Failure to Provide Ordered Diet and Alternatives
Summary
The facility failed to ensure that a Minced and Moist (MM5) diet was provided as ordered for one resident, and an alternative of MM5 texture was not offered when needed. Resident #12, who had diagnoses including malnourishment, weakness, dysphagia, cerebral palsy, and poor dentition, was observed multiple times receiving food that appeared pureed instead of minced and moist. This discrepancy was noted during lunch, dinner, and breakfast observations, where the resident's meals did not meet the specified MM5 texture, leading to emotional distress and refusal to eat by the resident. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Dietary Manager (DM), revealed a lack of adherence to the MM5 diet specifications. The CNA acknowledged that the breakfast provided looked pureed rather than minced and moist. The DM explained the facility's process for preparing MM5 diets but admitted that certain foods, like bread, were pureed instead of minced and moist. The DM also noted that alternatives for foods that could not be minced were not provided, and the resident's emotional reactions to the pureed food were known but not addressed adequately. The facility's policies on dietary services and menu substitutions were reviewed, indicating that food should be prepared and served in a form designed to meet individual needs and that substitutes of similar nutritive value should be offered. However, the DM confirmed that alternatives were not provided for the MM5 diet, and the resident's dissatisfaction with the pureed food was documented in Resident Council meeting minutes and a dietary note to the resident's physician. Despite the resident's emotional distress and expressed dislike for the pureed food, the facility did not make necessary adjustments to meet the resident's dietary needs and preferences.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with dysphagia, severe cognitive impairment, and an order for a pureed/mechanically altered diet was repeatedly served food and beverages that did not match the prescribed texture, including improperly textured chicken and a cookies-and-cream milkshake. The resident’s care plan and MDS documented the need for a pureed diet, yet observations and interviews showed multiple instances of incorrect meal trays and non-pureed items being provided and consumed. A provider later documented radiographic evidence of recurrent aspiration pneumonia and noted a report that the resident had recently received a milkshake containing candy pieces, which was identified as likely contributing to the aspiration episode.
A resident with severe cognitive impairment and dysphagia was not provided with food in the required mechanical soft, ground form as ordered by her provider. Instead, she received a regular pork chop and pie with crust, contrary to her tray ticket and care plan. Staff and dietary management acknowledged the error, and documentation showed ongoing confusion due to family preferences, but facility policy required adherence to provider diet orders.
During a meal service, pureed snow peas were served with pod fibers and a chopped, non-smooth consistency, making them unpalatable and not in accordance with dietary guidelines for pureed diets. The dietary manager acknowledged the error, noting that snow peas may not be suitable for pureeing and that the food did not meet the required smooth, lump-free consistency.
A resident did not receive meals in the physician-ordered mechanically altered texture due to a delay in communicating the diet change from nursing to dietary staff. The process required nurses to update records and hand-deliver a diet communication slip, but the form was not completed until several days after the order, resulting in the resident not receiving food in the correct form.
Several residents with dysphagia or special dietary needs were served food items that did not match their prescribed diet textures, such as being given regular rolls, cubed meats, and whole fruit slices instead of ground or chopped alternatives. Staff and dietary personnel confirmed that the meals did not conform to the required consistencies, and care plans lacked documentation of the altered diets, despite clear physician orders and facility policy.
A resident with moderate cognitive impairment and left-sided weakness was not provided meals in the required bite-sized form, despite physician orders and meal ticket instructions. Interviews with staff revealed that CNAs were responsible for cutting the food, but the facility lacked a specific policy to ensure compliance.
Failure to Provide Ordered Pureed Diet Resulting in Aspiration Pneumonia
Penalty
Summary
Facility staff failed to provide a provider-ordered pureed/mechanically altered diet to a resident with dysphagia and severe cognitive impairment, resulting in pneumonia requiring antibiotic treatment. The resident’s diagnoses included dysphagia, vascular dementia, stridor, and cerebral infarction, and the hospital discharge summary specified a pureed diet. The admission MDS documented severe cognitive impairment (BIMS score 2/15) and a mechanically altered diet, and the comprehensive care plan identified dysphagia requiring a puree diet. Although an initial order on 12/19/25 was for a regular diet with dysphagia advanced texture and thin liquids, this was changed on 12/22/25 to a pureed diet per hospital recommendations. Despite these orders, the resident was observed on 02/11/26 with a lunch tray containing chicken that the dietician and SLP determined was a mixture of mechanically altered and pureed textures; the SLP stated it would not be safe for this resident to consume. The tray ticket listed the entrée as puree crispy chicken thigh, indicating a discrepancy between the ordered/printed diet and the actual food consistency served. In addition, the resident’s family reported multiple occasions when the resident did not receive the correct diet, including being provided a milkshake containing Oreo cookies and Reese’s Pieces on Super Bowl Sunday and receiving wrong meal trays on three occasions. Facility emails related to this incident showed a CNA first acknowledging giving an Oreo milkshake to a resident on a puree diet, then later stating the milkshake given was safe and that the Oreo milkshake was not provided. Another resident reported ordering a cookies and cream milkshake for the resident via a delivery service and instructing that the pieces be ground up because the resident was on a puree diet, and confirmed the resident consumed it. The provider documented that a chest radiograph on 02/11/26 showed infiltrate consistent with recurrent aspiration pneumonia and noted it was reported the resident recently received a milkshake containing candy pieces, which likely contributed to this aspiration episode. Documentation from the DON also indicated the resident had previously been served the wrong diet over the weekend of 12/20/25–12/21/25, which the resident ate, followed by chest X-ray findings of bilateral perihilar atelectasis/infiltrate and initiation of antibiotic therapy for pneumonia on 12/24/15.
