F0692

D

Failure to Provide Ordered Fortified Foods and One-on-One Feeding Assistance

Saint Louis, Missouri Survey Completed on 11-17-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered fortified foods and adequate nutritional support, including one-on-one feeding assistance, to residents identified as needing enhanced nutrition. The facility’s own policy on weight variances required RD assessment and interventions such as fortification and supplements for residents with significant or unplanned weight loss. During a breakfast meal preparation observation, dietary staff prepared oatmeal using two 42-ounce tubs of quick oats in a 40-quart pot with steaming water, adding an unmeasured amount of melted butter. The oatmeal was described as thin, watery, undercooked, lacking flavor, and greasy, and the cook stated it was not cooked longer due to time pressure. Despite a facility recipe specifying 2½ gallons of water and 3 pounds of instant oatmeal with a defined cooking process, the oatmeal did not meet the described consistency, and super cereal, the facility’s fortified oatmeal product, was not prepared at all that morning.

The facility had identified 33 residents who were to receive fortified foods, and its fortified list and RD guidance required that fortified foods, including super cereal, be prepared and served daily to residents with orders. However, during the observed breakfast service, the same oatmeal was served to residents on both regular and fortified diets, and no health (house) shakes were placed on the trays, despite expectations that dietary staff would ensure shakes were included. A CNA later reported not being familiar with fortified foods or super cereal and could not confirm whether residents received them with breakfast. The Dietary Manager and RD both stated that super cereal should be made daily, separate from regular oatmeal, and that house shakes should be provided on trays with meals for residents with orders, but on the observed day these fortified items were not provided as required.

The deficiency also involved a specific resident with documented nutritional needs and significant weight loss who did not receive ordered fortified foods, health shakes, or one-on-one feeding assistance. This resident had impaired cognition, dementia, anxiety, and Parkinson’s disease, required substantial/maximal assistance with eating per the MDS, and had experienced unplanned weight loss from 167.8 lbs in April 2025 to 138.4 lbs by early September, and then to 131.0 lbs by the end of September. The care plan and physician’s orders called for a regular diet with double portions, fortified foods with all meals, a divided plate, house shakes with meals, and one-on-one feeding assistance. Observations showed the resident alone in the room at lunch with a regular plate (not divided), attempting but unable to eat spaghetti independently, stating they were done eating despite a nearly full plate, and reporting not receiving a shake. The lunch ticket listed double portions, fortified foods, a 4 oz house shake, and feeding assistance, yet no shake was present and no assistance was provided. On a subsequent morning, the resident did not receive a breakfast tray at all by mid-morning, despite call lights being activated and turned off, and staff acknowledging the resident had not been given a tray. Documentation in the MAR and nutrition intake records indicated a house shake was given and high meal consumption percentages, which conflicted with direct observations that the resident did not receive the ordered shake, fortified foods, or required one-on-one feeding assistance.