Failure to Provide Palatable, Well-Balanced, and Appropriately Modified Diets
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, and well-balanced diet that met their daily nutritional and special dietary needs, as well as their preferences. Multiple residents reported dissatisfaction with the menu, describing it as repetitive and lacking variety, particularly noting the frequent serving of chicken and rice. Resident council minutes from February and April documented ongoing concerns about menu variety and the overuse of chicken, with no evidence that these concerns were addressed by the facility. Observations and record reviews revealed that residents on modified diets did not consistently receive appropriate menu options. One resident on a pureed diet repeatedly received only applesauce and pudding as dessert, rather than a variety of pureed dessert options, and did not receive the pureed mandarin oranges specified in the menu modification. Another resident with an order for a minced and moist level five IDDSI diet was served pureed food instead of the required minced texture, and at another meal, received ground meat without sauce or gravy, contrary to IDDSI standards. Recipes and meal preparation instructions did not include necessary modifications for the prescribed IDDSI diets. Staff interviews indicated a lack of comprehensive training and resources regarding IDDSI diet modifications. Cooks reported receiving only verbal instructions and did not have access to diet spreadsheets or recipes specifying IDDSI modifications. The DON stated that IDDSI diets were used, but was unsure if staff training included IDDSI standards. The quality director was also uncertain if the menu program included all necessary IDDSI resources, despite the facility having used IDDSI diets for about a year.