Federal inspectors observed breakfast service on November 18, watching dietary aides plate food in the kitchen while residents upstairs received meals missing items their care plans specifically required.
R13 wanted whole milk with his breakfast. His care plan, revised in August, noted his preference clearly. His meal ticket listed whole milk. But when his bedside tray arrived at 9:31 AM, it contained 2% milk instead.
"He prefers whole milk and that he only gets 2% milk," R13 told inspectors the day before the observed meal service.
The kitchen sent up coolers filled with 2% milk cartons for nursing assistants to distribute. No whole milk went upstairs.
R13 also didn't receive the fruit yogurt printed on his meal ticket. Neither did four other residents whose breakfast orders included yogurt or cottage cheese.
V33, a dietary aide plating food in the kitchen, explained the facility "does not have yogurt as they have run out for a while."
R21's meal ticket showed 4 ounces of pudding. She didn't get it. Her care plan from that same day included "yogurt with meals" and interventions to "determine dietary preferences" and "provide dietary supplements, as ordered."
R31's breakfast ticket listed fruit yogurt. His care plan from June specified "yogurt per request" and "lactose free milk." The interventions included determining food preferences through interviews with residents and families, then providing dietary supplements as ordered.
No yogurt arrived on his tray either.
R32's meal ticket included both cottage cheese and plain yogurt. Her October care plan listed "cottage cheese at breakfast and yogurt" with the same intervention language about determining preferences through resident and family interviews.
She received neither item.
R33's ticket showed fruit yogurt, and her care plan specified a lactose-free diet. Like the others, her plan included interventions to determine food preferences through interviews and provide dietary supplements as ordered.
Her tray came without yogurt.
During the breakfast observation, inspectors watched V33 plate food while V53, another dietary aide, placed nutritional supplements, thickened drinks and condiments on trays. The milk cartons and juice boxes went into coolers for nursing assistants upstairs to distribute with coffee from pitchers.
The meal tickets for the five residents showed no yogurt, pudding or cottage cheese would be provided. The kitchen plated accordingly.
V31, the facility dietitian, told inspectors two days later that "if the food preferences are on the meal ticket/tray cards, it should be given."
But the meal tickets didn't match what the care plans required. R13's care plan interventions included preparing and serving "the resident's nutritional diet as ordered." His August revision specifically noted his whole milk preference based on resident interviews.
The other four residents had similar care plan language. R31's plan called for determining food preferences through "one-to-one interview and/or family interview." R32's plan used nearly identical wording about resident and family interviews. R33's plan included the same interview requirements.
All five care plans included interventions to "provide dietary supplements, as ordered."
The breakfast service proceeded without the ordered items. Residents received standard 2% milk regardless of documented preferences. No yogurt, pudding or cottage cheese made it onto any observed tray, despite appearing on meal tickets and care plans.
The facility's dietary staff acknowledged the disconnect. V31 confirmed that items appearing on meal tickets should be provided to residents. V33 explained they'd run out of yogurt and hadn't restocked.
Federal inspectors cited the facility for failing to provide food that accommodates resident preferences, affecting five of five residents observed during dietary services sampling.
The violation occurred despite care plans that specifically documented resident food preferences and required staff to interview residents and families about dietary needs, then provide those foods and supplements as ordered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest View Rehab & Nursing Center from 2025-11-24 including all violations, facility responses, and corrective action plans.
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