F0803

E

Failure to Provide Breakfast Variety and Honor Resident Food Preferences

Ganado, Texas Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure menus reflected the needs and preferences of the resident population, particularly regarding breakfast variety, despite policy stating that every attempt would be made to honor resident food preferences. Facility menus in effect from November 2025 through May 2026 listed the same breakfast each day: choice of juice, hot or cold cereal, fresh pasteurized eggs, bacon or sausage, breakfast bread, margarine, jelly, and whole milk. Observations on three separate mornings showed that residents were consistently served scrambled eggs, toast, sausage patties, bacon, gravy, and cereal, indicating that the same breakfast meal pattern was being followed daily. The Dietary Manager confirmed that the current menu had been in effect for a couple of months and that cooks were required to follow the menu as written.

Multiple residents with moderate cognitive impairment and various medical conditions reported dissatisfaction with the lack of breakfast variety. One resident with Alzheimer’s disease, dementia, major depressive disorder, and a care plan identifying potential risk for malnutrition stated she had the same breakfast every day, found it boring, and said dietary staff had not asked for her preferences, despite her dietary profile noting she liked breakfast and her care plan calling for updating food preferences as needed. Another resident with degenerative disease of the basal ganglia and altered mental status reported being served sausage and eggs every day since admission and expressed a desire for more options, even though her care plan required staff to anticipate and meet her ADL self-care needs.

Additional residents with diagnoses including severe protein calorie malnutrition, atrial fibrillation, renal osteodystrophy, pleural effusion, and emphysema also reported being tired of the same breakfast of eggs and sausage every morning and wanting variety, despite care plans directing staff to determine and provide food preferences within dietary limitations. Resident Council meeting notes for February 2026 documented a concern under Nutrition Services regarding breakfast variety, and the resident who had reported boredom with breakfast was in attendance at that meeting. The Dietary Manager acknowledged that a few residents had complained about having the same breakfast every day and stated she had not discussed any deviation from the set menu with the consultant dietitian, resulting in menus that did not incorporate resident input or provide variety as requested. The report states this practice could affect residents who consume breakfast and could result in psychosocial harm and/or weight loss.