Failure to Honor Resident's Dietary Preferences
Summary
The facility failed to honor the dietary preferences of a resident, identified as Resident 59, by serving fish, a food the resident dislikes, during lunch on February 28, 2025. This incident was observed during a concurrent observation and interview with the resident, who confirmed the presence of fish on their plate despite their known dislike for it. The resident's dietary profile, updated on January 29, 2025, clearly indicated a dislike for fish, and the meal ticket for that day also reflected this preference. However, the meal ticket was not adhered to, resulting in the resident being served fish. Interviews with the Dietary Supervisor and Certified Nursing Assistant (CNA) 6 revealed that the kitchen staff was aware of the resident's dietary preferences and intolerances, and the meal ticket system was in place to prevent such errors. Despite this, the oversight occurred, and the Dietary Supervisor acknowledged that multiple staff members failed to notice the error. The Director of Nursing expressed concern that serving a disliked food could lead to psychosocial issues and potential weight loss for the resident. The facility's policy emphasizes respecting residents' dietary choices and ensuring their nutritional needs are met, but this incident demonstrated a lapse in following these guidelines.
Plan Of Correction
A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 59 is receiving his meals per his choices and preferences. The Dietary Services Supervisor completed a Food Preference Evaluation to identify Resident 59's food likes and dislikes to ensure Resident 59 is served meals according to his preference on 2/28/2025. The Dietary Service Department updated Resident 59's tray card with his current food likes and dislikes to ensure he is served meals according to his preferences. The Dietary Services Department updated Resident 59's tray card with his current food likes and dislikes to ensure he is served meals according to his preferences. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents not receiving meals per their preferences are potentially affected. The Social Service Director audited resident grievances from January 1 through February 28th, 2025, to identify grievances related to meal service on 3/17/2025. The Activities Director audited the last two months of Resident Council minutes to identify any grievances related to meal service on 3/17/2025. No other residents were identified as having concerns related to meal service and food preferences. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Dietary Supervisor completed dietary competency evaluations of the cooks and meal service staff on 3/13/2025 to ensure the cooks and meal service staff prepare the resident's meal tray per their documented meal ticket preferences. The Dietary Supervisor will implement the use of the CAHF Meal Accuracy Report once weekly to identify meal service accuracy concerns and report findings to the Quality Assurance Committee for improvement beginning December 2025. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Registered Dietitian will, as part of the routine kitchen audit, monitor meal service to ensure meals are prepared in accordance with the physician order and the cook has the appropriate skills and competency to prepare the resident meals. This will be done twice a month, and the RD will utilize the CAHF Food & Nutrition Meal Tray Accuracy - Quality Assurance Report. The IDT, including the RD, will monitor resident weight monthly to identify residents with unplanned weight loss and determine the root cause of the weight loss. The Director of Activities monitors the grievances of residents monthly during resident council and will report food-related concerns to the DSS following the resident council meeting for immediate correction. The Director of Social Services will monitor the grievance log for meal preparation concerns and report these concerns to the dietary services department for immediate correction. The Director of Nursing/designee will report trends identified in the dietary feedback audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F812 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The two dented cans in dry storage were removed and placed in the dented can area by the Dietary Manager on 2/24/2025 at the time of observations during the survey to avoid using them for residents, as the seal of the dented cans had already been broken and can release chemicals which can cause cross-contamination. 2. The Dietary Manager removed the box of open, undated graham cookie crumbs. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: 128 residents are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Dietary Services Director will re-educate the dietary staff on or before 3/19/2025 regarding the facility policy and procedures: Dented cans must be removed from the food supply and placed in the dented can area to avoid using them for residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a documented No Added Salt (NAS) diet and clear instructions for no sauce, gravy, or chicken skin was repeatedly served meals that did not follow these specifications. During one observed meal, the resident received chicken with skin and gravy despite the diet card prohibiting these items, and the resident reported that the previous evening’s dinner plate also contained a large amount of gravy. The resident stated they did not report the issue to staff because they did not want to complain and feared their meal would be delayed, demonstrating that the facility did not consistently honor the resident’s documented food preferences and restrictions.
The facility failed to provide a variety of appealing meal substitutions in line with resident preferences and its own written menu standards. Although the alternate menu listed deli sandwiches, grilled cheese, chef salads, and bread, residents and staff consistently reported that only grilled cheese, and occasionally ham sandwiches without cheese, were offered when residents refused the main meal. Resident council leaders and multiple residents stated they had repeatedly complained about the lack of variety and the removal of prior options such as hamburgers and pizza, without any resolution. CNAs, an LPN, and an RN confirmed frequent resident complaints and the limited substitution choices, while dietary staff and the Food Service Manager acknowledged that budget-driven changes had reduced the alternate menu and that key salad ingredients like tomatoes and cucumbers were not routinely stocked, resulting in monotonous and restricted substitution offerings.
