Failure to Follow Therapeutic Diet Orders for Two Residents
Summary
The deficiency involves the facility’s failure to provide prescribed therapeutic diets consistent with physician orders for two residents. One male resident with intact cognition, muscle wasting and atrophy, hypothyroidism, hypotension, and type 2 diabetes was admitted on 1/9/26 and had an order dated 1/23/26 for a Fortified Food Plan Diet with regular texture and liquids. His Initial MDS documented a therapeutic diet on admission and while a resident. However, his breakfast ticket dated 2/16/26 listed a Low Concentrated Sugar/Consistent or Controlled Carbohydrates diet instead of the ordered fortified food plan. On 2/17/26, surveyors observed an untouched breakfast tray in his room containing sausage, an egg-like item, oatmeal, French toast with syrup, and juice, with the tray ticket again reflecting a Low Concentrated Sugar/Consistent or Controlled Carbohydrate diet rather than the ordered fortified diet. The Dietary Manager stated on 2/17/26 that she had been providing this resident a Low Concentrated Sugar diet and only then noticed that the physician had changed the diet to a Fortified Food Plan requiring larger portions and more calories. She reported she did not recall receiving notification of the diet change from nursing or the dietitian and acknowledged that the Low Concentrated Sugar diet provided smaller portions and fewer calories than the ordered fortified plan. The DON later stated that it was the dietitian’s responsibility to notify the Dietary Manager of changes in therapeutic diets and believed the diet for this resident was not changed timely because a new dietitian had sent an incomplete spreadsheet of residents on therapeutic diets. A second female resident with intact cognition, hypertension, renal failure, diabetes mellitus, and irritable bowel syndrome was admitted on 1/30/26 with an order dated 1/30/26 for a Controlled Carbohydrate (Low Concentrated Sugar) diet, and her Initial MDS also documented a therapeutic diet. Her lunch tickets dated 2/9/26 and 2/10/26 showed a Regular Diet instead of a controlled carbohydrate/diabetic diet. She told surveyors she had been receiving regular portions of carbohydrates, regular sugar, and desserts, and produced saved meal tickets labeled Regular Diet. On 2/17/26, her lunch tray ticket finally reflected a Low Concentrated Sugar/Controlled Carbohydrate Diet, and the observed meal contained smaller portions and sugar substitutes. The Dietary Manager confirmed that when a ticket reflects “regular” there are no dietary restrictions, that diabetic residents should receive a Low Concentrated Sugar diet, and that this resident’s orders had always reflected a Low Concentrated Sugar diet, but she had been receiving regular meals. The ADON stated that diet orders from the speech therapist, dietitian, or physician should be given to the Dietary Manager as soon as they are changed. The facility’s Therapeutic Diets policy required that therapeutic diets be prescribed by the attending physician or delegated dietitian and that diet orders match the terminology used by food and nutrition services.
Penalty
Resources
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Surveyors found that during a lunch meal, pork and sauerkraut intended for residents on regular diets were prepared and served in a mechanically textured form to multiple residents whose orders specified regular diets. A dietary staff member stated she routinely prepares the meat this way so all residents receive similar-looking portions and to reduce choking risk, and also reported using milk in the pureed pork and sauerkraut to add calories and nutrients. Record review confirmed that numerous affected individuals were on regular diets, and facility leadership acknowledged that serving mechanically textured meat to these residents and not following the established puree recipe was inappropriate.
A facility failed to provide refried beans with a regular diet lunch for 21 of 73 residents reviewed. During kitchen observation, staff ran out of refried beans and only the last 4 trays received rice, while 17 trays went out without the menu item. The DM and Dietician stated rice was not an appropriate nutritional substitute, and the substitution log was blank.
The facility failed to honor resident food preferences and provide adequate alternative meal options. During multiple observed meals, residents were not offered substitutes, and staff told them requested items were not on the menu. Meal slips showed that a resident’s written requests for extra yogurt and cottage cheese were limited or marked as not approved per the administrator, and another resident’s request for a double turkey and cheese sandwich was denied. Resident council minutes documented concerns about reduced food items such as burger vegetables, PB&J evening snacks, and daily ice cream, with no evidence of follow‑up. Several residents reported hamburgers without condiments and sandwiches with very little meat or cheese, stating that if an item was not on the menu, it was not provided. Nursing staff, CNAs, and kitchen staff reported that the administrator had reduced yogurt and cottage cheese availability, removed various commercial snacks, cut back food ordering, and restricted what residents could have, while there was no dietary manager and a newly hired dietitian had not yet evaluated residents or meals, contrary to the facility’s own nutritional management policy.
