Deficiency in Food and Nutrition Services Due to Lack of Qualified Staff
Summary
The facility was found to be deficient in providing adequate food and nutrition services due to the absence of a full-time qualified dietician or a director of food and nutrition services. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility lacked a full-time registered dietician (RD) or a certified dietary manager (CDM) to ensure effective nutritional and dietary services for all 22 residents. The deficiency was considered an immediate jeopardy situation, indicating a reasonable likelihood for serious harm, which began on October 30, 2024. The surveyors noted that the facility did not have dietary policies readily available, and the Nursing Home Administrator (NHA) was unable to locate them when requested. Interviews with staff, including a dietary aide and a new employee, confirmed the absence of a dietary manager and a full-time RD. The NHA was observed cooking meals due to the lack of qualified dietary staff, and there were issues with meal ticket management and food ordering, which the NHA had to address personally. The deficiency led to several problems, including insufficient dietary support staff to provide meals, failure to follow accepted standards of practice for food safety and sanitation, and the inability to ensure residents received proper diets as ordered. These issues were compounded by the lack of a system to ensure meal tickets were available and the absence of necessary dietary products like Thick-It for residents with specific dietary needs.
Removal Plan
- All staff will be educated prior to their next working shift.
- CDM started working.
- We currently employ a registered dietician who works. The RD will review and sign off on all competencies initiated by the CDM prior to QAPI Meeting.
- Prior to food and nutritional service staff working, a competency to be completed by the CDM, with sign off by the RD.
- Competency checks for all food and nutritional services employees will be completed until all dietary staff are checked off. No dietary staff will work until competency checked.
- All staff were trained on Serve Safe food handling and sanitation of kitchen and dishroom. All new staff will be required to complete training and competency checkoff by the CDM with subsequent sign off by the RD.
- In the event of a staff call off, the staff shall first contact the CDM. If the CDM cannot be reached, all staff will contact the NHA for staffing assistance.
- In the event of a call in, only qualified staff will work in the kitchen (Serve Safe certified and competencies checked off).
- The schedule will be developed by the certified dietary manager and provided in advance for the food and nutritional services employees.
- The dietary schedule will remain posted and updated by the CDM as needed in a visible area of the kitchen.
- The CDM will provide education to all dietary staff on the following: emergency preparedness plan, scheduling, competencies and audits.
- The CDM/Administrator/Designee will conduct audits.
- All staff working in the dietary department will have the competency checks completed.
- Schedule completed for dietary staffing.
- The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement committee for patterns, trends, and continued recommendations for process monitoring and improvement.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Lack of Qualified Dietary Leadership: The facility failed to employ either a full-time RD or a qualified DM to oversee food and nutrition services, affecting all 54 residents. The CSD stated she had only recently enrolled in the CDM program and had no other food service certification or training, while the administrator said an RD worked one day a week and was on call. Requested documentation for the CSD’s qualifications and the dietary staff qualification policy were not provided.
Surveyors found that the facility did not employ a qualified dietitian or clinically qualified nutrition professional and had no active dietary manager, while the owner, who lacked a food handler certificate, was observed preparing meals in the kitchen. A dietary aide’s food handler certificate was expired, yet the aide assisted with drinks and desserts on meal trays. Facility policy required valid Texas Food Handler Certificates for all dietary employees handling food and appropriate certification for dietary leadership, but these requirements were not met. The Administrator reported that the facility had been without a dietitian for several months and acknowledged that, without qualified dietary oversight, residents may not receive proper nutrition, which could lead to weight loss.
The facility did not employ a certified dietary manager to oversee food and nutrition services, despite having residents who required pureed and mechanical soft diets. During observation of a breakfast meal, dietary staff prepared meals while the person acting as dietary manager was confirmed by both dietary and administrative staff to be uncertified. When surveyors requested documentation, the facility was unable to provide a policy regarding the requirement for a certified dietary manager.
The facility failed to ensure the Dietary Manager met CDM qualification requirements. The Dietary Manager stated she did not have kitchen manager certification and was still enrolled in a class to obtain it. Her file showed she started work before earning CDM status, and her application noted she was not yet a CDM and was still in school for the certification.
Missing Qualified F&NS Leadership: The facility did not employ a director of food and nutrition services after the dietary manager resigned, and the part-time RD worked about 24 hours per week. The Head temporarily oversaw kitchen operations without a formal assignment or dietary manager’s degree, and the administrator could not provide inservice records for dietary tasks. The RD’s role was limited mainly to menu coordination, resident meetings, dietary profiles, and resident assessments.
Unqualified Dietary Oversight: The facility failed to ensure qualified dietary staff oversaw food and nutrition services. The Dietary Manager was not certified as a dietary manager, and there was no Certified Dietary Manager in place. The Dietician worked remotely as a consultant and did not come to the facility in person, as confirmed by the Dietician, Regional Dietary Manager, and Administrator.
Lack of Qualified Dietary Leadership
Penalty
Summary
The facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since January 2020, affecting all 54 residents in the facility. During the initial kitchen tour, the Culinary Services Director (CSD) stated she worked full time at the facility and that an RD worked one day a week and was available by phone for questions. On follow-up interview, the CSD stated she had recently enrolled in the certified dietary manager (CDM) program about a month earlier and had no other certification or food service training, and she had originally enrolled during COVID but did not finish. The administrator stated the facility had an RD who worked once a week and was on call, and that the CSD had started as kitchen manager in January 2020 and was currently enrolled in school for her CDM license; the administrator also stated she believed the CSD only needed to be enrolled in the program to be qualified as the CSD. Requested documentation for the CSD’s qualifications and a facility policy regarding dietary staff qualifications were not received.
