Complaint·December 10, 2025

staff members by staff or residents. One staff member stated they have not observed “PDA (public display of affection)” between any staff. Although this may violate a facility’s staff policy, no corroborating evidence was obtained to show the staff have been inappropriate in front of residents. Therefore, the allegation that staff engage in inappropriate behavior with another staff member in the presence of residents is Unsubstantiated at this time. On the allegation: Staff does not provide a healthy and safe environment to residents. It was alleged on 11/14/2024, one food server came down sick, but was not allowed to leave due to short staffing. It was alleged ‘instead the server wore a mask and served food’. LPA conducted interviews with staff and residents on 12/24/2024, 12/5/2025, 12/9/2025 and 12/10/2025. Interviews of staff and residents overwhelmingly stated no staff have been observed being at work while being sick. One resident stated they observed staff to be conscious of people coughing and being sick. Staff interviews revealed knowledge of the facility’s sick leave policy and stated they would call their supervisor if they were having symptoms of illness. Based on the interviews conducted, the allegation that the facility staff does not provide a healthy and safe environment to residents in care is Unsubstantiated at this time. On the allegation: Staff withhold food from residents. It was alleged residents who want tray service must request it by 4:00 pm and will not be served if ordered after 4:00 pm. Interviews stated the kitchen closed at 5:50 pm. LPA conducted interviews with staff and residents on 12/24/2024, 12/5/2025, 12/9/2025, and 12/10/2025. Interviews conducted revealed residents are aware of the facility’s dining service’ hours and the time(s) in which they are required to make their tray service request. Interviews revealed the staff are accommodating to the residents with regard to the tray service and the residents understand the parameters of the facility’s dining services’ hours and tray service hours. Interviews revealed that they are satisfied with Dining Services’ efforts to accommodate the residents when there are extenuating circumstances at hand. Staff interviews revealed that when they know a resident and/or residents will be away from the facility outside the Dining Service hours, they will provide for the resident by reserving a meal, or accommodating in some way with a sandwich, fruit, cereal and milk. Administrator stated, if need be, they will ensure a resident has a meal provided either by having something from the kitchen or calling an order to be delivered to the facility. Administrator provided the facility handbook to include the Dining Service Hours and a weekly menu showing Dining Service hours as well as additional meal options. Additionally, Administrator stated the facility conducts Town Hall meetings where dining information is discussed on a regular basis. Based on the interviews conducted and information obtained, the allegation that staff withhold food from residents is Unsubstantiated at this time. Please continue to 9099-C, Pg 3. On the allegation: Staff does not accommodate resident's food needs: It was alleged Resident 1 (R1) returned to the facility from hospitalization with a diagnosis of diabetes and a special diet. It was alleged the executive chef did not follow the special diet and informed the resident to buy their own food. During an interview with Wellness Director on 12/5/2025, Wellness Director confirmed R1 was on a special diabetic diet. Administrator stated the facility does not accommodate special diets such as diabetic preferences, gluten free, kosher diets, etc., unless their diet is specified in a resident’s Physician’s order. Administrator stated although R1 may prefer a “diabetic” diet, the facility is not obligated to accommodate that diet. Administrator further stated the facility menu offers a variety of menu items and alternative choices many of which may be conducive to a resident’s special diet preference. Administrator pointed out the weekly menu dated 11/30/2025 through 12/6/2025 included diabetic preference foods including a fish dish “Catch of the Day”, grilled chicken, eggs, green house salads, fresh fruit, and other such items. During today’s visit, interviews revealed R1 was determined to be “pre-diabetic” rather than diabetic and was provided alternative options from the current menu. Therefore, based on records reviewed and interviews conducted, the allegation that staff does not accommodate resident’s food needs is Unsubstantiated at this time. On the allegation: Staff does not allow resident visitors. It was alleged that a former staff was denied visiting a resident. Administrator stated they do have a policy that staff who have been terminated cannot come into the facility under another agency, such as home health or a private caregiver agency. Administrator stated a former employee came to the facility to work as a private caregiver, and they were informed of the policy. Administrator stated the former employee did not respond well to this information. Administrator stated a responsible party had hired the former employee, but the family preferred a different private caregiver who the family decided to hire. Interviews revealed no resident specifically asked for the former staff to visit and was denied visitation. Administrator stated they understand if a resident requests a specific visitor, even if it conflicts with their internal policy, they need to accommodate the visit in some way. LPA discussed resident visitation rights with the Administrator and emailed the Provider Information Notice (PIN) 25-04-ASC to the Administrator. Based on record review and interviews conducted, the allegation that staff does not allow resident visitors is Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.