Failure to Offer Alternate Meal to Cognitively Impaired Resident
Summary
The facility failed to provide an alternate meal to a severely cognitively impaired resident, identified as R23, during a meal observation. R23, who had a BIMS score of five out of 15, indicating severe cognitive impairment, was observed spitting out each bite of the pureed meal being fed by the Unit Manager. Despite the resident's clear dislike for the meal, the Unit Manager did not offer an alternate meal, as per the facility's policy, which requires nursing staff to offer alternatives if a resident does not eat at least 25% of their meal or refuses food. The Assistant Dietary Manager later confirmed that there were alternate pureed meal options available, such as a pureed hamburger or hotdog, which R23 expressed a preference for. The resident eventually received the alternate meal and expressed satisfaction with it. Interviews with staff, including a Geriatric Nursing Assistant and the facility's Administrator, confirmed that alternate meals should be offered to residents who do not like their food, highlighting a lapse in adherence to the facility's meal delivery policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with Alzheimer’s disease and other comorbidities, who was cognitively impaired and dependent on staff for care, was not provided a meal consistent with documented food preferences and restrictions. During a breakfast service, the resident received pureed sausage, scrambled eggs, pureed toast, and cranberry juice, despite a meal ticket specifying yogurt, half a banana, tea, and no juice or soda. A CNA confirmed the resident did not receive the ordered items and was served juice contrary to the documented restriction, in violation of facility policy requiring that individualized food preferences and restrictions be reflected in the tray ticket system.
The facility failed to provide alternate meal choices of similar nutritional value and did not consistently honor resident food and beverage preferences during a period when the main kitchen was closed and meals were prepared from the dining room using limited equipment. Only a single entrée was offered at each meal, with peanut butter and jelly or deli sandwiches as the only substitutes, and several residents reported they could not order and were simply served whatever was prepared, including food they disliked or items that did not match their stated preferences. Residents also did not consistently receive requested beverages such as chocolate milk, 2% milk, cranberry juice, fruit punch, or ice with meals, and one resident reported being served burnt pizza with no alternative. The Dietary Manager confirmed there was no second meal option of similar nutritive value during the shutdown and that new dietary aides had not been fully trained on tray line duties.
Surveyors found that the facility failed to honor documented food preferences and allergy restrictions for two residents. One resident, with multiple behavioral and medical diagnoses, was served rice despite a recorded dislike and reported frequently receiving tomato-based items that upset her stomach. Another resident, with COPD and an allergy to raw onions, was served sautéed peppers and onions even after dietary staff verbally reminded each other to avoid onions, and the resident reported repeatedly receiving onions, mayonnaise, and sour cream despite stating he did not want them.
Two residents with intact cognition and multiple medical conditions did not receive the food items they selected on their meal tickets, such as vegetable soup and crackers. Staff interviews and Resident Council notes confirmed ongoing complaints about residents not receiving their requested menu items, despite CNAs being responsible for collecting and submitting meal selections to the kitchen.
Two residents with specific dietary preferences, including avoidance of pork and beef due to health and religious reasons, did not have their preferences consistently honored. Nutrition assessments were not completed in a timely manner, and staff failed to accurately document and follow dietary restrictions, resulting in residents receiving meals with items they wished to avoid.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, resulting in residents not always receiving meals that met their individual dietary requirements.
Failure to Follow Documented Food Preferences and Restrictions
Penalty
Summary
The facility failed to provide meals according to a resident’s documented food preferences and restrictions. A resident with Alzheimer’s disease, congestive heart failure, anxiety, and seizures, admitted in mid-September 2024, had a comprehensive MDS indicating a cognitive deficit and dependence on staff for all care. The resident’s care plan showed a need for supervision and occasional feeding assistance. On the observed breakfast service, the resident was served pureed sausage, scrambled eggs, pureed toast, and cranberry juice, with appropriate adaptive equipment. However, review of the resident’s meal ticket for that breakfast showed the resident was supposed to receive yogurt, half a banana, and tea daily, with explicit instructions for no juice or soda. Despite these documented preferences and restrictions, the resident was served juice instead of tea and did not receive the ordered yogurt and banana. A CNA confirmed that the resident was not supplied the ordered food and acknowledged that residents’ preferences changed often. Facility policy on accommodation of food preferences required that resident food preferences be listed in the tray ticket system and that alternate menu items be available to meet individualized needs and requests, but this was not followed in this instance.
