Deficiency #1
Rule/Regulation Violated:
R9-10-817.B.1-2. Food Services<br> B. If the assisted living facility offers therapeutic diets, a manager shall ensure that: <br> 1. A current therapeutic diet manual is available for use by employees, and<br> 2. The therapeutic diet is provided to a resident according to a written order from the resident's primary care provider or another medical practitioner.
Evidence/Findings:
<p><span style="font-size: 11px;">Based on record review, documentation review, and interview, the manager failed to ensure a current therapeutic diet manual was available for use by employees. The deficient practice posed a risk if the employees did not have access to the dietary information required to meet a resident's needs. </span></p><p><br></p><p><br></p><p><span style="font-size: 11px;">Findings include:</span></p><p><br></p><p><br></p><p><span style="font-size: 11px;">1. A review of R2's medical record revealed a document titled "Medical Practitioner Plan of Care" signed by a medical practitioner dated February 12, 2025, that documented R2 required "minced and moist" textured foods.</span></p><p><br></p><p><br></p><p><span style="font-size: 11px;">2. The Compliance Officer requested the facility's therapeutic diet manual. However, a therapeutic diet manual was not provided for review.</span></p><p><br></p><p><br></p><p><span style="font-size: 11px;">3. In an interview, E1 acknowledged there was not a therapeutic diet manual available for review at the time of the inspection. </span></p>
Temporary Solution:
Educational dietary courses are assigned to all employees on the Relias training platform.
Exhibit A & B
Permanent Solution:
Two Therapeutic Diets books have been purchased and are in two locations within the community for staff access. Locations of books are in the kitchen and behind the front desk for all staff.
Therapeutic Diet Manuals purchased and located within the community and are accessible to all staff.
Specialized diet training and education added to staff onboarding and annual training.
A specialized diet board created in the kitchen area for each resident with a specialized diet. This board includes the location of each therapeutic diet book.
Diets will be added for new residents upon move in and reviewed in Quality Management
Person Responsible:
Elizabeth Clark -Executive Director
Deficiency #2
Rule/Regulation Violated:
R9-10-817.C.3.a-b. Food Services<br> C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: <br> 3. Food is prepared: <br> a. Using methods that conserve nutritional value, flavor, and appearance; and<br> b. In a form to meet the needs of a resident, such as cut, chopped, ground, pureed, or thickened;
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure that food was prepared i<span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">n a form to meet the needs of a resident, for </span>one of five residents reviewed. </p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R2's medical record revealed a service plan for personal care services dated February 22, 2025. The service plan stated, "...the resident's dining/nutritional needs will be met per resident preference and provider orders..."</p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed a document titled "Medical Practitioner Plan of Care" signed by a medical practitioner dated February 12, 2025, that documented R2 required "minced and moist" textured foods.</p><p><br></p><p><br></p><p>3. In an interview, E1 reported that R2 was provided chips and cheese and acknowledged that R2 was not provided with a diet in a form to meet R2's needs. </p>
Temporary Solution:
Below Permanent Solution
Permanent Solution:
A specialized diet board created in the kitchen area for each resident with a Photo and specialized diet. This board includes the location of each therapeutic diet book. Added Specific training in Relias training platform for cooks to insure compliance to the regulations.
Person Responsible:
Elizabeth Clark -Executive Director
Summary:
No deficiencies were found during the on-site investigation of complaints 00132768 and 00124900 conducted on June 9, 2025.