F0806

F

Failure to Follow Documented Food Preferences and Restrictions

Perrysburg, Ohio Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The facility failed to provide meals according to a resident’s documented food preferences and restrictions. A resident with Alzheimer’s disease, congestive heart failure, anxiety, and seizures, admitted in mid-September 2024, had a comprehensive MDS indicating a cognitive deficit and dependence on staff for all care. The resident’s care plan showed a need for supervision and occasional feeding assistance. On the observed breakfast service, the resident was served pureed sausage, scrambled eggs, pureed toast, and cranberry juice, with appropriate adaptive equipment.

However, review of the resident’s meal ticket for that breakfast showed the resident was supposed to receive yogurt, half a banana, and tea daily, with explicit instructions for no juice or soda. Despite these documented preferences and restrictions, the resident was served juice instead of tea and did not receive the ordered yogurt and banana. A CNA confirmed that the resident was not supplied the ordered food and acknowledged that residents’ preferences changed often. Facility policy on accommodation of food preferences required that resident food preferences be listed in the tray ticket system and that alternate menu items be available to meet individualized needs and requests, but this was not followed in this instance.