Lack of Qualified Dietitian and Noncompliant Food Handler Certifications in Dietary Services
Penalty
Summary
The facility failed to employ sufficient qualified staff to carry out food and nutrition services, including not having a qualified dietitian or clinically qualified nutrition professional on staff in any capacity. The Administrator stated the facility had not had an active dietitian since December 2025, and the last dietitian consult was completed on 12/17/2025. The Owner confirmed that at the time of survey there was no dietary manager in place, noting that the previous Dietary Manager had not reported to work for four days and had not officially quit. Despite this, the Owner was observed preparing meals in the facility kitchen and acknowledged he did not have a food handler’s certificate, although he is a licensed nursing administrator. The facility was unable to provide a policy for dietitian coverage when requested. The surveyors also identified that dietary staff did not meet required food handling certification standards. Observation of the kitchen bulletin board showed that Dietary Aide C’s food handler certificate had expired on 01/30/2026. In interview, Dietary Aide C stated he did not know he needed another certificate, had recently returned to work after medical issues, and primarily washed dishes but also helped set up drinks and desserts on trays. The facility’s own Food Handler Hygiene and Safety Policy required all dietary employees handling food to obtain a valid Texas Food Handler Certificate and for dietary leadership to maintain required Food Manager Certification. The job description for the Dietary Manager required a current and valid Food Service Manager’s Certificate and Certified Dietary Manager credential within a designated timeframe. Staff interviews, including with RN B and the Administrator, acknowledged the importance of qualified dietary staff and that without qualified dietary oversight, residents may not receive proper nutrition, which could lead to weight loss.
Lack of Certified Dietary Manager Oversight for Specialized Diets
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager to oversee the food and nutrition services for residents receiving meals from the kitchen. During a breakfast meal observation, dietary staff were seen preparing the meal, and subsequent interviews confirmed that the individual functioning as the dietary manager was not certified. Dietary staff reported that two residents were on a pureed diet and eight residents required a mechanical soft diet, indicating the presence of residents with specialized dietary needs. Administrative staff also verified that the dietary manager lacked certification, and when requested, the facility was unable to provide a policy regarding the requirement for a certified dietary manager. These findings demonstrate that the facility did not employ a certified dietary manager as required and did not have a related policy available when requested by surveyors, despite having residents who required modified diets such as pureed and mechanical soft diets.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure the Dietary Manager was certified for 1 of 1 Dietary Manager Qualifications reviewed. During an interview, the Dietary Manager stated that she did not have kitchen manager certification and was enrolled in a class to obtain it. Review of her employee file showed that she began employment with the facility on 3/5/26 and had been enrolled in a Certified Dietary Manager (CDM) course on 2/17/26. Her job application indicated that she was not a CDM and was still in school to obtain the certification. The Administrator later provided a current CDM Job Description policy dated 2025 stating that the position required graduation from a foodservice manager training program or a 2-year or 4-year foodservice management or nutrition program, along with successful completion of the CDM Credentialing Exam and active CDM, CFPP certification status.
Missing Qualified Food and Nutrition Leadership
Penalty
Summary
The facility failed to employ a director of food and nutrition services when the registered dietician was only employed part-time. During a concurrent observation and interview in the kitchen on 4/13/2026, the Head [NAME] stated the prior dietary manager had resigned about 2 months earlier and that the facility was in the process of recruiting a new one, while the Head temporarily managed the kitchen. The administrator later stated the dietary manager had resigned since 2/12/2026 and that the facility only had a part-time registered dietician working about 24 hours per week. During subsequent interviews, the administrator stated that both the administrator and Head oversaw the overall operation of the kitchen, and that the registered dietician’s responsibilities were mainly to coordinate the menu, meet with residents, complete dietary profiles, and resident assessments. The Head stated he was temporarily helping oversee dietary services and had been taught dietary tasks by the previous dietary manager. The administrator also stated there was no formal assignment for the Head to manage dietary tasks and that he did not have a dietary manager’s degree. When inservice training related to dietary tasks was requested during record review, the administrator could not provide the records. A review of the job description for Director of Food & Nutrition Services listed responsibilities including supervising staff, food preparation and service, sanitation, inventory, menu adjustments, resident diet cards, ordering food and supplies, nutritional screening, and attending weight variance meetings.
Unqualified Dietary Oversight
Penalty
Summary
The facility failed to ensure that qualified dietary staff carried out the functions of food and nutrition services. Based on record review and staff interview, the Dietary Manager was not certified as a manager for dietary services, and the facility did not have a Certified Dietary Manager overseeing food and nutrition services at the time of the survey. Dietician #90 confirmed in interview that she worked remotely as a consultant and did not come to the facility in person. The Regional Dietary Manager and Administrator also confirmed that there was not a Certified Dietary Manager overseeing food and nutrition services and that the Dietician worked remotely. The deficiency had the potential to affect all residents receiving nutrition from the kitchen, with a census of 63.
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