F0806

E

Failure to Honor Food Preferences, Standing Orders, and Always Available Menu Items

Sault Ste. Marie, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to honor resident food preferences, standing diet orders, and to offer substitutes or alternative menu items as ordered or documented. During meal observations, multiple residents did not receive the type or amount of juice specified on their tray cards, including residents whose cards called for 8 fl oz of assorted or apple juice but who received only 4 fl oz, and one resident whose card specified certain acceptable vegetables but who was served carrots without an alternative vegetable. Another resident whose tray card allowed deli meat and specified an alternative meal of ham or turkey sandwich instead received a peanut butter and jelly sandwich. A resident who was supposed to receive two bowls of soup when no selective menu was filled out did not receive any soup, and several residents who requested hot dogs from the Always Available menu instead received hamburgers.

Additional observations showed that condiments and beverage additions documented as standing orders were not provided. One resident’s tray card specified cream and sugar substitute, but the tray arrived without cream, sugar substitute, salt, or pepper, despite staff acknowledging the resident would want these items. Several residents with tray cards indicating “extra sauces or gravy” or “sauce/gravy on all meats” received dry ground or chopped meat without sauce or gravy; one of these residents reported the meat was too dry, did not like it, and ate only a sip of milk and part of a muffin. At breakfast, a resident who had handwritten yogurt on a selective menu did not receive yogurt and stated this had happened before, and another resident whose standing orders included a daily banana did not receive one, although other residents had bananas and the resident stated he would like one.

Surveyors also noted failures to offer substitutes when meals were not eaten and ongoing, unresolved food availability issues. One resident with malnutrition and severe cognitive impairment had a breakfast tray placed out of reach and did not eat any of the food before a hospitality aide removed the tray without offering any substitutes or alternatives. Another cognitively intact resident had a meal tray removed by an LPN without being offered any food or beverage substitutes or alternative menu items. In a confidential group interview, four residents reported the facility frequently ran out of preferred items listed on the Always Available menu, including ice cream, yogurt, pudding, cookies, hamburgers, and hot dogs; one resident requiring a gluten-free diet reported being served salad for two meals a day, five days per week and expressed frustration, stating they wanted anything other than salad. Resident council minutes over several months documented repeated, unresolved complaints that residents continued to receive foods listed as dislikes on their meal tickets and that the kitchen repeatedly ran out of requested items such as hamburgers, hot dogs, tomato juice, hot chocolate, ice cream, creamer, sweetener, and cottage cheese.