Complaint Investigation Report

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.”