F0805

E

Failure to Provide Ordered IDDSI Level 6 Soft & Bite-Sized Diets

Burr Ridge, Illinois Survey Completed on 12-31-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide IDDSI Level 6 soft and bite-sized mechanically altered diets as ordered for four residents. Facility diet reports and physician orders showed that these residents were prescribed a regular diet with Level 6 Soft & Bite Sized texture and Level 0 thin liquids. Speech therapy recommendations for one resident specified a mechanical soft/thin diet with small bites, slow rate, and diet advancement only with speech therapy involvement. Despite these orders and the facility’s own policy defining Level 6 soft and bite-sized foods as items that can be mashed with a fork, cut into pieces no larger than 1.5 cm x 1.5 cm, with bread soaked and no regular dry bread or mixed consistencies, the meals prepared and served did not meet these requirements.

On multiple observed meals, residents on Level 6 diets were served food in regular texture and size rather than mechanically altered form. At a lunch observation, two residents on Level 6 diets received pork roast in large cut pieces, whole California medley vegetables with large, firm pieces of cauliflower, broccoli, and carrot slices, and whole scalloped potatoes, identical to regular diet meals. They were not served the prescribed strawberry shortcake slurry dessert listed on the Level 6 menu. At a dinner observation, one resident on a Level 6 diet was served bratwurst sausage with the skin on, cut into large slices, along with a salad containing large pieces of lettuce, tomato, and cucumber with skin, and large slices of peaches, half strawberries, and chunks of melon in liquid, instead of the specified soft and bite-sized preparations and bread slurry.

The Culinary Director acknowledged during observation that the bratwurst pieces and salad components were too large for a soft and bite-sized diet and confirmed that for this diet, food pieces should be no larger than the tines of a fork. The Culinary Director also stated that the slurry bun, defined as bread softened in milk, was not prepared or served. Additionally, during an initial kitchen observation, the Culinary Director identified one resident on a puree diet and four residents on mechanically altered diets, yet there was no mechanically altered food prepared for the lunch meal, despite the Level 6 menu specifying roast beef and roasted vegetables in small bite-sized pieces without skin, a slurry bread roll with margarine, and crustless cherry pie. These observations, interviews, and record reviews demonstrate that the facility did not prepare or serve meals in accordance with the ordered Level 6 soft and bite-sized diet and its own IDDSI-based policy for four residents.