Failure to Provide Resident-Preferred and Prescribed Dietary Options
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, intolerances, and preferences, as well as appealing options, for six out of seven residents reviewed for meal preferences and substitutions. Multiple residents with complex medical histories, including conditions such as diabetes, heart failure, dementia, and dysphagia, reported not receiving the food items listed on their dietary tickets, missing substitutions, and receiving items they specifically disliked or were not supposed to have. For example, one resident with dietary restrictions did not receive cranberry juice as ordered for several weeks, while another received rice despite a documented dislike, and another received beans despite a restriction against them. Several residents also reported not receiving requested or required items such as bananas, yogurt, or cereal, and noted that substitutions were often unavailable or significantly delayed. Staff interviews corroborated these resident reports, revealing that dietary staff shortages and supply issues contributed to the deficiencies. Staff described a period when all dietary staff walked out due to poor working conditions, including lack of gas for cooking and no air conditioning in the kitchen. During this time, non-dietary staff, including nurses and CNAs, prepared meals, which resulted in limited food options such as peanut butter and jelly sandwiches and oatmeal, with some residents missing supplements and double protein items. Staff also reported that food trays frequently lacked condiments and that substitutions and supplements were not consistently provided. The facility's dietary manager acknowledged ongoing issues with dietary tickets not being read carefully and missing items, and stated efforts were being made to address these problems. The facility's policy on dining experience emphasizes providing an exceptional dining experience that honors individual care plans and preferences, but observations, interviews, and record reviews demonstrated that these standards were not met during the survey period.