F0692

D

Failure to Provide Ordered Breakfast Nutritional Supplement

Anna, Illinois Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered nutritional supplements as prescribed by the physician for one resident. The resident was admitted with multiple diagnoses including Parkinson’s disease, spondylolysis, repeated falls, COPD, heart disease, adult failure to thrive, anxiety, and a cognitive communication deficit, and had a BIMS score of 09 indicating a moderate cognitive deficit. The physician’s order summary directed that the resident receive an NCS diet with mechanical soft texture, thin liquids, super cereal at breakfast, health shakes TID with meals, and fortified foods TID. The resident’s care plan also identified a nutrition focus area, noting potential nutritional problems and specifying interventions including an NCS diet, super cereal at breakfast, fortified foods TID, and health shakes TID, with an intervention to provide and serve supplements and diet as ordered.

On the morning of the survey observation, the resident’s breakfast tray contained fruit loops, orange juice, milk, a mighty shake, coffee, cookies, pears, and a bowl of milk, with no super cereal present. The resident’s meal card for breakfast documented “Fortified Super Cereal – 1 serving” under breakfast supplements, but this item was not on the tray. When interviewed, the Dietary Manager identified the super cereal as oatmeal and confirmed that the resident should have been served oatmeal as a super cereal with breakfast. The facility’s Therapeutic Diets Policy states that therapeutic diets are prescribed by the attending physician and that the Food Services Manager will establish and use a tray identification system to ensure each resident receives the diet as ordered. Despite this policy, the ordered super cereal supplement was not provided with the resident’s breakfast.