A resident receiving hospice services was observed at lunch on a mechanical soft diet with nectar thickened liquids, but the meal tray was missing three items listed on the meal ticket, including a pureed cranberry crunch bar, a frozen nutritional treat, and mandarin oranges. The GNA did not know why the items were absent, and the dietician confirmed the resident’s ordered diet, meal preferences, supplements, and adaptive equipment were documented in the care plan.
Menus were not followed for a pureed meal service. A cook identified pureed tray items as mashed potatoes, spinach, and turkey, but the posted dinner menu listed winter blend vegetables and baked macaroni and cheese. The Corporate Chef confirmed spinach was used as the pureed vegetable and that mashed potatoes were being served instead of mac and cheese for consistency. A resident with a pureed diet order had family report concern that the resident did not get the same food as others and sometimes received an all-white tray.
Outdated menus were posted outside the nurses' station, and current menus were not available for resident review before meals. A resident stated menus had not been posted for at least a week and that the resident requested a salad because the lunch selection was unknown, only to learn later that another option was available. The FSD said printing problems after a contractor and meal-tracking transition led to the missing menus, and the usual intercom announcement was not made that day.
A resident’s dinner tray did not match the posted menu or the resident’s meal choice. The tray included egg salad sandwiches, broccoli, and potato salad, but no chips, peach parfait, or milk, even though those items were listed or expected. The NHA reviewed the tray and confirmed the resident should have received the dessert, chips, and milk.
Resident meal tickets were not followed during the lunch tray line. Surveyors observed multiple residents receiving items that did not match their tickets, including brownies instead of cake, missing ordered fruit and beverages, sugar on a tray marked no sugar, gravy on a tray marked no gravy, and planned entrees or starches being substituted when the tickets called for different items. The FSD stated that the kitchen ran out of some planned foods and served substitutions instead of the items indicated on the meal tickets.
Failure to document and honor a resident’s food preferences led to inconsistent meal selections. A resident with a hx of CVA with hemiplegia, dysarthria, and DM2 was served fish despite stating they had received fish or pork multiple times and staff noting the resident would not eat fish. The meal ticket showed only a No Pork restriction, and the dietitian’s notes did not include the resident’s dislike for fish.
Meals Served Did Not Match Meal Tickets: During lunch tray line observation, staff served a resident turkey instead of the garlic egg noodles listed on the meal ticket and substituted broccoli for squash medley after the kitchen ran out of the menu item. The issue affected 11 of 83 trays, including residents in the dining room whose meal tickets still listed squash medley.
Failure to provide a requested meal alternative: A resident declined lunch, stating the food was too hard and that they did not eat fish, and asked for an egg salad sandwich. An GNA did not contact the kitchen for an alternate tray, and the resident later repeated the request to the UM. Records showed the resident had a hx of stroke, unspecified dementia, and anxiety, with a BIMS score of 12 and diet orders including a daily snack and weight monitoring.
Posted menu meals were not consistently provided as planned, and meal tickets did not match what was served. A resident reported receiving the wrong items and too little food, while another resident said the food was not good and portions were insufficient. During lunch tray line observation, dietary staff ran out of meatloaf and green peas, so 8 residents received a substitute meal instead of the posted menu. The FSD and District FSD were present when the shortage occurred, and the LNHA was later notified.
Surveyors found that staff failed to serve meals according to printed meal tickets for two residents during a lunch service. One resident, who reported disliking most facility food and relying on milk as the only item they enjoyed, did not receive the 8 oz of whole milk listed on their ticket, a fact confirmed by the Regional Food Service Director. Another resident was served mashed potatoes instead of the pasta specified on their ticket. The Food Service Director stated that the end-of-line employee is responsible for ensuring that what is served matches the meal ticket and acknowledged that residents are to receive the items indicated.
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