F0812

F

Failure to Procure and Serve Food According to Approved Menu

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to procure and provide sufficient food items and ingredients to follow the written, approved menu for all residents who consume meals from the kitchen. The census showed 112 residents, with 6 NPO, meaning 106 residents relied on the facility’s food service. Cognitively intact residents reported that the food was “terrible,” “barely edible,” and “nasty,” and described frequent situations where the main entrée or substitutes were unavailable, resulting in them receiving different items than ordered or not eating at all. A CNA and an LPN confirmed that residents complained about the taste of the food almost daily and that there were times when the main meal or substitute ran out, requiring staff to serve sandwiches or other unplanned items instead of the planned entrée.

Surveyor observations in the kitchen showed that the cook did not follow the written menu and recipes due to missing or unused ingredients. For a stuffed pepper entrée, the cook stated the recipe called for ground turkey but used ground beef instead, believing ground turkey had not been ordered. For mechanically altered diets, the menu called for creamed corn, but the cook prepared carrots instead, stating there was no creamed corn available. The cook also burned a large portion of the cornbread and chose not to use it, stating there was no more cornbread and that no additional cornbread would be made, resulting in residents receiving plain wheat sandwich bread in place of the cornbread listed on the menu. A dietary aide confirmed that at least six residents would receive plain sandwich bread instead of cornbread.

A test tray provided to the survey team contained corn, a plain piece of bread, and an unidentifiable rice/meat mixture in tomato-based sauce, without the cornbread, stuffed pepper, or spiced peach dessert specified on the menu. The cook stated they had run out of stuffed peppers, cornbread, and the spiced peach dessert. The dietary manager later stated that the correct meat for the stuffed peppers and additional cornbread were actually available and thawing, and did not know why the cook failed to use them or follow the menu. The consultant RD reported not being aware of any ingredient substitutions or menu changes and had not approved any changes for that day, and stated that the facility should be following the approved menus and recipes. When asked, the administrator acknowledged that the facility should be following the written menu and procuring all needed ingredients, and further stated that the facility had no policy for food procurement/ordering, despite having a written “Menu Changes” policy requiring that changes be documented, nutritionally similar, and, if permanent, approved by the dietitian.