F363

Based on observation, record review and physician and staff interviews, the facility failed to serve Resident #1 a therapeutic diet as ordered by the physician. The sample consisted of 4 residents and the facility reported a census of 45 residents. Resident #1 was not served the ordered mechanical soft diet, choked and died . During the investigation, observation of a meal served revealed mechanical soft/ground meat diets were not served. The facility identified 8 residents were to receive ground meat/mechanical soft diets. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 5/23/14. The MDS identified the resident had [DIAGNOSES REDACTED]. …

Ossian Care Center · Iowa

Based on observation, interview and record review the facility failed follow their policy by not using tray cards to ensure correct diets are followed for one of three residents (R1) reviewed for therapeutic diets in the sample of 12. This failure resulted in R1 being served the wrong diet, choking and requiring hospitalization for aspiration pneumonia. Findings include: The facility policy for Resident Tray Identification Card documents, Purpose: to identify the resident's diet and food preferences in order to ensure correct meal service .the resident tray identification card will contain at least the following information: Resident name, room number, diet as ordered by the physician, resident dislikes, special items to be served: either by the resident request or per care plan… …

Sharon Health Care Pines · Illinois

Based on observation, interview, and record review, the facility failed to ensure 10 (Residents #91, #158, #148, #152, #84, #82, #77, #170, #89, and #150) residents received their meals as requested. The facility also failed to ensure 14 (Residents #1, #9, #10, #12, #28, #38, #61, #68, #71, #81, #96, #120, #150, and #152) residents on pureed diets received the foods as planned on the menu. The facility census was 165 residents. Findings include: Review of the resident council meeting minutes dated August 2017 revealed the residents meal tickets were not being followed correctly. Further review of the resident council meeting resolutions revealed there was no documented evidence of a resolution of follow-up for the concerns. 1. …

Wyant Woods Healthcare Center · Ohio

Complaint # (AR 638) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure that when changes were made to the planned, written menu prior to the meal preparation, the food items were substituted with items of similar nutritional content to meet the nutritional needs of the residents for 1 of 2 meals observed. The failed practice had the potential to affect 86 residents who received meals from the kitchen (total census: 88), as documented on the Diet Roster provided by the Administrator on 10/26/17. The findings are: 1. …

Hudson Memorial Nursing Home · Arkansas