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F0806
E

Failure to Honor Resident Food Preferences, Allergies, and Portion Sizes

Kalamazoo, Michigan Survey Completed on 06-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consistently honor resident food preferences, allergies, and portion size requirements, as evidenced by multiple resident and staff interviews, observations, and record reviews. Several residents reported receiving food items they were allergic to or disliked, such as one resident with a cinnamon allergy being served food containing cinnamon, and others receiving disliked items like chocolate or pears. Residents also reported that their specific dietary needs, such as requests for no sugar or large breakfast portions, were not met, and that meal tickets were not always accurately completed or followed by kitchen staff. Staff interviews revealed ongoing issues with the kitchen frequently running out of both main and alternate menu items, resulting in residents not receiving their preferred or required foods. Dietary staff admitted to not always having the necessary food items due to incomplete deliveries and restrictions on purchasing missing items locally. There was also a lack of clarity and consistency in portion control, with dietary aides unable to explain or demonstrate how portion sizes were determined, leading to residents receiving insufficient amounts of food. Nursing and dietary staff described communication breakdowns and difficulties in correcting meal errors, further contributing to resident dissatisfaction. Residents and their representatives consistently voiced concerns about small portion sizes, lack of alternate menu options, and being served foods they could not or did not want to eat. These issues were corroborated by staff observations and interviews, which highlighted that residents were often left without adequate or appropriate meal choices. Facility leadership, including the NHA and DON, were unaware of the extent of these food service concerns at the time of the survey.

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