Failure to Provide Adequate Meals and Snacks, Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide meals and snacks in accordance with resident needs, preferences, and requests, resulting in nutritionally inadequate meals for all residents. Surveyors found that the facility did not consistently provide bedtime snacks as required, and residents reported not receiving snacks for several months. The facility's policy required three meals daily and snacks, with no more than 14 hours between the evening meal and breakfast unless a nourishing bedtime snack was provided. However, there was no documentation to confirm that snacks were offered or that meals met nutritional and therapeutic requirements, especially for residents with special dietary needs such as pureed or gluten-free diets. During the survey, the kitchen's dishwasher and three-compartment sink were non-operational due to sanitation issues, and the facility was unable to provide the planned meals. Meals were served in disposable containers, and residents requiring texture-modified diets received commercial baby food with only about 100 calories per serving. There was no evidence that these substitute meals were nutritionally equivalent to the planned menu or met physician-ordered dietary restrictions. Additionally, the facility lacked a contingency plan for meal provision during dietary staff absences, and there was no qualified dietary staff present to prepare meals on the morning of the survey. Staffing challenges further contributed to the deficiency, as the facility had only one inexperienced cook on staff, and other staff members with limited food service experience were temporarily assigned to kitchen duties. The Registered Dietitian was working remotely and did not physically oversee the dietary program. Interviews with residents and staff confirmed that bedtime snacks were not consistently offered, and there was no process in place to ensure their provision. The lack of documentation, qualified staff, and oversight resulted in the failure to provide adequate nutrition and hydration to all residents, placing them in Immediate Jeopardy.