complaint·July 21, 2025

***CONTINUE FROM 9099*** W1 stated that R1 was not being reminded to eat and was possibly experiencing health decline as a result, including needing a blood transfusion. S1 explained that dietary needs are determined through physician assessments and then communicated to the kitchen staff. The Assisted Living Director works closely with the culinary team to ensure preferences and restrictions are followed. S3 and S4 stated that caregivers and servers monitor who attends meals and report non-attendance or poor appetite to the med tech. S3 said, “We always notice if someone hasn’t eaten. We either check on them or bring a meal to their room.” S4 recalled R1 having occasional fluctuations in appetite but said, “She tells us when she doesn’t like something. She’s very clear.” R1 stated she typically eats in the dining area but sometimes feels tired or forgets, and on those days, someone usually reminds her or brings food to her room. She added, “If I want something, I ask. They usually help.” R2 stated that R1 is socially active and frequently seen in the dining room. Review of meal-related documentation did not show consistent patterns of meal refusal or weight loss. Care notes indicated regular dietary monitoring and no recent physician concerns about nutritional status. Allegation: Staff do not seek timely medical attention for residents - Unsubstantiated W1 stated that R1 had to receive a blood transfusion due to poor medical follow-up and that there was little coordination with her physician. S1 acknowledged that contacting outside providers, particularly Kaiser, can be challenging due to call wait times and follow-up delays. However, S1 and S2 stated that when a family member or resident informs them of a health issue, staff follow protocol by alerting the med tech and care coordinator, and contacting the provider. S5 added, “We’ve had to call Kaiser multiple times to get things moving. It’s not us ignoring anything—it’s just delays from their side.” ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** R1 confirmed that she has experienced delays getting doctor appointments but said staff helped her make calls or forwarded messages. She stated, “They try to help, but Kaiser is slow. I get frustrated, but I don’t blame them.” R2 did not report any issues with medical attention but stated that she manages most of her own appointments. Review of communication logs and incident reports showed attempts by staff to follow up on R1’s medical needs, including calls and coordination of transportation. Allegation : Licensee does not ensure enough staff to meet residents’ needs - Unsubstantiated W1 reported that R1 calls late at night asking for help and expressed concern that the facility may be understaffed or unresponsive during the day. S1 stated that the facility maintains a staffing ratio of approximately 1 staff per 10 residents in Assisted Living, and there are typically 5 to 6 staff members per shift. Staff schedule for 04/25/2025 confirmed this ratio. S2 explained, “We have coverage across all shifts. If someone calls out, we have floaters or back-ups.” S4 and S5 both stated that they check in with residents throughout the day and respond to call buttons promptly. S4 noted, “If someone says they’re not getting attention, it’s probably because they didn’t let us know. We try to anticipate needs, but we can’t guess everything.” S5 added, “We always have someone walking the floor.”R1 confirmed that staff generally respond when she presses her call pendant, though she mentioned she sometimes calls her family late at night because she “just feels anxious.” She said, “It’s not that they’re not helping me—it’s more that I don’t want to bother them sometimes.” R2 reported no concerns about staffing levels or response times. Review of staffing records did not indicate staffing shortages. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation : Staff are not dispensing medication as prescribed - Unsubstantiated W1 stated that R1 has a prescription for anxiety that was never filled and expressed concern about medications that are supposed to be taken every three hours. S1 stated that all medications are managed using MARs and administered by trained med techs. S3 explained that medication times are scheduled based on physician orders and any special instructions are clearly marked. S3 stated, “We’re very strict with the med passes, especially for time-sensitive meds. We double-check the MAR each shift.” S5 added that when a prescription is delayed due to pharmacy or provider issues, it is documented and the family is informed. According to S2, the anxiety medication W1 referred to had not been delivered by the pharmacy and was under follow-up .R1 acknowledged that one of her medications hadn’t arrived yet but said she was aware of the reason and had spoken to staff about it. “They told me they’re waiting on it from the doctor. I’ve been okay,” she said. R2 reported no issues with medication timing or availability. Review of MARs confirmed consistent medication administration. The anxiety prescription was noted as “pending delivery,” with follow-up calls documented. According to MAR, there were no missed doses of other routine medications. This agency has investigated allegations above. We have found that the above allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, a copy of this report provided.