Failure to Follow Posted Menu and Address Ongoing Food Quality Complaints
Penalty
Summary
The deficiency involves the facility’s failure to ensure food and drink were palatable, attractive, and served according to the planned and posted menu, as well as failure to provide meals in a manner consistent with residents’ nutritional needs. For one resident, admitted with multiple complex medical conditions including breast cancer history, diabetes with chronic kidney disease, hypertension, chronic kidney disease, and other comorbidities, the quarterly MDS showed she was not cognitively impaired and required setup or clean-up assistance for ADLs. A photograph dated 11/25/25 showed she was served burnt lasagna, mashed potatoes, and gray-green green beans instead of the planned lasagna, tossed salad, and mixed fruit. There was no documentation of any planned or approved menu substitution on the menu or substitution log for that date. The Ombudsman reported that this resident received burnt lasagna, mashed potatoes and gravy, and gray-colored green beans without requesting these substitutions, and also relayed broader resident complaints about food substitutions without notification and the use of Styrofoam plateware. The Ombudsman stated she had exhausted all avenues with management. The Dietary Manager confirmed that the posted menu was not followed for this resident’s lunch meal on 11/25/25, that no documentation of the substitution was completed, and that the photograph accurately showed burnt lasagna and mashed potatoes and gravy served instead of the planned tossed salad and mixed fruit. When shown the image, the Dietary Manager acknowledged he would not eat the burnt lasagna that had been served to the resident. The resident herself confirmed she was served a piece of burnt lasagna with mashed potatoes and gravy and had not ordered any substitutions. She also stated there was no fresh bread on site, that food was sometimes cold by the time it was served, and that she had raised these concerns in Resident Council and Food Committee meetings without improvement. A second resident, also not cognitively impaired and independent in ADLs, reported that the food “sucked,” that the facility did not listen to his concerns despite his attendance at Food Committee meetings, and that he was disgusted with the options and choices provided. He complained about plastic silverware, too many sandwiches, food sometimes being so tough he could not cut it, and an inconsistent snack cart with no variety. The Ombudsman corroborated multiple food complaints from several residents, including burnt lasagna, lack of fresh bread, unannounced food substitutions, and Styrofoam plateware. The Administrator confirmed there was no tracking system to ensure food-related complaints raised through Food Council were followed up and resolved.
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