Failure to Provide Ordered Fortified Foods for Nutritionally At-Risk Resident
Penalty
Summary
The facility failed to provide ordered fortified foods to a resident identified as being at risk for malnutrition. The physician order summary dated 01/07/26 directed that the resident receive fortified food three times daily for poor oral intake, specifically super cereal at breakfast and fortified mashed potatoes at lunch and dinner. The resident’s dietary profile effective 12/23/25 documented a nutritional supplement of fortified foods and a preference for potatoes, and the care plan initiated 4/18/25 identified the resident as at risk for malnutrition with an intervention to provide fortified foods three times a day, including fortified mashed potatoes at lunch and dinner. On 01/05/26 at 11:47 AM, surveyors observed the resident in his room with a covered meal tray; when the lid was removed, there were no potatoes on the tray. The resident stated he was supposed to receive potatoes and that not receiving them happened from time to time. On 01/06/26 at 11:55 AM, the dietitian explained that fortified mashed potatoes are prepared with whole milk and protein powder and are used to help manage a resident’s weight, and confirmed the resident should have received fortified mashed potatoes. At 12:59 PM the same day, the dietary manager stated that the kitchen relies on the meal ticket to identify fortified foods, reviewed the resident’s lunch meal ticket from 01/05/26, and confirmed it did not indicate fortified foods. She reported assisting the resident in filling out the meal ticket, with both mashed potatoes and a baked potato circled, and acknowledged the resident should have received mashed potatoes and a baked potato.
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