Failure to Provide Alternate Meal Choices and Honor Resident Food Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide appealing meal options of similar nutritive value and to honor residents’ food preferences during a prolonged kitchen shutdown and subsequent transition period. For 19 days while major plumbing repairs were performed in the kitchen and dry storage, the facility prepared meals out of the dining room using limited equipment such as roasters, crockpots, a microwave, a griddle, and a waffle maker. During this time, only one meal choice was offered at each meal, and the only substitutes available were peanut butter and jelly sandwiches or deli sandwiches. The Dietary Manager confirmed that there was no second meal option of similar nutritional value available during the kitchen shutdown. Multiple residents reported not being able to order or receive their preferred items. One resident stated there were no second options or substitute items and that he was simply given food he did not like, including peas, carrots, and rice. Another resident’s meal ticket indicated a preference for chocolate milk, which was not provided on the tray. A different resident reported she does not order and is just served whatever is given; her stated preferences for 2% milk, cranberry juice, and fruit punch resulted in her receiving only fruit punch. Another resident reported being served burnt pizza with no other option when the kitchen was down and stated that even when she tells staff what she wants, she usually does not receive it; her ticket also indicated she should receive ice with every meal and fruit punch at lunch, neither of which were delivered. The Dietary Manager further acknowledged that new dietary aides were still in training and had not been given sufficient time to learn their tray line duties during and immediately after the kitchen relocation.
Failure to Honor Resident Food Preferences and Allergy Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to provide food that met documented resident preferences and allergies for two residents out of three reviewed for food preferences, in a census of 38. For one resident admitted with multiple diagnoses including post-traumatic stress disorder, alcohol use, major depressive disorder, generalized anxiety disorder, history of traumatic brain injury, convulsions, anemia, essential hypertension, vitamin D deficiency, and insomnia, the food preference and allergy sheet documented numerous dislikes, including any type of tomato products and rice. During observation of the lunch tray line, this resident was plated rice despite the tray card indicating rice as a disliked item, which was confirmed by the Dietary Manager and another staff member. In interview, the resident reported that tomatoes upset her stomach and that she often receives tomato-based soups or spaghetti sauce, which she does not eat when they are served. For a second resident admitted with diagnoses including chronic obstructive pulmonary disease, emphysema, acute chronic respiratory failure, anxiety disorder, essential hypertension, and major depressive disorder, the food preference and allergy sheet documented an allergy to raw onions and dislikes of tomatoes or tomato products and yogurt. During observation of the lunch tray line, the Dietary Manager reminded a staff member not to give this resident sautéed peppers and onions, and the resident’s tray card showed an allergy to raw onions. Despite this, the plated meal for the resident included sautéed peppers and onions, which was confirmed by the Dietary Manager and the staff member. In interview, the resident stated he keeps receiving onions despite telling staff multiple times he did not want them and also reported repeatedly receiving mayonnaise and sour cream, which he does not like. This deficiency was investigated under Complaint Number 2722647.
Failure to Provide Residents with Selected Menu Items
Penalty
Summary
The facility failed to ensure that residents received the menu items they selected at mealtime, as evidenced by observations, interviews, and review of records. Two residents with intact cognition and specific medical diagnoses, including hemiplegia, type II diabetes mellitus, hypertensive heart disease, and heart failure, did not receive the food items they had chosen on their meal tickets. One resident did not receive vegetable soup as selected, and another did not receive crackers, despite both items being available and provided only after staff intervention during the meal service. Staff interviews confirmed that residents frequently complained about not receiving their requested menu items. Further review revealed that CNAs were responsible for distributing and collecting menu tickets, but there were ongoing issues with ensuring residents' selections were honored. Resident Council Food Committee notes documented concerns about menus not being filled out and residents not getting what they requested. These findings demonstrate a pattern of the facility not providing food according to residents' documented preferences and selections.
Failure to Complete Timely Nutrition Assessments and Honor Dietary Preferences
Penalty
Summary
The facility failed to ensure that nutritional assessments were completed in a timely manner to determine dietary preferences and failed to honor food preferences for two residents. For one resident with multiple diagnoses including congestive heart failure, diabetes, and moderate cognitive impairment, the care plan and physician orders did not specify the resident's request to avoid pork and beef, despite documentation and interviews indicating these preferences. Observations confirmed that this resident received beef on his meal tray, and staff verified the presence of beef despite the resident's stated aversion. Another resident, with a history of kidney transplant, end stage renal disease, and diabetes, also reported a preference to avoid pork for religious reasons. Although the dietician was made aware of this preference, the resident continued to receive pork on meal trays and had to return them. Staff interviews revealed that dietary staff did not consistently review meal tickets thoroughly and relied on cheat sheets, which were incomplete regarding certain preferences. The facility's policy required interviews within 72 hours of admission to determine food preferences, but this was not completed for one of the residents involved.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of facility practices, which showed that residents were not always provided with meals that met their individual dietary needs and preferences.
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