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F0803
D

Failure to Honor Resident Food Choices and Menu Consistency

Grand Rapids, Michigan Survey Completed on 12-29-2025

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 ensure that a resident's food choices were consistently obtained and honored, resulting in dissatisfaction with meal services and the potential for inadequate food or fluid intake. The resident, who had a complex medical history including iron deficiency, slow transit constipation, mixed irritable bowel syndrome, lymphedema, CHF, morbid obesity, recurrent UTI, hypertension, depression, and a history of pressure injuries, was on a regular vegetarian diet and was supposed to be offered food and beverage selections with substitutes as requested. Despite this, the resident reported not receiving planned menu items on multiple occasions, such as the Christmas lunch meal and lentil meatloaf, and expressed frustration over the lack of suitable vegetarian options and necessary condiments for her meals. Interviews with dietary staff and the registered dietician revealed that errors in ordering and meal preparation contributed to the resident not receiving her selected meals. The dietary manager admitted to forgetting to order specific items, and the registered dietician confirmed that some preferred items were not available from the supplier, requiring alternative discussions with the resident. The resident also reported feeling that she was expected to supply her own food due to the limited vegetarian options available, and staff acknowledged lapses in providing the correct menu items as ordered.

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