The resident's spouse discovered the problem after the regular meal period had ended. She told inspectors on October 30 that her husband had failed to fill out his meal selection form, marking the second time he had missed a meal due to the facility's meal ticket system.
The resident requires staff assistance to complete his meal selection forms, according to the inspection report. Evening staff typically deliver meal tickets for the following day, residents choose their meals, and a different shift collects the completed forms.
His certified nursing assistant that day, identified as V6, said October 26 was "really busy" when the resident's spouse approached her after the noon meal service. The spouse reported that her husband had not received a lunch tray.
V6 called the kitchen immediately. Kitchen staff told her the resident's tray "should have gone out," but she searched extensively and could not locate it anywhere on the unit.
She went to the kitchen between 1:00 PM and 1:30 PM to request a replacement meal. The kitchen had already closed operations and had no remaining food from the noon service. V6 improvised, getting the resident a grilled cheese sandwich instead of his ordered mechanical soft diet meal.
The nursing assistant told inspectors she wasn't sure what happened to the original meal tray. She confirmed the resident never received his scheduled noon meal on October 26.
"Sometimes the kitchen will call and let us know if they did not receive a meal ticket for a resident, but she did not receive a call," according to the inspection report.
The facility's dining service director, V8, explained that room trays for lunch are delivered between 11:00 AM and 12:00 PM. Meal tickets are printed the day before, and dietary staff should print out the census, count the meal tickets, and confirm all forms were received.
"We rely on the floor staff to pass the tickets, pick up the tickets, delivery trays and inform dietary of any missed meals," the dining director told inspectors.
He said he was unaware of the resident missing his noon meal on October 26. "If the kitchen received a meal ticket the resident should receive a meal," he stated.
The dining director acknowledged that the kitchen closes "sometime after 1:00 PM" and said alternatives are available if a resident doesn't receive their scheduled meal.
The resident's physician orders from October 2025 specify a mechanical soft diet, which requires food to be chopped or ground to aid swallowing and digestion. The grilled cheese sandwich he ultimately received did not meet these dietary requirements.
The facility's meal service policy, revised in 2024, states that three meals will be provided daily "at regular times comparable to standard mealtimes in the community or accordance with resident needs, preferences, requests and individualized plan of care."
The breakdown occurred at multiple points in the facility's meal delivery system. The resident needed assistance completing his meal selection form but apparently didn't receive it. Staff failed to notice the missing meal ticket during the morning collection process. Dietary workers didn't catch the discrepancy when counting forms against the resident census.
The nursing assistant discovered the problem only after the resident's spouse intervened. By then, the kitchen had completed lunch service and begun closing operations for the afternoon.
Federal inspectors found the facility failed to ensure meals are served at scheduled times according to residents' needs and preferences. The violation affected one resident during the inspection sample, but the systemic nature of the breakdown suggests the meal ticket process had multiple failure points.
The resident's spouse had to monitor whether her husband received his meals, effectively serving as a backup system for facility operations. Her intervention prevented the resident from going without food entirely, though he still missed his prescribed mechanical soft diet and received an inappropriate substitute hours after the scheduled mealtime.
The facility's reliance on multiple staff shifts to handle different aspects of meal planning created gaps where residents requiring assistance could fall through the system. The resident missed his second meal in an undisclosed timeframe, indicating the problem had occurred before October 26.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village At Victory Lakes, The from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
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