F0802

F

Inadequate Dietary Staffing Leading to Poor Food Quality and Service

Terre Haute, Indiana Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient food and nutrition services staff as outlined in its own facility assessment, which called for a director and three food and nutrition services staff. Surveyors reviewed a confidential statement indicating that the food from the kitchen was described as disgusting and that there were not enough kitchen workers. During a lunch observation, only two dietary staff were present: the Dietary Manager, who was also the cook, and a Dietary Aide. The Dietary Manager was the only person plating food for both the dining room and hall trays and was unable to provide an additional food item requested by a resident, stating she did not have time because she needed to prepare all the hall trays.

Multiple residents reported concerns about food quality and lack of alternatives, which they attributed to insufficient kitchen staffing. One resident stated that the food had gone downhill, was repetitive, and not worth eating, and commented that there was only one cook who could not manage all the work. Another resident reported that the food was terrible and that no alternatives were offered because there was only one cook who did not have time to prepare other options. A third resident reported that meals were often late and that food quality had declined, acknowledging that there was only so much one person could do.

Interviews and schedule reviews showed that the Dietary Manager had effectively been working as the only cook for an extended period. The Administrator stated the facility should have a full-time Dietary Manager, day cook, evening cook, and dishwasher, and that other non-dietary staff could help in the kitchen if needed. The Dietary Manager reported she had been performing manager duties since August 2025, had been prepping, cooking, and cleaning up all meals daily, working approximately 14 hours a day, 7 days a week, and had worked over 30 days without a day off. She also reported not being trained on the computer system for ordering food and lacking time to properly clean the kitchen or begin ServSafe certification. Review of dietary schedules over several weeks showed repeated days with only two staff in the kitchen, the Dietary Manager consistently working 13–14 hour shifts, and at least one day with only one staff member in the kitchen and no cook scheduled, demonstrating a sustained pattern of inadequate staffing relative to the facility’s own assessment.