A resident with recent MI, CABG, and HTN was admitted on a hospital discharge order specifying a Heart Healthy DASH diet and a no added salt diet. The facility entered a no added salt diet and later changed it to a 2–3 g sodium diet, despite the RD acknowledging that the regular menu would exceed 3 g sodium on most days and that the facility did not have a formal DASH diet option. On the first night, the resident was served a large portion of pulled pork with barbecue sauce and visible fat, which she recognized as inconsistent with her low sodium, low fat diet and ate only partially. The RD later stated she would have expected staff to enter a no added salt diet based on the discharge orders and acknowledged that the intended order may have been for both a DASH diet and a no added salt diet.
A resident with a physician’s order for double entrée portions at meals was observed receiving only a single BBQ sandwich, despite the tray ticket specifying a double entrée. During the meal, the NA assisting the resident left the table briefly, during which time the resident consumed almost the entire sandwich and ate meat that had fallen onto their clothing. When the NA returned and was informed of the double-entrée order, the NA stated they were unaware of the order. Record review confirmed the active order for double entrées, and the observation showed the meal served did not match the ordered diet.
A resident with a regular diet order and medical conditions including high blood sugar and a weak heart did not receive the ordered breakfast sausage with his meal after requesting meat such as bacon or sausage. A dietary staff member prepared the breakfast tray without using the resident’s tray card and later acknowledged that this caused the omission of meat, while the DM confirmed that residents are expected to receive items listed on their tray cards, consistent with facility dietary policies.
Failure to Follow Regular Diet Orders When Serving Mechanically Textured Meat
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered diets by serving mechanically textured pork and sauerkraut to residents who were ordered regular diets. During a lunch observation, the scheduled meal of pork and sauerkraut, mashed potatoes, and bread pudding was prepared so that the pork and sauerkraut were mechanically textured and served in that form to residents on regular diets, affecting 18 residents who were ordered regular diets. The dietary associate who prepared the meal confirmed that she mechanically textures the pork so that all residents receive the same looking meat and to reduce choking hazards, and also confirmed that the pureed pork and sauerkraut were made with milk to add calories and nutrients. Review of medical records showed that these 18 residents were on regular diets, and the Administrator later confirmed that serving mechanically textured meat to residents on regular diets was not appropriate and that an existing puree recipe for the lunch meal had not been followed. This deficiency was cited under the requirement to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs and was investigated under Complaint Number 2984105.
Missed Menu Item and Improper Food Substitution
Penalty
Summary
The facility failed to provide each resident with a nourishing, well-balanced diet to meet daily nutritional and special dietary needs for 21 of 73 residents reviewed for food and nutrition services. On the posted menu for a regular diet, lunch included soft tacos, refried beans, tortilla soup, and brownie. During observation of food preparation and service in the kitchen, the facility did not have enough refried beans or a comparable substitute, resulting in 21 residents not receiving refried beans. After 17 residents were served trays without refried beans, the Dietary Manager provided rice to the last 4 trays/residents. In interviews, the Dietary Manager said there were 53 residents on a regular diet and that she would try to identify the residents who did not receive refried beans and give them rice. The Dietician stated that rice was not an appropriate substitute for refried beans and would not have approved that substitution, and that when the kitchen runs out of food, a nutritional equivalent substitute should be provided. The substitution log for April 2026 was blank, and the Dietary Manager said she had not filled it out yet. The Dietary Manager and Administrator stated they did not know why the facility ran out of refried beans, and the Dietary Manager said she was not sure whether rice was a comparable nutritional substitute and should have called the Dietician before making the substitution.
Failure to Honor Food Preferences and Provide Adequate Alternatives
Penalty
Summary
The deficiency involves the facility’s failure to provide nourishing, palatable, well‑balanced diets that considered resident preferences and honored reasonable food requests. During three separate meal observations, residents were not offered substitute meal items, and when alternatives were requested, staff told residents the requested foods were not on the menu. Meal slips for one resident showed repeated written requests for additional yogurt and cottage cheese that were either limited by direction of the administrator or marked as “Not Approved” or “Not on Menu.” Another resident’s meal ticket documented a request for two turkey and cheddar sandwiches, with a notation at the bottom stating “No Double Sandwiches” per the administrator. Resident council minutes documented that residents reported recent changes to food service, including removal or reduction of vegetables for burgers, PB&J sandwiches for evening snacks, and daily ice cream desserts, with no evidence the concern was addressed. Multiple resident interviews confirmed that hamburgers were served without condiments such as lettuce, tomato, and onion, and that sandwiches were very thin on meat and cheese, with bread being the main component. Residents consistently reported that if items were not on the menu, they were not provided and that the administrator had changed meals and what was allowed. Nursing and CNA staff interviews confirmed that the administrator had cut back the availability of yogurt and cottage cheese to breakfast only and that commercially prepared snacks such as chips, crackers, cream pies, pudding, and ice cream had been removed, with snacks instead being made in‑house. The cook reported there had been no dietary manager since a specific date, there was no dietitian in place until shortly before the survey, and that the administrator had taken over dietary services, reduced the amount of food ordered, and restricted what items residents could have. The newly hired dietitian stated she had just started and had not yet evaluated residents or meals. The administrator stated residents had previously agreed to a change in the alternative menu and suggested residents could use vending machines for additional snacks, but he was unable to provide information showing that alternative items available met required nutritional needs, despite a written policy requiring assessment of food preferences and dietitian evaluation of nutritional adequacy.
