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.
The facility failed to follow its own policies and practice of offering daily menu alternatives by not providing consistent food substitutions on weekends. Cognitively intact residents reported that activity staff offer meal choices and alternatives only on weekdays, and that on weekends they are told they must eat the posted menu item, with some residents stating they go hungry or must obtain outside food if they dislike the meal. Staff interviews corroborated that menu substitutions are routinely offered Monday through Friday but not on weekends, despite management statements and written policies indicating that alternatives and an "Always Available Menu" should be offered every day at every meal.
A resident with multiple medical conditions and intact cognition repeatedly did not receive requested scrambled eggs at breakfast or expected double portions, despite dietary notes documenting these preferences. CNAs and LPNs reported that the resident’s meals were often incorrect and required frequent calls to the kitchen for corrections. Review of records showed only a regular diet order without double portions and no documented Food Preference Interview, indicating that the resident’s stated dietary preferences were not consistently incorporated into formal diet orders.
The facility failed to consistently honor resident diet orders and food preferences, including during use of an emergency menu while the kitchen was under renovation. A resident with multiple comorbidities and a moderate cognitive deficit, ordered an NCS diet and documented to prefer Cheerios, was served Fruit Loops instead of a non‑sugar cereal. A resident with diabetes reported repeated peanut butter and jelly sandwiches over several days due to reliance on a shelf‑stable emergency menu with limited variety. Despite resident council feedback that some did not want corned beef, the facility served corned beef hash, leading several cognitively intact residents to refuse the meal, describe lunch as awful, and substitute other foods or personal supplies. The Dietary Manager and Social Services Director acknowledged awareness of these expressed preferences, and facility policy required assessment and communication of individual food preferences.
Two residents were not provided meal options that accommodated their food dislikes, despite a facility policy stating that resident likes and dislikes would be considered for substitutions. One resident ate a fish entrée he disliked only by covering it with tartar sauce and reported that the only alternative offered was a peanut butter and jelly sandwich, which he also disliked, and he was not offered a substitute for a dessert he did not eat. Another resident, who also disliked fish, skipped the facility meal and obtained outside food instead. The Dietary Manager reported there was no anytime menu and that available substitutes were limited to peanut butter and jelly or possibly a cheese sandwich, which were acknowledged as not nutritionally equivalent to the main meal.
A cognitively intact male resident admitted for skilled therapy, with chronic pain and multiple comorbidities, repeatedly informed staff that he avoids bread, rice, noodles, pasta, corn, breaded foods, and flour because he believes they worsen his joint pain. His diet ticket clearly listed a No Added Salt diet with explicit restrictions against these items, yet during an observed meal a CNA reviewed only the ticket, failed to verify the tray contents, and served Caribbean Jerk chicken that was breaded with bread and flour. The resident became visibly upset, declined a substitute meal, and reported that this problem had occurred repeatedly despite discussions by him and his family. The RD and regional dietary consultant confirmed that the recipe contained bread and flour and that staff are expected to follow tray tickets, while other staff and the DON stated that meal tickets and resident preferences must be checked and honored in accordance with facility dietary policies.
A resident did not receive food and supplements consistent with documented dietary preferences and orders. During a mealtime observation, the resident’s tray contained an uneaten turkey casserole, carrots, and a small cup of fluid, but no soup or health shake, despite the dietary sheet specifying a daily health shake, a serving of soup, and no casseroles. The resident reported that the wrong food was sent every day and that requested soup was not provided. An RN confirmed that no health shakes had been sent to the floor after checking multiple dietary carts, and the Dietary Manager acknowledged that soup was not available even though it was listed on the resident’s dietary sheet.
A resident with osteoporosis, who prefers milk and yogurt with meals and had a tray ticket indicating they should receive plain yogurt daily, did not receive yogurt with breakfast. Kitchen observations showed multiple tubs of yogurt available in the walk‑in cooler, while the resident reported being told the facility was out of yogurt and awaiting a shipment. A dietary aide confirmed the resident was to receive yogurt daily and that aides on the tray line are responsible for dishing yogurt for trays, indicating the resident’s documented dietary preference was not followed in practice.
The facility did not honor resident preferences for bacon, a previously available breakfast item, after a change in ownership and guidance from the food service provider. Multiple residents and staff reported frequent requests and complaints about the absence of bacon and other breakfast meats, with documentation in grievance logs and resident council meetings. The dietary manager and registered dietitian confirmed the removal was based on nutritional guidance, and the facility lacked a policy addressing resident menu preferences.
Several residents with complex medical needs did not receive food items according to their documented preferences and dietary restrictions, with missing substitutions, delayed service, and incorrect items provided. Staff and resident interviews revealed that dietary staff shortages, supply issues, and poor kitchen conditions led to non-dietary staff preparing limited meal options, resulting in missed supplements and incomplete trays. The facility's own policies for honoring resident preferences and care plans were not followed during this period.
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