Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Summary
The deficiency involves the facility’s failure to provide residents with appropriate menu choices that matched their physician-ordered diets, thereby not assuring residents’ rights to knowledge of available choices and independent personal decisions. One resident with severe cognitive impairment was admitted with multiple medical diagnoses and had a physician’s order for a controlled diet with pureed texture and honey-thick liquids. During a lunch observation, this resident’s meal ticket was found stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were compatible with the resident’s ordered pureed diet. The Registered Dietitian and the Dietary Manager confirmed that Daily Menu printouts for the Regular Menu were provided to all residents, including those on mechanically altered diets, and acknowledged that residents on such diets would be offered items like fresh fruit that could not actually be provided according to their prescribed diet consistency. Another resident with moderate cognitive impairment and multiple medical diagnoses, including failure-related conditions, had a physician’s order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray was observed with a meal ticket stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s meal ticket was again stapled to a Regular Menu that listed fresh fruit as a choice. The resident had circled fresh fruit as her preference but instead received canned peach halves on her tray and verbally expressed that she wanted her chosen item rather than the peaches, reiterating her food preferences before the surveyor left the room. These observations, along with staff interviews, showed that residents on modified diets were routinely given Regular Menus with options that could not be honored due to their diet orders.
Plan Of Correction
Resident Rights/Exercise of Rights Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required N0181 1. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on [R] . Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets. On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits. Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] and resolving any variances that may occur.
Penalty
A resident who is cognitively intact and independent in eating reported consistently receiving cold food, particularly at breakfast, and stated that requests to staff for reheating were often dismissed or not acted upon. Another resident also reported receiving cold food and did not ask for reheating, believing staff would not comply. Staff interviews showed inconsistent awareness of these requests, and the facility's policy to consider resident preferences was not consistently followed.
A resident who was fully dependent for care did not receive scheduled showers as requested by her representative, despite a posted note and care plan specifying shower days. Instead, the resident received bed baths and tub baths, with staff and DON confirming the lack of shower documentation and the absence of a tub in the facility.
A CNA in a facility referred to a resident requiring assistance with eating as a "feeder," which was acknowledged by the DON as a dignity issue. This terminology was used despite the facility's policy on promoting resident dignity and the CNA's competency in maintaining patient self-worth. The resident had a severe condition, as indicated by a low assessment score.
Failure to Provide Food at Resident's Preferred Temperature
Penalty
Summary
The facility failed to provide food at an appropriate temperature according to a resident's preference, as required by their rights to choice and personal decision. One resident, who is cognitively intact and independent in eating, reported that receiving cold food, especially at breakfast, was a daily occurrence. The resident stated that requests to staff, particularly CNAs, to reheat food were often met with responses that staff were too busy or that the microwave was too far away. The resident also indicated that previous complaints to kitchen staff had not resulted in any changes. Another resident also reported receiving cold and unappetizing food and expressed reluctance to ask staff for reheating, believing the request would not be fulfilled. Staff interviews revealed inconsistent responses regarding whether the resident had requested food to be reheated. One CNA recalled reheating the resident's lunch upon request, particularly when the resident missed the initial meal service due to sleeping. Other staff members, including CNAs and an RN, either did not recall such requests or stated that the resident had not complained to them. The facility's policy requires that residents be provided with nourishing, palatable, and well-balanced diets that consider individual preferences, but observations and interviews indicated this was not consistently achieved for at least one resident.
