency exits, and appropriate food storage.