F0806

D

Failure to Honor Resident’s Documented Dietary Preferences for Bread and Breaded Foods

Glenwood, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to consistently honor a resident’s clearly documented dietary preferences, resulting in the resident being served food that he had repeatedly requested to avoid. The resident is an adult male admitted for skilled therapy services with diagnoses including vertebrogenic low back pain, PTSD, atrial fibrillation, chronic low back pain, depression, polyneuropathy, and a cardiac pacemaker. His MDS showed a BIMS score of 12, indicating intact cognition, with no acute change in mental status or disorganized thinking. From admission, the resident and his family repeatedly informed staff that he avoids bread, rice, noodles, pasta, corn, breaded foods, and flour because he believes these foods worsen his chronic joint pain.

During an observation, the resident stated that he did not find the food very good and was particularly concerned about being served bread or breaded foods, which he described as “like a poison” to his joints. He reported that despite multiple discussions with staff since admission, he continued to receive these items and that his wife brought food from home several times a week so he would have food he could eat. While the surveyor was interviewing him, a CNA entered to deliver his lunch tray. The CNA was observed reviewing the meal ticket but did not compare the actual food items on the tray to the ticket. When the resident removed the cover, he found a piece of breaded chicken, became visibly sad and frustrated, and declined an offered substitute meal, stating that this problem “always happens.”

Review of the meal ticket for that tray showed that the resident’s diet order included No Added Salt (NAS), regular texture, and a specific written restriction of “No Rice, Noodle, Pasta, Rice, Corn, Bread, Breading on food, Flour,” along with a listed menu of Caribbean Jerk Chicken, steamed rice, black beans, pineapple, and beverage. The regional dietary consultant confirmed that the Caribbean Jerk chicken recipe uses bread and flour for coating and acknowledged it should not have been served to this resident given the documented preferences on the ticket. The RD stated that preferences are written on the tray ticket and are expected to be followed, and that the error should have been caught in the kitchen before the tray was sent. Staff interviews, including with CNAs, a dietary aide, and the DON, confirmed that facility practice and expectations are to check meal tickets, verify that trays match residents’ diets and preferences, and send incorrect trays back to the kitchen. One CNA admitted that on the day of the observation she was “moving too fast” and failed to check the food items against the ticket, resulting in the resident receiving breaded chicken contrary to his documented dietary preferences.

Facility policies, including the Dietary Standardized Menu Policy and OnTray Dietary Policies and Procedures, state that the facility will make reasonable efforts to provide appetizing food based on individual assessment and plan of care, support residents’ rights to personal dietary choices, and follow each resident’s preferences to the extent nutritionally and medically possible. Despite these policies and the clear documentation of the resident’s preferences on the meal ticket, the resident was served breaded chicken that contained bread and flour. This event, combined with the resident’s and family’s reports of multiple prior communications about his preferences, demonstrates that his dietary preferences were not consistently followed.