F0803

F

Failure to Provide Menu Variety, Honor Preferences, and Follow Dietician-Approved Menus

South Holland, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide menu variety, honor resident preferences and cultural/ethnic considerations, follow written recipes and menus, and obtain dietician input for menu and recipe substitutions, affecting 106 residents who consume food from the facility’s kitchen. The facility census showed 112 residents, with 6 documented as NPO, leaving 106 residents dependent on the kitchen for meals. Residents reported that the food was of poor taste, often cold, and lacked variety, with frequent sandwich-style dinners. One resident with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, obesity, COPD, and major depressive disorder stated that the food was “terrible,” often caused diarrhea, and that dinner was “always just sandwiches of some sort,” describing being served a dry ham sandwich without condiments and expressing that this was particularly problematic given the cultural importance of Sunday dinners in the Black community. Other residents described the food as “nasty” and lacking variety, and confirmed that many dinners consisted of sandwiches.

Surveyors observed multiple instances where staff did not follow the written menu or recipes and made unapproved substitutions. During a lunch service, the cook reported that the stuffed pepper recipe called for ground turkey but ground beef was used instead, stating that ground turkey was not available, despite the dietary manager later stating that the correct meat had been thawed and available. For mechanically altered diets, the menu called for creamed corn, but the cook prepared carrots instead, without knowing why creamed corn was unavailable. At the same meal, desserts labeled as spiced peach parfait were prepared using canned spray whipped cream directly onto peaches, then covered with plastic wrap, which caused about half of the whipped cream to adhere to the plastic. The dietary aide confirmed using spray whipped cream and that no honey was mixed into the topping, despite the recipe requiring whipped topping prepared from mix with honey incorporated. There was no visible indication that honey had been added, and the facility did not provide a pureed carrot recipe when requested.

Additional observations showed failure to follow the posted menu and to obtain dietician approval for substitutions. Cornbread listed on the menu was partially burnt; the cook discarded the burnt portion and did not prepare additional cornbread, later serving plain wheat sandwich bread in its place. The cook and dietary aide confirmed that at least six residents received plain bread instead of cornbread and that the dietician was not notified of this change. A test tray provided to surveyors contained corn, a plain piece of bread, and an unidentifiable rice/meat mixture in tomato-based sauce, without the stuffed pepper, cornbread, or spiced peach dessert listed on the menu. The cook stated that the rice/meat mixture was the inside of the stuffed pepper used for mechanical soft diets and that the facility had run out of stuffed peppers, cornbread, and the spiced peach dessert. The dietary manager, employed for about two months, acknowledged that the corporate-approved menu cycle contained many sandwich-style dinner entrees and that residents had complained about lack of flavor and palatability. Resident council minutes documented concerns about vegetables on sandwiches and noted an in-service on making grits, but did not document corrective action regarding residents’ expressed preferences for vegetables on sandwiches. The consultant RD confirmed not being informed of or approving any ingredient substitutions or menu changes for the observed meal and affirmed that food should be prepared as directed by the recipes and menu. Facility policies required that menu items be served as planned whenever possible, that changes be documented and of similar nutritional value, and that permanent changes be approved by the dietician, as well as that cycle menus provide variety and reflect religious, cultural, and ethnic needs and resident preferences, which did not occur in these instances.