A resident with diabetes, heart failure, and HTN, who was cognitively intact and on a consistent carb, regular texture diet, repeatedly received oatmeal on meal trays despite stating multiple times that he did not like it. Review of the care plan and nutrition assessment showed no documented food preferences, and the daily menu for the resident lacked any notation of likes or dislikes, even though the facility’s policy and the DM’s process required recording such information on nutritional assessments and menus.
Failure to Honor Documented Food Dislike: A resident with dementia and malnutrition had a documented dislike for breakfast sausage on the meal ticket, yet sausage was served on breakfast trays during two observations. The resident stated she did not eat breakfast sausage, and dietary staff and the ADM confirmed it should not have been served.
Two cognitively intact residents with documented food dislikes were repeatedly served items listed as dislikes and did not consistently receive alternate menu selections they ordered. One resident received beets despite this item being listed as a dislike and reported frequently having to request a peanut butter and jelly sandwich instead, while another resident with rice listed as a dislike reported receiving incorrect meals and that the menu was wrong on most days of a week. Surveyors also observed that the posted menu listed spiced pears, but residents were served mangoes with whipped topping, and a dietary aide stated that staff often prepared whatever food was on hand rather than what was on the menu. The Administrator acknowledged emerging dietary issues and confirmed that residents should not receive foods on their dislike/allergy lists and that served food should match the menu or be communicated if changed.
Failure to honor documented food allergies, intolerances, and preferences: Two residents were served foods listed as allergies or dislikes, including raw tomatoes, milk, tomatoes, and cucumbers. One resident’s chart also failed to include a documented raw tomato allergy, and lactose-free milk was not available on the unit drink cart despite being in the kitchen. The NHA and DON confirmed the transcription and meal service failures.
Failure to Honor Resident’s Documented Food Preferences and Restrictions
Penalty
Summary
The facility failed to honor a resident’s documented food preferences and diet specifications when serving meals. During a dining observation, the resident reported she was not supposed to have gravy or chicken skin, yet her lunch tray contained chicken with the skin on and gravy covering the chicken. Review of the resident’s meal card on the tray showed an order for a No Added Salt (NAS) diet with explicit instructions for no sauce, gravy, or chicken skin. The resident further reported that her dinner plate the previous evening had a lot of gravy, and she did not report the concern to staff because she did not want to complain and was worried her meal would arrive later if she did. Review of the facility’s daily dinner menu for that evening showed that crispy pork cutlet with gravy was served, indicating that the resident’s stated and documented preferences and restrictions were not followed.
Failure to Provide Variety and Choice in Meal Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a variety of appealing meal substitutions consistent with resident preferences and the facility’s own policy. The facility census showed 58 residents, with 57 on oral diets, and the Alternate Menu listed deli sandwiches, grilled cheese, chef’s choice salad, and bread as substitution options. However, interviews and observations revealed that in practice residents were typically only offered grilled cheese sandwiches, with occasional ham sandwiches that were served without cheese. The Food Service Manager reported that hamburgers, hot dogs, and pizza had been removed from the substitution menu after a budget review, and that the alternate list was reduced to deli sandwiches and grilled cheese. Multiple residents, including resident council leaders, stated they did not like the food served and that the only consistent substitution offered was grilled cheese, despite the facility’s written list of other options. Residents reported that they had previously been offered a wider variety of substitutions such as pizza and hamburgers, but those options were no longer available. Some residents stated they had repeatedly voiced concerns at meals and during resident council meetings about the lack of variety and appealing choices, but no changes were made, leading at least one resident to stop speaking up because complaints did not result in any resolution. Staff interviews corroborated the residents’ complaints. Several CNAs and nursing staff stated that residents frequently complained about the food, the lack of variety, and the limited substitutions, confirming that grilled cheese was essentially the only substitute offered. The Food Service Manager acknowledged that the chef salad on the substitution list was limited to lettuce, American cheese, and deli meat, and that items like tomato and cucumber were only included if they happened to be on the main menu and in stock, as they were not ordered specifically for substitution salads. During a lunch observation, kitchen staff confirmed that there were no cucumbers, tomatoes, or onions available, and grilled cheese sandwiches were seen prepared in a steamtable pan on the serving line, further demonstrating the restricted and repetitive nature of the substitution offerings.
