Complaint·January 12, 2024

Interview and record review of facility documentation of the incident reveal that R1 experienced a fall in the shower while being assisted by hospice aid and facility care provider. Written statements from both as well as the chart note by Med Tech include that R1’s head came in contact with the wall during a fall. The facility did not report the incident to CCLD as required. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the areas of Personnel Requirements, Hospice Care of Terminally Ill Residents and Reporting Requirements. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were signed and emailed to AD Hsetty@oakmontmg.com.. Based on observation, interview, and record review the Department is unable to determine if Activities of Daily Living (ADLs) and basic services were provided to R2. LPA visited the facility multiple times between 9/12/23 and 12/12/23 and observed water available during and in between meals as well as residents being assisted to eat. Record review of facility chart notes and emails show that between 3/8/23 – 4/8/23 housekeeping and hands on care service was increased for R2 due to increased need. This additional care was suspended 4/8/23. Hospice records do not mention basic services not being provided. Hospice records document that R2 continued to lose weight between 10/2022 – 8/2023 related to disease process and minimal/poor food intake. Based on record review, an order was written for R2 to receive weekly routine lab work on 7/18/22. R2 was admitted to hospice 10/25/23. R2's facility and hospice records were obtained and reviewed. It is not able to be determined when or if this routine order was discontinued. Additionally, the hospice agency ordered lab work to be done 3/14/23 which was scheduled by the facility to be completed 3/20/23. The hospice agency revised that order for the lab work to be conducted sooner by a mobile service. Based on interview, record review and observation, the above allegations are UNSUBSTANTIATED . Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued An exit interview was conducted and a copy of this report was signed by AD and emailed to HSetty@oakmontmg.com