Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for five residents, leading to deficiencies in meeting their nutritional needs. Resident #27 expressed dissatisfaction with not receiving her preferred chef salad on scheduled days and noted issues with the oatmeal's texture and receiving coffee instead of her preferred hot tea. Despite her requests, the facility did not consistently provide her with whole milk at every meal. Photographic evidence confirmed the absence of the chef salad on a scheduled day, and the Certified Dietary Manager acknowledged the oversight. Resident #29, who required a double protein portion due to his size, was served a regular portion of meat, contrary to his meal ticket. He expressed the need to supplement his intake with additional food due to the insufficient portion size. Similarly, Resident #44 did not receive her preferred peanut butter and jelly sandwich or dry cereal, as documented on her breakfast ticket. The resident expressed enjoyment of a specific brand of sandwich that was no longer provided, and photographic evidence supported the absence of these items. Resident #50, who was supposed to receive large portions and fortified foods, did not receive fortified oatmeal and was served a regular-sized portion of meat. His wife confirmed his dislike for oatmeal, and the resident expressed willingness to eat more meat if provided. Resident #85, who was on fortified foods and chocolate milk, reported inconsistencies in receiving these items. Observations confirmed the absence of milk and fortified foods, and the resident expressed resignation to the situation. The Certified Dietary Manager and Registered Dietitian acknowledged the discrepancies when shown photographic evidence.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #27, 29, 44, 50, and 85 were assessed by licensed nurse, no concerns identified. On 4.4.25 resident #27, 29, 44, 50, and 85 were provided meals per their preference and meal ticket; no concerns identified. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. On 4.14.25 facility with external consulting company for dietary services to include management oversight, line staff and cooks. Same practice and what corrective actions will be taken: On 4.9.25 a quality review was completed by Registered Dietician/designee on current residents to ensure food preferences in place, accurately reflected on meal tray tickets and resident provided with correct meal per menu. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.17.25 Ad Hoc Resident Council meeting held to review survey results and plans being implemented for correction of alleged deficiencies identified. On 4.22.25 Dietary Manager completed education with dietary staff and nursing staff on the components of F803 menus meet resident needs/prep in adv/followed with emphasis on ensuring food preferences are in place per resident preferences and reflected on meal tray ticket by the Director of Nursing/designee. Newly hired dietary and nursing staff will be educated on the components of F803 menus meet resident needs/prep in adv/followed with emphasis on ensuring food preferences are in place per resident preferences and reflected on meal tray ticket by Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Registered Dietician/Designee to conduct audits of 5 residents meals twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F803 menus meet resident needs/prep in adv/followed with emphasis on ensuring food preferences are in place per resident preferences and reflected on meal tray ticket. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.