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F0806
E

Failure to Provide Substitute Food Choices and Accommodate Dietary Preferences

Gillespie, Illinois Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate substitute food choices for five residents who were reviewed for meals, resulting in unmet dietary preferences and needs. Multiple residents, including those with cognitive impairments, malnutrition, and special diet requirements, were observed not receiving alternatives when they disliked or could not eat the food served. For example, one resident with dementia and severe protein calorie malnutrition requested plain turkey but was repeatedly served turkey in a sandwich or with gravy, contrary to her stated preference. Another resident on a consistent carbohydrate diet due to diabetes and at risk for malnutrition was not offered alternatives when he disliked the processed turkey served and was unable to cut it, leading to minimal food intake. Residents with mechanical soft diets or other dietary restrictions also experienced similar issues. One resident without teeth, on a mechanical soft diet, repeatedly received grilled cheese sandwiches despite expressing dislike for them and not being offered other options. Another resident with a history of CVA and dysphagia, requiring a mechanical soft diet, was not asked about food preferences and only ate limited portions of her meal. Additionally, a resident with Parkinson's disease and low BMI reported not being asked about meal preferences and not liking the food provided, resulting in poor intake. Observations revealed a lack of staff presence in the dining room to assist or offer alternatives to residents who were not eating their meals. Interviews with staff, including the Dietary Manager and Administrator, confirmed that there was no clear policy or consistent practice for offering meal substitutions, and staff were not routinely checking with residents about their food preferences or providing alternatives when meals were refused or disliked. Facility policies referenced food preference interviews and the provision of alternate selections, but these were not consistently implemented in practice.

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