A dietary services lapse left multiple residents without documented assessment of food likes, dislikes, or menu choices. Several cognitively intact residents, and one moderately cognitively impaired resident, reported they were not asked about preferences, did not receive menus, and were served foods or drinks they did not want; the DSD said she was behind on nutritional risk assessments and could not produce completed menus for some residents.
A resident with dementia and a documented egg allergy was served an egg and cheese sandwich even though the chart and physician order specified no eggs. Two other residents also reported repeated meal errors, including receiving the wrong breakfast items and being served chicken instead of ordered foods such as egg salad and cream of mushroom soup. The Food Service Supervisor stated residents are supposed to receive the foods they request based on the meal ticket.
Meal substitutions were not consistently available or appealing during lunch service. Staff served the planned meal items, but residents and the Culinary Assistant confirmed that alternate choices were generally limited to a beef patty, chicken salad sandwich, or leftovers, with no regular substitute vegetable or bread option. Multiple alert and oriented residents stated that alternate selections were not routinely offered and that the food was generally not good, despite the facility policy requiring appealing alternate options of similar nutritive value at all meals.
A facility failed to honor the food preferences of two residents who preferred Indian meals and alternative choices. One resident with DM2, heart disease, anemia, thrombocytopenia, and ordered Glucerna received an Indian-style tray that did not match the posted menu, was not offered an alternate menu, and had documented weight loss. Another resident with DM2, CKD, GERD, and double portions was repeatedly served grilled cheese despite stating she did not like it, and staff did not provide an alternative when she refused the meal.
The facility failed to honor meal preferences and lactose-free diet orders for two residents. One resident who reported lactose intolerance was served pudding and mashed potatoes, and the Dietary Manager confirmed the pudding contained dairy and that mashed potatoes may be prepared with milk. Another resident's meal ticket listed no fish and lactose intolerance, yet the ticket also showed fish and red beans and rice, and the meal was changed to mashed potatoes when beans were not ordered. Records showed both residents had lactose-free orders, and one care plan directed staff to obtain and honor food preferences.
Failure to provide a resident’s menu preference. A resident reported not receiving yogurt at breakfast or the noon meal, despite yogurt being added to the diet menu during a care plan meeting and listed on the dietary card as yogurt at all meals. The Dietary Manager stated the facility was out of yogurt, that it had been ordered for the resident, and that this was the second time the resident had not received it.
Lack of Planned Meal Alternatives: Staff did not have a planned alternative menu of similar nutritive value at mealtimes. During a meal observation, the cook said residents who disliked the main entrée could only be offered cold cut, egg salad, or PB&J sandwiches after all meals were served. In Resident Council, multiple residents said they lacked variety and wanted alternative choices, and one resident said the menu was not always posted. The Administrator confirmed there was no policy for alternative food selections and no planned meal alternatives at that time.
The facility failed to provide a variety of appealing meal substitutions in line with resident preferences and its own written menu standards. Although the alternate menu listed deli sandwiches, grilled cheese, chef salads, and bread, residents and staff consistently reported that only grilled cheese, and occasionally ham sandwiches without cheese, were offered when residents refused the main meal. Resident council leaders and multiple residents stated they had repeatedly complained about the lack of variety and the removal of prior options such as hamburgers and pizza, without any resolution. CNAs, an LPN, and an RN confirmed frequent resident complaints and the limited substitution choices, while dietary staff and the Food Service Manager acknowledged that budget-driven changes had reduced the alternate menu and that key salad ingredients like tomatoes and cucumbers were not routinely stocked, resulting in monotonous and restricted substitution offerings.
A facility failed to offer meal alternatives per resident preferences for 4 residents reviewed. Residents with regular diets stated they were not asked what they wanted to eat before meals, were given whatever was served, and in one case coffee was only available during breakfast hours. The Dietary Mgr and Activities staff stated menus and alternates were supposed to be reviewed with residents, and the facility policy required appealing alternate options of similar nutritive value for residents who refused menu items.
Failure to honor documented dietary preferences for two residents. One resident with BIMS 13 and another with moderate cognitive impairment both had charted dislikes that included broccoli, and one also disliked pineapple. Despite this, they were served those items with meals, and each stated he did not like the food when asked. The Dietary Manager stated staff should follow dietary cards and avoid serving items listed as dislikes, using nutritionally equivalent substitutions instead.
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