OAKMONT OF EAST SACRAMENTO

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) 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... This requirement is not met as evidenced by: Based on interview a staff asked a resident and their privately hired companion who was in the library to move their breathing exercise to the spa area. This posed a potential risk to residents in care.

Official plan of correction

Facility Designated Administrator (FDA), Kathleen Gilbey agrees to have their stand-up meeting held in the FDA’s office moving forward and not in the library. FDA and AED will review the regulation cited and provide LPA Lee with a statement of acknowledgment of understanding the regulation cited today. POC due 10/13/2025 end of day 5:00 PM.

Deadline recorded: Oct 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

CCR

What the official deficiency says

Deficiency narrative not available.

Official classification

Type B

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

87303(i)(1)(B) Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidence by: Based on 7 out 8 resident SMART care log it was learned that residents alert call was not responded to and that occasionally calls took over 15 minutes to respond, which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The administrator will review SMART care log and conduct an audit and ensure to conduct additional training with facility staff; furthermore, ongoing training will also be conducted. Administrator also agrees to submit proof of training and the training materials used along with staff sign in sheet. Administrator will also review regulations being cited today and write a statement of acknowledging that administrator along with facility staff are aware of the regulation being cited today. POC will be email to LPA Lee at pang.lee@dss.ca.gov by POC date 08/02/2024 by end of day 5:00 PM.

Deadline recorded: Aug 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by staff statements that they were aware of R1's decline in mobility but did not have a fall prevention plan in placement to address recurring falls which resulted in additional falls where R1 sustained a fracture which required hospitalization which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility will submit an updated fall risk/prevention plan to the facility for approval and when approved will become part of the facility plan of operation. facility will also conduct training on communication, implementation and oversight of fall risk program by the POC due date 3/21/24.

Deadline recorded: Mar 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(8)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. this requirement was not met as evidenced by statements from A1, A2 and R2 who corroborated statements that authorized representatives were not notified by facility staff of R1's fall and subsequent hospitalization which poses an immediate health, safety and personal rights risk for residents in care.

Official plan of correction

Facility will provide and updated written plan of correction identifying the policies and procedures for notifying authorized representatives of incidents at the facility and will conduct appropriate training for staff to ensure reporting requirements are met.

Deadline recorded: Mar 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation: Facilities shall have signal systems which shall meet the following criteria: Operate from each resident's living unit. This requirement was not met as evidenced by statements obtained from A1, A2, S1, S5, S3, and S7 that state they do not believe the call system operates properly and there are times where they are not notified of an alert from a resident's room and documented concerns of call system not working as designed which poses an immediate health safety and personal rights risk to residents in care.

Official plan of correction

Facility will submit a written plan of correction indicating the steps the facility takes to ensure regular testing of resident pendents and staff pagers to ensure they are operating as intended and staff receive notifications for assistance.

Deadline recorded: Mar 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

87303(i)(1)(B) Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidence by: Based on LPA Lee investigation 7 out of 10 residents has a concern in regards to staff not responding to resident’s call pendant in a timely manner. LPA Lee requested and reviewed 10 residents Personal Health Button Report (PHBR). The documents revealed that 3 residents (PHBR) were not responded within 15 minutes or less minutes per administrator, Luis and VIP of Operation, Terry. Furthermore, the documents also revealed that 7 residents (PHBR) stated that residents’ calls were ever respond to, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Effective immediately the administrator will start reviewing Personal Health Button Report (PHBR) and conduct an audit and ensure to conduct additional training with facility staff; furthermore, ongoing training will also be conducted. Administrator also agrees to submit proof of training and the training materials used along with staff sign in sheet. Administrator will also review regulations being cited today and write a statement of acknowledging that administrator along with facility staff are aware of the regulation being cited today. POC will be email to LPA Lee at pang.lee@dss.ca.gov by POC date 11/07/2023 by end of day 5:00 PM.

Deadline recorded: Nov 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.88(b)

Regulation authority

CCR

What the official deficiency says

1569.884(b) Contents of residential care facility admission agreements (b) A comprehensive description of, and the fee schedule for, all items and services not included in a single fee. In addition, the agreement shall indicate that the resident shall receive a monthly statement itemizing all separate charges incurred by the resident. This requirement was not met as evidence by... Administrator did not ensure that a resident is receiving a monthly statement itemizing all separate charges incurred by the resident on resident's invoice statement.

Official plan of correction

POC cleared during today's visit. On 09/08/2023 Administrator modify ledger entries to show itemized entry for resident incurred fees. Facility will ensure that (R1) recieves itemized ledger monthly.

Deadline recorded: Oct 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by four instances of theft of a resident's credit card and unauthorized use by a staff member who was arresed by local law enforcement while at the faclity on 9/12/23 which poses a potential health, safety and personal rights risk to resident's in care.

Official plan of correction

Faciilty has agreed to conduct retraining for all staff members on the personal rights of residents in a privatly operated faciilty and documentation of training and training materials will be submitted to the department by the POC due date.

Deadline recorded: Oct 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by the facility did not meet all reporting requirements as identified in welfare institutions code for mandated reporting for financial abuse as a suspected dependent adult/elder abuse report should have been submitted to the local ombudsman within two working days. The Administrator had provided reports for three of the four instances but did not complete reporting requirements for the reported incident in March 2023. per welfare institutions code 15630.2.(b)(3) If the mandated reporter knows that the elder or dependent adult resides in a long-term care facility, as defined in Section 15610.47, the report shall be made to the local ombudsman, local law enforcement agency, and the Department of Financial Protection and Innovation. which poses a potential health safety and personal rights risk to residents in care.

Official plan of correction

The facility has agreed to conduct training for all staff members on Mandated reporting including but not limited to what is a mandated reporter, types of abuse, and how to fill out and submit a suspected dependant Adult/Elder abuse form (soc 341) and who and where to submit the document to complete the process of a mandated reporter.

Deadline recorded: Oct 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(3)(g)

Regulation authority

CCR

What the official deficiency says

Payment provisions, including the following: A comprehensive description of billing and payment procedures. This requirement was not met as evidenced by Facility disclosure of reimbursement to R1 for pet service fee that was intended for dog care, not cats, which poses a potential health, safety and presonal rights risk to residents in care.

Official plan of correction

Facility has, prior to LPA delivering fidings to the facility, have credited to account of R1 for upon discovery of the error. No further action is required.

Deadline recorded: May 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interview and record review Licensee did not ensure residents were accorded dignity by Staff 1 (S1). This poses a potential health and safety risk to residents in care.

Official plan of correction

Executive Director has given S1 two written warnings and moved S1 to a different shift. In-Service training has also been conducted. Executive Director has agreed to provide LPA a copy of the In-Service conducted by POC due date.

Deadline recorded: Dec 16, 2022. A deadline is not proof that correction was completed.