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F0803
E

Failure to Follow Menus and Provide Adequate Portions Leads to Food Shortages

West Frankfort, Illinois Survey Completed on 09-16-2025

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 follow the prescribed menus and provide adequate portion sizes as directed, resulting in multiple instances where residents did not receive meals that met their nutritional needs. Several residents, including those with diagnoses such as protein-calorie malnutrition, diabetes, and vitamin deficiencies, reported that the facility frequently ran out of food or essential meal components. In some cases, residents received smaller portions or were given inappropriate food items, such as a diabetic resident being served two cinnamon rolls and a bowl of cereal due to a lack of suitable alternatives. Staff interviews corroborated these accounts, with multiple CNAs and dietary staff acknowledging that food shortages led to reduced portion sizes and an inability to provide seconds or alternative options when requested. Residents described situations where staff and sometimes other employees consumed food intended for residents, further contributing to shortages. There were also reports of the kitchen discarding leftover food after serving the main meal, leaving nothing available for residents who requested additional servings. The issue was not isolated to a single meal or day, as both residents and staff recounted repeated occurrences of running out of food, including breakfast meats and eggs, and lacking basic supplies like sugar and condiments. These deficiencies were documented through resident interviews, staff statements, and concern forms submitted by residents requesting larger portions and more snacks, especially during long intervals between dinner and breakfast. Care plans and medical records reviewed for affected residents indicated that many were at risk for malnutrition or had specific dietary needs that were not consistently met due to these failures. The facility's inability to ensure that menus were followed, meals were prepared in advance, and adequate food was available for all residents directly led to the deficiency. The administrator and dietary staff acknowledged awareness of the problem, with the administrator stating efforts were being made to address menu compliance, but the deficiency persisted at the time of the survey.

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