Failure to Provide Ordered Low Sodium Cardiac Diet
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with the ordered low sodium diet consistent with hospital discharge instructions and physician orders. The resident had significant cardiac history, including myocardial infarction, coronary artery bypass graft surgery, and hypertension, and was cognitively intact. The hospital discharge packet, printed the day before admission, specified a Heart Healthy DASH diet and a No Added Salt diet, with a note that the hospital diet order could be substituted with the facility’s equivalent diet description. Upon admission, the physician’s orders reflected a No Added Salt diet starting on 5/28/25, which was later changed on 6/6/25 to a 2–3 g sodium diet with thin liquids. The Registered Dietitian (RD) stated that at the time of admission the facility only had two sodium-restricted options: a No Added Salt diet (regular diet with no salt packets) and a 2–3 g sodium diet, and that the regular menu would exceed 3 g of sodium on most days. On the night of admission, the resident reported being served a large portion of pulled pork with barbecue sauce and visible fat, which she described as salty and inconsistent with her understanding that she should be on a low sodium and low fat diet. She took a picture of the meal and shared it with her family, stating she ate less than half because she knew she was not supposed to eat it. The RD acknowledged being notified by staff the day after admission that the resident had been served pulled pork and that the resident’s son was unhappy. When later shown the hospital discharge orders, the RD stated she would have expected staff to enter a No Added Salt diet because that was what was ordered and the facility did not have a DASH diet option, and further acknowledged that the intended order may have been for both a DASH diet and a No Added Salt diet. The RD also stated that if the DASH diet’s sodium recommendation was less than 3 g, the facility’s 2–3 g sodium diet would most closely align with that restriction, and confirmed that the purpose of sodium restriction is to minimize swelling and reduce blood pressure.
Failure to Provide Ordered Double Entrée Portions at Meal Service
Penalty
Summary
The facility failed to provide a resident with the ordered double entrée portions at a meal. The resident had a physician’s order, written on 12/15/24, specifying double entrées with meals. During a noon meal observation on 04/20/2026, the resident was seated in the dining room with a nurse aide assisting. The resident’s tray ticket indicated he was to receive a double entrée, but his tray contained only one BBQ sandwich. While the nurse aide briefly left the table to obtain a clean spoon for another resident, the resident ate almost the entire BBQ sandwich, leaving only some bun, and picked BBQ meat that had fallen onto his shirt and ate it. When the nurse aide returned and was informed by the surveyor that the tray ticket called for double entrées, the nurse aide stated she did not know about the order and then indicated she would obtain another BBQ sandwich. No additional information was provided through the completion of the survey process. This deficiency involved a single resident (Resident #69) out of a facility census of 88 and was identified as a random opportunity for discovery during the survey. The record review confirmed the active physician’s order for double entrées, and the observation confirmed that the meal served did not comply with that order. Staff interview with the nurse aide further established that she was unaware of the double entrée requirement at the time the meal was served.
Failure to Follow Tray Card Resulting in Omission of Ordered Breakfast Protein
Penalty
Summary
The deficiency involves the facility’s failure to provide a nourishing, palatable, well‑balanced diet that met a resident’s daily nutritional and special dietary needs, including preferences, for one breakfast meal. Record review showed that the resident, who was admitted in April 2026 with diagnoses including high blood sugar, a weak heart, and uncontrollable worry, had a physician’s order for a regular diet. The resident reported in an interview that he did not receive any meat with his breakfast and had requested bacon or sausage. He stated this had happened before, though he could not recall how often or when, and said he had informed a staff member of his desire for meat but could not remember which staff member. In a separate interview, a dietary staff member stated that someone had requested meat for the resident that morning, but breakfast had already been put away. He acknowledged that he had prepared the resident’s breakfast tray without using the resident’s tray card and therefore did not provide meat. The Dietary Manager stated that residents should receive what is listed on their tray cards and provided the printed tray card for the resident, which indicated the resident was to receive breakfast sausage along with cereal, egg, and a biscuit. The facility’s Dietary Services Policy & Procedure Manual stated that diets are to be ordered and provided in accordance with the approved Diet Manual and that the department’s role is to serve attractive, appetizing, nourishing, high‑quality food to help keep residents healthy.
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