Arbor Springs Of West Des Moines L L C

F 0805 In an interview on 05/29/2025 at 09:03 AM with Staff I, CNA, she stated it is the kitchen's responsibility to plate the food, they include the appropriate diet and the CNAs pick up and serve the food to the residents. Level of Harm - Minimal harm or She stated the diet card for Resident #30 reflected he was to receive a mechanically altered diet, and that potential for actual harm she was going to serve the soup to the resident. When asked why she looked confused she stated it was because she knows soup can be served to residents on mechanically altered diets, but the meat chunks Residents Affected - Few looked far bigger than mechanically altered soups usually had. She confirmed the meat she cut for the resident was tough, not at all soft enough.

In an interview on 05/29/2025 at 09:12 AM with Staff H, Certified Medication Aide (CMA), she stated the kitchen is responsible for plating the food and the CNAs are responsible for serving it to residents. She stated if a CNA notices the wrong diet has been served they are to report the issue to the kitchen and not serve the resident the incorrect meal.

In an interview on 05/29/2025 at 11:04 AM with the Director of Nursing (DON), she stated CNAs are responsible for serving food to residents, dietary staff are responsible for plating food and matching it to the dietary card. Her expectation is that if a therapeutic diet is prescribed to a resident they received the correct therapeutic diet.

In an interview on 05/29/2025 at 11:19 AM with the Registered Dietician, she stated Resident #30 had been

on a mechanically altered diet for a significant period of time. She stated the resident does not have a diagnosis of dysphagia, but had been moved to a mechanically soft diet by hospice to promote intake and prevent weight loss.

In an interview on 05/29/2025 at 11:32 with the Dietary Manager, she stated Resident #30 had been under

the care of a different hospice provider at one point in time, and that the previous hospice provider had ordered a mechanically soft diet with pleasure feedings of normal textured foods. The resident had since switched hospice providers and the current order only recommended mechanically altered diet with ground meats. She stated she believed this is where the confusion had occurred.

Review of a facility provided document titled Addendum to Simplified Diet Manual: Texture Altered Diets, with

an effective date of 06/01/2024, stated the following:

The Facility will offer the following diets for consistency alteration.

The mechanical soft diet is designed to permit easy chewing. The general diet is modified in consistency and texture by cooking, grinding, chopping, mincing, or mashing.

The diet includes foods soft in texture such as cooked fruit and vegetables, moist ground meats and soft bread and cereal products.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 2 165548