Dietary Staff Training and Supervision Deficiency
Summary
The facility failed to ensure that dietary staff were supervised and trained by a qualified dietary manager, resulting in several residents receiving incorrect physician-prescribed diets. This deficiency led to a serious incident where a resident, identified as R6, choked on a piece of tomato that was not appropriately prepared for a mechanical soft diet. The choking incident required the Heimlich maneuver and resulted in the resident being hospitalized for aspiration pneumonia. The facility's failure to provide the correct diet placed the resident at risk for further episodes of choking and aspiration. The deficiency was observed in four residents who were supposed to be on mechanical soft diets. The dietary staff, including the Food Service Manager (FSM), lacked the necessary qualifications and training to ensure compliance with dietary orders. The FSM, who had been in the role for three years, did not possess a current food protection manager certification and was not a certified dietary manager. The Registered Dietitian (RD) contracted by the facility provided limited oversight and had not conducted face-to-face meetings with the dietary staff, resulting in inadequate training and supervision. The facility's dietary staff, including cooks and dietary aides, were not properly trained in preparing mechanical soft diets. Observations revealed that residents on mechanical soft diets were served inappropriate foods, such as whole hot dogs, ham cubes, and fresh fruit chunks, which were not consistent with the prescribed diet texture. The facility's policy required that meats be mechanically ground, but this was not followed. The lack of proper training and supervision led to the dietary staff's inability to adhere to the prescribed diets, directly contributing to the deficiency.
Removal Plan
- Immediate Recruitment Efforts: We have placed a Certified Dietary Manager (V31) in this position. The current Supervisor (V4) will attend a class to renew his Food Safety Manager Certificate. All other dietary staff files will be audited for compliance with the current Food Handler's Certification by Human Resources (V17). The Certified Dietary Manager (CDM) (V31) has started the training for dietary staff. The Registered Dietitian (V7) will continue with the training for proper production and serving of mechanical soft diets. The CDM (V31) will supervise food service production.
- Enhanced Training Programs: In-servicing and training have begun for dietary staff by the CDM (V31) on providing diet as ordered, communication protocol, review diet, and update orders, in-servicing will continue until all dietary staff is trained before starting their next shift. The ADON (V3) started in-servicing nursing staff on monitoring dietary cards to ensure correct food consistency is being served; in-servicing will continue until all nursing staff is trained. We are enhancing our current training programs to ensure all dietary staff receive continuous education on a yearly basis for food safety, nutritional guidelines, and regulatory compliance. These programs will be provided by our contracted Registered Dietitian (V7) or her designee.
- Policy Review and Updates: A review of our Dietary Policies and Procedures Manual will be reviewed by the CDM (V31) and our contracted Registered Dietitian (V7) this process will be started and continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be implemented by in servicing the Dietary and Nursing Staff to reinforce our commitment to compliance and high-quality care, this procedure will be given by our contracted Registered Dietitian or her designee.
- Regular Audits and Monitoring: To prevent future occurrences, we will establish a random weekly audit of 3 meals a week for 90 days done by the CDM (V31); this audit will be focused on food consistency matching the dietary card. This procedure will help us monitor for compliance, identify potential issues early, and take corrective actions promptly. Results will be reported at QA meeting to ensure ongoing compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Qualified RD The facility failed to employ a qualified RD for the food and nutrition service. The FSGM could not identify the current clinical RD, and the NHA confirmed the prior RD had resigned and no replacement had been hired, leaving two full-time RD positions open and no RD on staff to complete the essential job functions.
The facility failed to provide a full-time certified dietary manager for residents receiving meals from the kitchen. Dietary staff prepared breakfast, and staff later stated the person serving as dietary manager had only been in the role for one month and was not certified. Administration confirmed the prior dietary manager had quit about a month earlier and that the current staff member would be enrolled in CDM classes soon. The facility policy required a qualified Dietary Supervisor/CDM with state-approved certification.
The facility failed to provide the services of a full-time CDM for the 36 residents who received meals from the kitchen. Dietary staff stated there was no CDM in place, one staff member was serving as kitchen supervisor, another was just starting CDM classes, and the RD only came to the facility once a month. The facility policy stated the dietary department’s day-to-day functions are to be supervised by a qualified dietary manager.
The facility failed to provide a full-time certified dietary manager for 41 residents receiving meals from the kitchen. Record review did not show certification for the dietary manager, and the staff member serving in that role stated she was not yet certified and was taking classes. She also said she had taken over after the prior dietary person left and that she would seek help or research answers for food allergy questions.
Unqualified dietary leadership and no full-time nutrition professional: The facility failed to have a qualified director of food and nutrition services, a full-time RD, or another full-time clinically qualified nutrition professional for the residents receiving meals from the kitchen. The DM was also the Housekeeping Director but did not meet the required CDM, CFSM, degree, or experience qualifications, and the RD only visited quarterly rather than working full time.
Food and nutrition services lacked qualified oversight after the RD resigned. The facility did not have a long-term RD or CDM directing the department, and routine on-site clinical nutrition coverage was not provided. A remote RD covered multiple sister facilities and logged only limited off-site consultation hours, with no documentation of on-site meal observation, resident nutrition assessments, or other duties listed in the RD job description.