Failure to Provide Diet Texture as Ordered for Resident with Dysphagia
Penalty
Summary
Facility staff failed to provide a resident with food prepared in a form designed to meet her individual dietary needs, as ordered by her medical provider. The resident, who had diagnoses including dysphagia, dementia, and a history of falls, was assessed as severely cognitively impaired and required a mechanical soft diet with ground meats. Despite clear orders and care plan interventions specifying a mechanical soft diet, the resident was observed receiving a regular pork chop cut into large strips and a piece of pie with crust, instead of ground meat and crustless pie as indicated on her tray ticket. Staff present at the time acknowledged the discrepancy, and the dietary manager confirmed the meal did not meet the ordered diet texture. Further interviews with staff and review of facility documentation revealed ongoing confusion regarding the resident's diet, partly due to conflicting preferences from the resident's family. The tray ticket system defaulted to ground meats for mechanical soft diets, but nursing staff were instructed to chop meat in an attempt to liberalize the diet per family wishes. The speech therapist and multiple CNAs confirmed the resident should have received ground meats for safety. Facility policy required meals to be provided as ordered by the healthcare provider, but this was not followed in this instance.
Pureed Food Served with Improper Consistency
Penalty
Summary
Facility staff failed to provide pureed food in a form that met the individual needs of residents during a dinner service. During test tray observations, pureed snow peas were served with pod fibers present, and the consistency was not smooth but appeared chopped. The food was tasted by the dietary district manager and two surveyors, who confirmed the presence of pod fibers and found the food unpalatable. The dietary manager acknowledged that snow peas may not be suitable for pureeing and that regular peas should have been substituted. The facility's policy requires pureed food to be blended to a smooth, lump-free consistency, which was not achieved in this instance. The dietary manager stated that the pureed food is typically prepared using a Robot Coupe blender to achieve a pudding-like consistency, but on the day in question, the pureed snow peas were not properly prepared and were served to residents. The issue was identified after the food had already been served, and the dietary manager admitted that the error occurred due to being busy and not catching the mistake. The facility's policy and diet consistency guidelines were not followed, resulting in the deficiency.
Failure to Timely Communicate and Implement Diet Texture Change
Penalty
Summary
Facility staff failed to provide food in a form designed to meet the individual needs of a resident. Specifically, a physician ordered a change in diet texture for a resident from regular texture to dysphagia mechanically altered texture. The order for the diet change was dated 11/25/24, but the dietary communication form reflecting this change was not completed until 11/30/24. During this period, the resident did not receive meals in the prescribed mechanically altered texture. Interviews with dietary and nursing staff revealed that the process for communicating diet changes involved nurses updating the electronic medical record and manually delivering a diet communication slip to the dietary department. The dietary manager confirmed that meal tickets and food preparation were based on these communication forms. Facility policy required licensed nurses to promptly complete and send the communication form to dietary services for any diet changes. The delay in communication resulted in the resident not receiving food in the appropriate form as ordered by the physician.
Failure to Provide Diet-Appropriate Food Consistencies for Residents with Dysphagia
Penalty
Summary
Facility staff failed to provide food in the prescribed texture and consistency for five residents with dysphagia or other dietary needs. Multiple observations revealed that residents on mechanical soft or advanced dysphagia diets were served regular rolls, peach cobbler with crust, cubed chicken, and whole pineapple slices, instead of the required ground or chopped meats, pureed bread, and appropriately prepared fruits and desserts. In one instance, a resident with a mechanical soft, nectar thick liquid order was observed consuming an unthickened beverage with a straw, contrary to physician orders and dietary guidelines. Meal tickets for these residents clearly indicated the required diet modifications, such as mechanical soft or advanced dysphagia textures, and specified items like ground chicken nuggets, pureed bread, and chopped fruit. However, the food served did not match these specifications. Staff interviews confirmed that the food items provided did not conform to the required consistencies, and the dietary manager acknowledged that the kitchen failed to check and prepare certain items as needed. Additionally, the care plans for these residents did not contain information about their altered diets, despite existing prescriber orders. Staff, including CNAs and dietary personnel, described their roles in ensuring that food served matches the meal ticket and diet orders. Despite these protocols, the observed discrepancies indicate that the process for preparing and verifying diet-appropriate meals was not consistently followed. The facility's policy requires individualized diet modifications based on interdisciplinary input and written orders, but these were not implemented as required for the affected residents.
Failure to Provide Food in Required Form for Resident
Penalty
Summary
The facility staff failed to provide food in a form designed to meet the needs of Resident #170, who was moderately cognitively impaired and had a physician's order for a regular diet with food cut into bite-sized pieces. Despite the meal tickets clearly documenting the need to cut the food into bite-sized pieces, the resident was repeatedly served meals that were not prepared according to these instructions. This included meals such as toast with sausage gravy, spaghetti with meat sauce, and sliced turkey with mixed vegetables, none of which were cut into bite-sized pieces as required. Interviews with facility staff, including a CNA and an LPN, confirmed that the responsibility for cutting the food lay with the CNAs, who were expected to follow the instructions on the meal tickets. The LPN noted that the resident's food needed to be cut due to left-sided weakness. However, the facility lacked a specific policy regarding the provision of food in a form to meet residents' needs, contributing to the oversight in care for Resident #170.
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