OAKMONT OF LODI

Official classification

Type B

Official code

1569.312(b)

Regulation authority

HSC

What the official deficiency says

(b) Assistance with instrumental activities of daily living in the combinations which meet the needs of residents. This is not met as evidenced by: Based on record review, The licensee did not ensure that the facility staff completed and initialed the logs for assisgned tasks and duties and monthly assisgnments were completed. This poses a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

The facility shall conduct training regarding the following Section for no less than an hour in duration. A statement of correction indicating how often the facility will audit the assigned tasks and duties book and acknowledgement along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.

Deadline recorded: May 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that [2] out of [10] facility personnel files did not contain updated annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2025 Plan of Correction The facility designated Administrator stated that all facility staff files will be audited and reviewed to make sure that annual training has been updated and completed for all facility staff. A statement of correction, along with copies of updated training for all facility staff, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on a review of the facility medication administration record (MAR) and Controlled Medication Administration Record, it was observed that required names/initials for narcotics counts were missing, dates were omitted or incorrect, and medications were not dispensed as prescribed which poses/posed an immediate risk to the health, safety, and personal rights of the residents in care.

Official plan of correction

The facility designated Administrator stated that an audit of the facility medication administration records will be conducted for both the Assisted Living and Memory Care (Traditions) components. Training, for no less than (1) hour in duration, will be conducted on the topic of proper handling, dispensing, and documentation of all facility resident medications. A statement of correction, along with proof of updated medication training, will be completed and submitted into CCL by the due date. Proof of training will include name of trainer, training topic(s), and list of attendees.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on a review of the facility medication administration record (MAR) and Controlled Medication Administration Record, it was observed that required names/initials for narcotics counts were missing, dates were omitted or incorrect, and medications were not dispensed as prescribed which poses/posed an immediate risk to the health, safety, and personal rights of the residents in care.

Official plan of correction

The facility designated Administrator stated that an audit of the facility medication administration records will be conducted for both the Assisted Living and Memory Care (Traditions) components. Training, for no less than (1) hour in duration, will be conducted on the topic of proper handling, dispensing, and documentation of all facility resident medications. A statement of correction, along with proof of updated medication training, will be completed and submitted into CCL by the due date. Proof of training will include name of trainer, training topic(s), and list of attendees.

Deadline recorded: Feb 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that [3] out of [10] facility personnel files did not have updated First Aid Training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2024 Plan of Correction The facility representative stated that all facility staff providing care and supervision to the residents will be scheduled for First Aid Training. A statement of correction, along with copies of updated First Aid Training certificates, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in that the narcotic counts were incomplete missing required information. In addition, there were errors in documentation for days when the narcotics were dispensed to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2024 Plan of Correction The facility representative stated that all facility staff dispensing, handling, and documenting the resident medications will be in-serviced, for no less that (2) hours in duration, on the topics of proper dispensing, handling, and documentation of the resident medications. A statement of correction, along with proof of updated staff training, will be completed and submitted into CCL by the due date.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that [10] out of [10] facility resident files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2024 Plan of Correction The facility representative stated that all facility resident files will be audited and any, and all, missing forms and documents will be updated and brought into compliance. A statement of correction, along with copies of all updated forms and documents, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on interviews and file review: The Licensee did not ensure R1 was administered the correct Metoprolol dosage from 06/06/24 to 07/09/2024. This posed an immediate health and safety risk to R1.

Official plan of correction

Facility Staff has conducted medication training on July 15 and will conduct a medication training by August 15. LPA Martinez was provided medication training materials on 07/25/2024. POC cleared at visit.

Deadline recorded: Jul 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

87465(a)(6) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility.When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidence by:Based on file review: The Feb & May MARs provided to LPA Martinez by Facility showed staff did not sign off on MARs for medication Metoprolol on May 23 and 25 & Feb 07 2024. This posed a potential health and safety risk to R1.

Official plan of correction

Facility Staff has conducted medication training on July 15 and will conduct a medication training by August 15. LPA Martinez was provided medication training materials on 07/25/2024. POC cleared at visit

Deadline recorded: Aug 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463(a) Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidence by: Based on interviews and file reviews, R2's assessments were not maintained and did not contain significant health changes and the assessments provided to LPA Martinez were not signed by RP, R2, or staff. This posed an immediate health and safety risk to R2.

Official plan of correction

Facility will conduct regular assessment audit for the next two months (September 25, 2024). Email LPA Martinez a bi-weekly update on audits. Email R2's assessment to LPA Martinez by August 09, 2024

Deadline recorded: Sep 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 ...Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 4 out of 5 staff did not have first aid training by a qualified agency. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2024 Plan of Correction Facility staff agrees to conduct a fire drill by POC date 06/10/2024. Fire drill logs will be emailed to LPA Martinez on POC date 06/10/2024 by 5:00 PM.

Official classification

Type B

Official code

87705(k)(3)

Regulation authority

CCR

What the official deficiency says

The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on file reviews and interviews, the licensee did not comply with the section cited above. The last fire drill conducted by facility staff was on 12/29/2023, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/10/2024 Plan of Correction

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews, file review, and medication audit, the licensee did not comply with the section cited above. facility staff did not follow R1's morphine orders and was not administered medication as noted on the controlled drug record and MAR. This posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2024 Plan of Correction Facility staff agrees to conduct a medication audit from an outside agency by POC date 07/03/2024. Facility staff agrees to email LPA Martinez an audit plan by 06/06/2024.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on file reviews, interviews, and medication audit, the licensee did not comply with the section cited above. A med-tech signed off on R1's controlled drug record that Morphine was administered when it was not administered. The medication was left in R1's room resulting in the medication to be unaccounted for. This action also resulted in controlled medication count being off. This posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2024 Plan of Correction Facility staff agrees to conduct a medication in-service by POC date 07/03/2024. Facility staff agrees to email LPA Martinez an medication in-service plan by 06/06/2024.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on file review and interviews, The licensee did not ensure staff were administering R1, R2, and R3's medication as required and did not ensure staff were administering the correct medication to R2 and R3. This posed an immediate health and safety risk to R1, R2, and R3.

Official plan of correction

The Administrator reported Medication Incidental and medical training was conducted on POC was cleared at time of visit.

Deadline recorded: Jan 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(6)

Regulation authority

CCR

What the official deficiency says

87465(6)Incidental Medical and Dental Care The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement was not met as evidence by: Based on interviews and file reviews, The Licensee did not ensure MARs were being maintained for R1, R2, and R3. This posed a potential health and safety risk to residents in care.

Official plan of correction

The Administrator reported Incidental and medical training was conducted on 01/05/2023. POC was cleared at time of visit.

Deadline recorded: Jan 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D)Reporting Requirements each licensee shall furnish to the licensing agency such reports...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: based on interviews and file review the facility did not submit incident reports in regards to medication errors. This posed a potential health and safety risk to R1.

Official plan of correction

The Administrator reported Reporting training was conducted on 01/17/2023. POC was cleared at time of visit.

Deadline recorded: Jan 17, 2024. A deadline is not proof that correction was completed.