complaint·August 26, 2025

Regarding the allegations, “Staff do not ensure resident is provided adequate food service and Staff does not ensure resident's food diet is being followed” it is the concern of the Reporting Party (RP) that Resident 1 (R1) was placed on a diet by their Primary Physician and staff does not follow it. Additionally, when R1 requests a specific breakfast, R1’s meal will be cold when delivered. File review revealed that R1 has a doctor’s order for a strict anti-reflux diet, mechanical soft diet, no acid, no seasoning, no sauce, and no beef, does not drink thin liquids, drinks ensure and cream of wheat, signed and dated 01/31/25. Nine (9) out of ten (10) residents interviewed revealed that they have no concern regarding the food provided, they are provided with adequate food service, staff know what the residents can and cannot eat, and that the community provides balanced meals, follows their diet and provides alternate dishes if needed. An interview with R1, revealed that they only eat breakfast at the community and buy their own canned food to eat during lunch and dinner, however the community prepares it for them or they grind it. R1 states that the staff prepares their food and grinds it but it is not the right consistency. On 04/01/2025, the LPA observed R1 eating a plate of canned corn, green beans, peas, carrots, and roasted turkey that seemed to be in a smooshy consistency and covered with ensure, and on the side bread inside milk. An interview with the communities Chef, revealed that everyone in the kitchen knows R1 and are very aware of R1’s diet (mechanical soft) as R1 has a history of complaints regarding their food no matter what they do. Furthermore, staff interviews revealed that the community provides breakfast, lunch and dinner, as well as snacks, however R1 is very particular about their food and only eat breakfast provided by the facility and buy their own food but for lunch and dinner, the staff always follow all the residents’ diets and even accommodated to the residents’ preferences. Additionally, R1 repeatedly complains about the consistency and temperature of their food and staff will take it back to the kitchen and have them re do it. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated at this time. Exit interview was conducted and report provided. Regarding the allegation, “Staff does not answer resident's call button”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) has been needing help getting in and out of bed, has pushed their call button on multiple occasions but staff never goes, and they will have to try to move in and out of bed on their own. No date(s) provided. LPA reviewed pendant records for R1 from 03/19/25, starting at 6:16 PM to 04/1/25 ending at 10:42 PM. R1’s pendant records revealed that ten (10) out of one hundred and twenty-five (125) pendant calls R1 made were never responded to. Oakmont’s PHB history indicated that on all 10 pendant calls made that were not responded to, the calls were announced 9 times. The LPA did not observe any charting notes from staff that indicated R1 had been helped but denied staff to reset their pendant during that date period. Based on the record review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, this allegation is deemed SUBSTANTIATED. The following deficiency was cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.