F0838

F

Failure to Address Cultural Food Needs and Define Dietary Staffing in Facility Assessment

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that identifies ethnic, cultural, or religious factors affecting resident care and a specific staffing plan for dietary services, including cooks and dietary aides. The written facility assessment dated 2/12/2026 includes a section instructing the facility to describe ethnic, cultural, or religious factors that may impact care, such as activities and food and nutrition services, and to list any specific or unique factors affecting care. However, the assessment only notes that residents and/or representatives will be interviewed to determine preferences and that activities will discuss these issues in resident council, and it lists the facility’s average age. It does not document any actual ethnic, cultural, or religious needs of the resident population, nor does it identify any specific or unique factors affecting care.

The assessment also requires the facility to describe its staffing plan based on resident needs, including other ancillary staff such as dietary. In the staffing plan section, the facility lists one Dietary Director but does not identify the requisite number of cooks or dietary aides needed to meet resident needs. During interview, the Administrator stated that the facility assessment does not have to list cooks or dietary aides and asserted that following the federal regulation only requires having enough staff to create and serve food, without specifying numbers in the assessment. This omission occurred despite the assessment tool’s instructions that the facility-wide assessment is to determine what resources, including staff and staffing plans, are necessary to care for residents competently during day-to-day operations and emergencies.

Interviews and record review further showed that resident cultural food preferences and dietary staffing needs were not adequately addressed in practice. One cognitively intact resident with multiple medical diagnoses, including type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, obesity, COPD, and major depressive disorder, reported that the food was “terrible,” lacked variety, and that dinners were routinely sandwiches, which did not align with their cultural expectation of a substantial Sunday dinner in the Black community. Other cognitively intact residents reported that meals were often served late, with one resident stating they received dinner at 7:10 p.m. instead of around 5:00 p.m. Dietary staff schedules for February 2026 showed frequent shifts with only one dietary aide or one cook on duty, and the Dietary Manager, employed for about two months, acknowledged that more kitchen staff were needed and that meals had been served late. These findings demonstrate that the facility assessment did not capture or plan for ethnic, cultural, or religious food needs or define adequate dietary staffing levels, contributing to the identified deficiency.