complaint·November 20, 2025

***CONTINUE FROM 9099*** During the visit, LPA with Justin Zackweski, Regional Director and LPA Lisha Holmes checked R3’s room. LPAs observed the room to be clean, organized and odor free. Staff interviewed state incontinent residents get changed 2-3 times during each shift. The first check/change is done at the start of shift, then after lunch and before end of shift. Allegation: Staff does not ensure adequate food options are available for residents with dietary restrictions - Unsubstantiated During the course of investigation, LPA reviewed facility menus for the last three months. There are two types of menu: regular and alternate. Interim ED states the regular menu has always two options for the residents to choose from. And then the alternate menu which can be served to the residents anytime they prefer to eat food apart from the regular. The information provided by the ED was confirmed by R3 who states that R3 has chosen the alternate menu a few times since living at the facility and everything is fine. An interview was conducted with R4 who states that R4 has dietary restrictions – Kosher diet, which the facility does not accommodate. R4 states the facility does not provide Kosher foods. When asked if the facility was made aware of R4’s restrictions during the admission process, R4 stated the facility should know but did not provide any further information. A review of R4’s medical assessment did not indicate any dietary restrictions or allergies. The report indicates R4 “has no special diet but has dietary preference .” The facility’s dietary board did not indicate R4’s name as one of the residents with dietary restrictions. Based on interviews and record reviews conducted, the above allegations are 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. A copy of this report was provided to Sarian Lichtenberger, Regional Operation Leader .