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F0803
E

Failure to Follow and Clearly Post Current Menu Cycle

Three Rivers, Michigan Survey Completed on 12-23-2025

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 posted menu and serve food items as scheduled, did not post the current menu in a manner accessible for residents to review, and did not update the menu with changes when they occurred. Observations revealed that the menu posted in the main dining room was not clearly marked to indicate the current week of the menu cycle, requiring residents to flip through multiple pages to determine what meals were scheduled. There were no dates on the menu to clarify which week was current, and the menu visible was consistently for Week 4, regardless of the actual week. Interviews with dietary staff confirmed that meals served did not always match the scheduled menu due to issues such as missing ingredients and confusion among newer staff about which week of the menu cycle was being followed. A resident with cerebral palsy, major depression, muscle weakness, and a need for assistance with personal care reported that the food served was often inconsistent with the posted menu and that she was frequently unaware of what would be served until the meal tray arrived. Dietary staff acknowledged serving meals from different weeks and substituting menu items based on availability, rather than following the planned menu. These actions resulted in inconsistencies in meal service and a lack of clear communication to residents regarding their meal options.

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