Failure to Follow Menus and Honor Resident Food Preferences
Penalty
Summary
Surveyors identified that the facility failed to prepare and serve menu items as planned and did not consistently provide residents with their requested food preferences. Observations and interviews revealed that several residents received meals that did not match their prescribed diets or stated preferences. For example, one resident with dysphagia and hyperkalemia, who was approved for a regular diet, continued to receive pureed foods and was served disliked items such as mashed potatoes, despite documentation of these preferences. This resident also experienced a significant weight loss over three months. Another resident with multiple diagnoses, including gastroparesis and food intolerances to corn, green peas, beef, and pork, reported repeatedly receiving foods he could not tolerate, such as corn and beef. Observations confirmed that corn was served to this resident despite clear documentation of these intolerances. Additional residents reported discrepancies between their meal tickets and the food actually served, such as missing items (lettuce and tomato) or receiving different desserts than listed on the menu (cookie instead of peach pie). Family members and residents also noted a pattern of receiving the same food items regardless of the menu, such as one resident consistently being served mashed potatoes and butterscotch pudding instead of requested or listed items. The facility's registered dietician confirmed that dislikes should not appear on trays and that the electronic meal tracker system is used to update preferences, but these updates were not consistently reflected in meal service. These findings demonstrate a failure to follow prescribed diets, honor food preferences, and serve menu items as planned, as required by facility policy and state regulations.