Complaint Investigation Report

This issue was previously investigated under complaint #29-AS-20251119115422 in November 2025. During the prior complaint, LPA reviewed posted menus as well as revised “as served” menus, interviewed residents and staff, and discussed the facility’s menu planning system. The facility utilizes a software program called Grove, which is designed to ensure menus meet regulatory nutritional standards and provides structured guidance for menu planning and substitutions.

During the current complaint, LPA interviewed residents on 4/7/26, and during annual visit on 7/8/26 who stated that there have been times when items are not replenished, such as bacon, certain fruits, etc. and that a recent holiday event was advertised to have a specialized menu, but ended up offering BLT sandwiches and one specialized item. Other than the holiday event menu, when asked about menu concerns and changes, those interviewed did not have issue with the changes and stated that it is occasional.

LPA also reviewed resident council minutes from 2/18/25 to 6/16/26 there was new comments regarding requesting more variety in dinners and deserts and more replacement items being stocked in the bistro.

During annual visit on 7/8/26, LPA was informed by residents and staff that the culinary department experienced significant staffing changes within the last two months, including the resignation of the Culinary Director, the hiring and subsequent resignation of a new Culinary Director, the termination of a cook, and the resignation of additional culinary staff. Through interviews and review of documentation, LPA found that Directors and the Administrator have been filling in for cooks and servers to assist with meal service.

Title 22 regulations do not prohibit substitutions, provided menus are planned in advance, maintained on file, and overseen by qualified personnel. Menus posted and menus maintained on file met regulatory requirements. While residents reported occasional substitutions or uncertainty about meals until arriving in the dining room, the investigation found substitutions to be infrequent and within required nutritional standards.

Based on review of records, resident interviews, menu documentation, and regulatory requirements, the facility is in compliance with Title 22 regulations regarding menu planning and nutritional offerings. Therefore, this allegation is UNSUBSTANTIATED at this time.