Plan Of Correction
Corrective Action: Resident #104 and #04 were visited by the Director of Nursing and Food Service Director to determine if the resident's meal was served at an appropriate temperature and to their liking on 07/25/2025. Resident #104 and #04 stated that the meals are being served at the right temperature per their request. Staff A, B, and C were given a one-to-one education by the Director of Nursing regarding the importance of providing residents with meals at an appropriate heated temperature per their request. Identification of Residents: All residents in the facility have the potential to be affected by this alleged deficient practice. Systemic Changes: Ongoing in-services were initiated on 07/25/2025 by the Director of Nursing/designee to direct care staff regarding providing meals at appropriate temperatures per resident's request. The Interdisciplinary Team will conduct daily random rounds in resident rooms and dining rooms to ensure that residents are receiving their meals at an appropriate temperature per resident's preference. Meal temperatures will be discussed at the next Resident Council meeting per the resident's invitation, where the Dietician and/or designee will review and update any concerns with residents to ensure meals are served at an appropriate temperature per resident preference. Monitoring: The Director of Nursing and Food Service Director will conduct random food observation audits to check that food is served at temperatures per resident preference. This audit will be conducted daily for five days, then weekly for eleven weeks to ensure that resident meals leave the dietary department at the correct temperature and are served to residents at an appropriate temperature per resident's preference. The results and findings from audits will be reviewed and reported to the QAPI committee monthly for three months to ensure continued substantial compliance.
Failure to Provide Scheduled Showers per Resident Representative's Request
Penalty
Summary
The facility failed to honor a resident representative's request to ensure that a resident received showers on their scheduled shower days. The resident, who was dependent for all care needs as indicated by a Minimum Data Set (MDS) assessment score of 3, had a posted note from her sister on the bulletin board requesting that she receive showers on her scheduled days. The resident's care plan included showers every Monday and Thursday during the 3 PM-11 PM shift. Record review showed that, instead of showers, the resident received four bed baths and three tub baths on the scheduled shower days. Staff interviews confirmed that a bed bath was provided instead of a shower, and the Director of Nursing verified the lack of shower documentation on the CNA task list. It was also confirmed that the facility does not have a tub, further indicating that the resident did not receive showers as scheduled.
Plan Of Correction
N 181 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #71 was provided with a shower as scheduled. Staff C was re-educated to provide and document showers provided on residents' shower days and any additional days that the residents receive a shower. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Facility audit conducted to ensure residents' showers are completed on scheduled shower days and documented appropriately. Other residents found to be affected were corrected. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Certified Nursing Assistants (C.N.As) have been re-educated regarding Resident Rights/Right of Choices as related to receiving shower on the scheduled shower days. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Random observation will be conducted three times per week/three months to ensure compliance. Director of Nursing/Designee will conduct weekly shower audits times four weeks and will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Inappropriate Terminology Used by CNA Compromises Resident Dignity
Penalty
Summary
The facility failed to promote dignity in dining for a resident, as evidenced by the use of inappropriate terminology by a Certified Nursing Assistant (CNA). During an observation, the CNA referred to a resident who required assistance with eating as a "feeder," a term that was acknowledged by the Director of Nursing as a dignity issue. This terminology was used despite the facility's policy on promoting and maintaining resident dignity, which emphasizes treating each resident with respect and dignity. The resident in question had a severe condition, as indicated by a Minimum Data Set quarterly assessment score of 3 out of 15. The CNA had previously passed the required competencies for her job, which included maintaining and enhancing a patient's self-worth. However, the use of the term "feeder" was inconsistent with these competencies and the facility's policy, highlighting a failure to uphold the dignity and individuality of the resident.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: CNA H was counseled regarding the inappropriate [R], and provided immediate re-education on maintaining resident dignity and respectful communication. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who require assistance during meals have the potential to be affected. Residents with a score of 12 and over were interviewed by the Social Services Staff and Administrator to determine if they have experienced or witnessed any undignified language or treatment. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on [date], all staff will receive mandatory training on resident rights, dignity, and person-centered communication, with a focus on respectful language. All staff will be in-service by [date]. Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-serviced by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will conduct 5 meal service audits weekly for 1 month, then 10 monthly for at least two additional months, to ensure staff are promoting dignity. Findings from audits will be reviewed in the facility's Quality Assurance and Performance Improvement meetings, and corrective actions will be taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) Date of compliance: [date]
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