Failure to Provide Complete and Appropriate Meal Service
Penalty
Summary
Surveyors found that the facility failed to provide meals that accommodated resident allergies, intolerances, and preferences for three out of five residents reviewed. Multiple residents did not receive all items listed on their meal tickets, including essential nutritional supplements and specific food items. The facility's policy required certified nurse aides to serve food per meal tickets and ensure accuracy, with nursing staff responsible for delivering and monitoring room trays. However, observations revealed repeated omissions of required food items during meal service. One resident with severe cognitive impairment, weight loss, and a mechanically altered diet was observed missing yogurt, coffee, fortified juice, health shake, and other items across several meals. Another resident with dysphagia and dehydration, who required supervision with eating, reported frequent missing items, and was observed receiving a tray lacking several components, including fruit, cottage cheese, and ice cream. Staff explained that some items were unavailable and offered substitutes, but not all missing items were replaced. A third resident with Alzheimer's and recent weight loss was repeatedly served incomplete trays, missing nutritional supplements and other foods, and reported that staff did not offer replacements for missing items. Interviews with staff, including certified nurse aides, a dining experience manager, and the food service director, confirmed that missing meal items were a recurring issue. Staff acknowledged that residents often complained about incomplete trays and that substitutions were not always provided. The food service director cited a national shortage of certain fortified juices but stated that alternative supplements should have been provided. Despite these expectations, the facility did not consistently ensure that residents received all items listed on their meal tickets.