F0808

D

Failure to Provide Ordered High-Protein Supplement and Honor Food Dislike

Shelbyville, Illinois Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a physician‑ordered high‑protein supplement and to honor a documented food dislike for a resident with multiple nutritional deficiencies and moderate cognitive impairment. The resident’s diagnoses include unspecified dementia with moderate cognitive impairment, vitamin D, E, and ascorbic acid deficiencies, and a disorder of teeth and supporting structures. A dietary physician order dated February 4, 2026, specifies that the resident is to receive a regular high‑protein supplement three times daily with meals at 7:30 a.m., 12:00 p.m., and 5:30 p.m. The same physician order/meal ticket also documents that the resident dislikes chicken.

On observation at a lunch meal, the resident was served chicken cordon bleu as the entrée and did not receive the ordered high‑protein milkshake supplement, despite both the supplement and the chicken dislike being clearly documented on the physician order/meal ticket. The resident later stated that he does not like chicken, but ate the entrée because the ham inside made it more tolerable, and reported that he enjoys the high‑protein milkshakes but does not receive them consistently at every meal as ordered. A CNA confirmed that the resident did not receive the high‑protein milkshake and was given chicken in error, acknowledging that both the supplement and the chicken dislike were on the ticket. The Dietary Manager confirmed that chicken was listed as a dislike and that the high‑protein supplement was ordered three times daily, and acknowledged that the kitchen staff missed adding the supplement. The DON also confirmed that the physician order/dietary ticket documented the chicken dislike and the high‑protein milkshake order.