Failure to Document and Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that a resident’s food preferences were documented and honored, resulting in the resident repeatedly receiving an undesired food item. During an interview, Resident B, who was cognitively intact per a 5-day MDS assessment, reported that he did not like oatmeal and had continued to receive it on his meal tray despite telling staff several times not to send it. Review of his medical record showed he was admitted with diagnoses including diabetes, heart failure, and hypertension, and had a physician’s order for a consistent carbohydrate, regular texture diet. However, his care plan contained no specific food preferences, and his nutrition assessment only stated that food preferences were on the tray card, with no additional information recorded. The DON stated that food preferences were recorded on nutritional assessments, while the DM explained that residents were given daily menus and asked to indicate what they wanted, and that she would include likes and dislikes if residents informed her. Neither the DON nor the DM reported being told of any food preferences by this resident. The DM provided a copy of the daily menu for the resident, which lacked any notation of likes or dislikes at the bottom where such information was supposed to be recorded. The facility’s policy, “Clinical Nutrition documentation,” stated that residents have the right to make their own food choices related to individual differences and cultural and ethnic preferences, but the documentation and meal service for this resident did not reflect his stated dislike of oatmeal.
Failure to Honor Documented Food Dislike
Penalty
Summary
The facility failed to honor and accommodate a resident’s food preference by serving breakfast sausage despite the resident’s documented dislike for it. Resident #68 was admitted with diagnoses including unspecified dementia and unspecified protein-calorie malnutrition, and her most recent MDS showed a BIMS score of 12, indicating moderately impaired cognition. Her meal ticket listed a special note that she disliked breakfast sausage. During observations on two separate mornings, Resident #68 was seen with a breakfast sausage patty cut up on her breakfast plate, and she stated both times that she did not eat breakfast sausage. During the second observation, the dietary staff member confirmed that breakfast sausage was listed as a dislike on the meal ticket and should not have been served. The administrator also confirmed that because breakfast sausage was listed as a dislike, it should not have been served to the resident.
Failure to Honor Food Preferences and Follow Posted Menus
Penalty
Summary
The deficiency involves the facility’s failure to honor resident food preferences, provide listed menu items, and offer appropriate alternatives. One cognitively intact resident, identified as Resident 2, had a documented dislike of beets on their meal slip but was observed receiving a lunch tray with a large serving of cut-up red beets. Resident 2 reported that they often received foods they did not like and frequently had to request a peanut butter and jelly sandwich instead. Resident 2 stated they had repeatedly spoken with the Administrator (Staff A) about ongoing problems with food service. Another cognitively intact resident, identified as Resident 3, was observed with a lunch tray containing mashed potatoes and reported that they were surprised because, when rice was on the menu, that was usually what they received. Resident 3 pointed to their meal slip, which listed rice under dislikes, and reported that they often ordered from the bistro menu but still received the main meal instead. Resident 3 stated the menu had been incorrect for four of seven days in the previous week. Additionally, during an observation of the posted daily menu, residents were supposed to receive spiced pears, but trays contained mangoes with whipped topping instead. A dietary aide (Staff F) confirmed that mangoes were served and stated that day-shift staff frequently prepared whatever food was on hand rather than what was on the menu. The Administrator (Staff A) acknowledged there were emerging issues in dietary services and affirmed that residents should not receive items on their dislike/allergy lists, should be able to receive alternate menu items they order, and that served food should match the menu or be communicated to residents if changed.
Failure to Honor Documented Food Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to provide food and beverages in accordance with residents’ documented allergies, intolerances, and stated food preferences for two residents. Resident 188’s lunch meal ticket identified a lactose allergy and dislikes for pineapple and raw tomatoes, but during lunch the resident was served a side salad containing raw tomatoes and a cup of white whole milk. At the time of the meal, the resident stated she was allergic to raw tomatoes, pineapple, and milk. Staff confirmed the resident was served raw tomatoes despite the meal ticket identifying tomatoes as a dislike, and the unit drink cart did not have lactose-free milk available even though an unopened half-gallon was present in the kitchen walk-in refrigerator. Clinical record review showed a CRNP progress note documented dietary allergies to chocolate, raw tomatoes, pineapple, and lactose intolerance, but the allergy list in the medical record included pineapple and lactose and did not include raw tomatoes. Resident 167’s lunch meal ticket documented dislikes of tomatoes and cucumbers, yet the resident was served a side salad containing both items. The resident stated he frequently receives foods identified on his dislike list. The NHA and DON confirmed the facility failed to accurately transcribe dietary allergies in the medical record and failed to ensure residents received meals consistent with their documented allergies, intolerances, and preferences.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