Missing Qualified Registered Dietitian
Penalty
Summary
The facility failed to currently employ a qualified Registered Dietitian (RD) to carry out the functions of the food and nutrition service. The facility’s job description stated that the RD’s primary purpose was to plan, organize, coordinate, and evaluate the nutritional components of the dietary service and to complete clinical duties and documentation accurately and timely. During an interview, the Food Service General Manager was unable to identify the current clinical RD or confirm who was employed in that position. The Nursing Home Administrator later stated that the facility did not have an RD on staff because the prior RD had resigned, and confirmed that the prior RD resigned on 7/8/26. The Administrator further stated that the facility had been unable to hire a replacement and that two full-time RD positions remained available, confirming that the facility did not have an RD currently employed to complete the essential job functions of the position.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for the 31 residents who received meals from the kitchen. Observation on 07/26/2026 at 08:35 AM showed dietary staff preparing the breakfast meal. On 07/27/2026 at 09:30 AM, Dietary Staff BB stated she was the certified dietary manager and had been in the position for one month, and she reported the facility had six residents on a pureed diet. On 07/28/2026 at 01:00 PM, Administrative Staff A verified that Dietary Staff BB was not certified and stated the previous dietary manager had quit a month earlier, that Dietary Staff BB had started in the role, and that she would be enrolled in Certified Dietary Manager classes soon. The facility policy dated 06/26/2026 stated the facility would employ a qualified Dietary Supervisor/Certified Dietary Manager responsible for organizing, directing, staffing, monitoring, and evaluating all food service operations, and that the Dietary Supervisor shall possess successful completion of a state-approved Certified Dietary Manager certification program.
Lack of Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for the 36 residents who received meals from the kitchen. During interviews, Dietary Staff CC stated the facility did not have a Certified Dietary Manager and that she was the kitchen supervisor, while the person taking over the CDM role was on vacation and another dietary staff member had just started taking classes for the CDM. Administrative Staff A stated he was aware the facility did not have a CDM and that the facility did have a person taking the class. Administrative Nurse A stated the Registered Dietician comes to the facility once a month. The facility's Dietary Manager policy dated 2018 stated that the day-to-day functions of the dietary department are under the supervision of a qualified dietary manager.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for the 41 residents who received meals from the kitchen. Record review did not include documentation that Dietary staff BB had certification as a dietary manager. During an interview, Dietary staff BB stated that she was serving as the dietary manager but was not yet certified and was taking classes. She said she had taken over the position in March 2026 after the prior dietary person walked out, and that she had worked at the facility for eight or nine years as a CNA and CMA. In a later interview, she stated that she had trained some staff in kitchen basics and would ask a nurse or someone knowledgeable to answer questions about food allergies if needed, or research the subject. The facility did not provide a policy when requested.
Unqualified dietary leadership and no full-time nutrition professional
Penalty
Summary
The facility failed to have a qualified director of food and nutrition services, a full-time qualified dietitian, or another full-time clinically qualified nutrition professional for the 45 residents who received food from the kitchen. Review of the Dietary Manager's personnel file showed that DM #64 was hired as the facility's Housekeeping Director on 08/30/23 and was serving as the facility's Dietary Manager, but she was not a certified dietary manager, certified food service manager, nationally certified in food service management, or a person with an associate's or higher degree in food service management or hospitality. She also did not have two or more years of experience as a director of food and nutrition services in a nursing facility setting with completion of a course of study in food safety and management. Interviews confirmed that DM #64 was acting as both Housekeeping Director and Dietary Manager without the required qualifications, and she stated she had been supposed to complete certifications but had not had time to do so. The Regional Director of Clinical Operations verified that DM #64 did not meet the qualifications for the role. The registered dietitian did not work full time at the facility, visited quarterly, and did not go into the kitchen during visits; the dietary technician also did not work full time. The facility policy stated that if a dietitian was not employed full time, the director of food service management would be designated and must meet the listed qualifications.
Food and Nutrition Services Lacked Qualified Oversight
Penalty
Summary
The facility failed to ensure the food and nutrition services department received required oversight by qualified personnel after the Registered Dietitian (RD) resigned. The report states that current federal guidance requires sufficient staff with appropriate competencies and, when a full-time qualified dietitian is not present, a designated food and nutrition services director who meets specified qualifications and receives frequently scheduled consultation from a qualified dietitian or other clinically qualified nutrition professional. The facility did not have a long-term RD or a Certified Dietary Manager directing the department, and routine on-site clinical nutrition coverage was not being provided. The facility’s RD job description showed the position was responsible for planning, organizing, developing, and directing resident nutritional care, including assessing and monitoring nutritional status, observing meal services, educating residents and staff, reviewing menu changes, conducting audits, completing nutritional assessments, inspecting food service areas, and participating in surveys. The facility also documented that the RD was responsible for recording resident weight changes in PointClickCare, completing comprehensive nutritional assessments, reviewing lab results and meal intake records, performing nutrition-focused physical assessments, and updating nutrition-related care plans. The Nursing Home Administrator stated the facility’s RD resigned and that the facility then used a remote RD who covered multiple sister facilities. The remote RD’s records showed limited off-site consultation hours on several Sundays in May and June 2026, but the facility could not provide documentation showing routine on-site oversight, meal service observation, direct resident nutritional assessments on-site, or other on-site responsibilities described in the RD job description. The facility therefore failed to ensure the food and nutrition services department was directed and clinically supported by qualified personnel as required.
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