Failure to Ensure Menus Meet Nutritional Needs and Are Reviewed by Dietitian
Summary
The facility failed to ensure that menus were prepared in advance, followed, and reviewed by a qualified nutrition professional. The facility's assessment tool indicated a transition to liberal diets with modifications as needed, and that menus would be created by the dietary staff and approved by a registered dietitian. However, the menus provided did not document therapeutic diets or portion sizes. The dietary manager (DM) pointed to a handwritten menu lacking these details, and the assistant administrator confirmed that a part-time cook, who was the previous dietary manager and not certified, had been making the menus for over a year without dietitian approval. Interviews revealed that the part-time cook determined menus based on residents' likes and dislikes, and staff were expected to know portion sizes from weekly meetings. The dietary aide prepared meals based on the DM's instructions without knowing the full menu details. The facility dietitian confirmed they had not signed off on menus for a year, and the assistant administrator admitted that the dietary staff did not follow the provided menus but instead followed those prepared by the part-time cook. The DM also admitted to serving meals not listed on the menu, such as beans every Wednesday, which contradicted the assistant administrator's statement that this practice had stopped.
Penalty
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Surveyors found that residents on pureed diets did not receive the same planned menu items as those on regular diets, despite orders for regular diets with pureed texture and, in some cases, nutritional supplements and adaptive equipment. During an evening meal, pureed plates contained generic green, orange, and beige purees and ice cream instead of the scheduled oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake, while other diners received the full regular-texture menu. Dietary staff reported that a broccoli blend was substituted for the listed asparagus and that no pureed cake was prepared, even though asparagus could have been pureed and facility policy required verification that each resident received the correct diet and consistency.
A resident with Alzheimer's disease and DM, on a regular diet with dysphagia-advanced texture and thin liquids, was served an incorrect portion of ground chicken salad when dietary staff used a #16 scoop (2 oz) instead of the #10 scoop (3.75 oz) specified on the diet ticket and in the recipe. During lunch tray line service, the staff member plated the smaller portion and sent the tray to the cart, and the error was only recognized when the tray was later pulled. The dietary manager later acknowledged that serving utensils had not been checked before tray service, and this error had the potential to affect multiple residents receiving the same menu item.
Surveyors found that the facility did not maintain an adequate food supply or consistently follow posted menus, affecting most residents. The Dietary Manager acknowledged low food stock, lack of a required emergency supply, and reliance on weekly deliveries and local store purchases. During one observed meal, residents on regular diets received only one cookie instead of the two listed on the menu, and those on mechanical soft or puree diets received pudding instead of the posted dessert. A review showed that menu substitution logs had not been completed for many months, and the Dietary Manager confirmed that substitutions and served meals were not documented, despite facility policy requiring such records. Residents reported not always receiving items on their meal tickets and feeling they did not get enough food to meet daily calorie needs.
Surveyors found that the facility did not follow RD-planned breakfast menus or provide appropriate nutritional substitutions when items were unavailable. On multiple mornings, residents who were supposed to receive scrambled eggs or egg substitutes instead received only toast and bacon, and a resident on a cardiac diet was served bacon despite diet restrictions. Staff reported there were no eggs or sufficient milk available, used bacon as an assumed protein substitute, and did not reference the specialized diet spreadsheet during meal service. On another morning, mandarin oranges listed on the menu were not served to residents, and no alternative fruit was provided except applesauce for those on pureed diets, contrary to facility policy requiring documented menu substitutions.
The facility failed to consistently honor and document resident dietary preferences and to assist residents and families with menu selection. One cognitively impaired resident on a mechanical soft diet had no documented updates to food preferences or family involvement in nutrition assessments, and the family reported they were never offered the option to complete weekly menus. Another resident with intact cognition but dependent for ADLs reported repeatedly refusing chicken and requesting help with daily menus, yet continued to receive chicken and had no dislikes documented on the diet ticket. A third resident with dementia received incorrect breakfast items despite having requested specific foods, with a CNA confirming that dietary orders were often wrong. The RD acknowledged lack of evidence that preferences were updated, uncertainty about staff assistance with menus, and difficulty among dietary staff in knowing what each resident wanted, despite policies requiring diets to reflect residents’ informed choices and preferences.
Surveyors found that the facility did not follow its posted lunch menu for all residents receiving meals in the dining room. Instead of the planned corn dog, cheesy mashed potatoes, mixed vegetables, white bread, and yellow cake, staff served corn dogs, plain mashed potatoes without cheese, mixed vegetables, and vanilla pudding, and omitted bread entirely. The cook reported there was no specific reason for not preparing cheesy potatoes, acknowledged forgetting to serve bread, and stated that pudding was substituted because cake had not been baked, even though cake mix was in stock. The Corporate Dietary Manager was unaware of some of these deviations, despite facility policy requiring that menus be followed and that any substitutions be nutritionally similar and documented.
Failure to Provide Pureed-Diet Residents with Menu-Consistent Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that residents on pureed diets received the planned menu items in the prescribed texture, as required by facility policy and diet orders. Three residents with severe cognitive impairment and significant dependence for eating and ADLs were affected. One resident with Alzheimer’s disease, COPD, anxiety, dementia, and dysphagia had orders for a regular diet with pureed texture and nectar-thick liquids, plus a nutritional supplement before lunch and dinner. Another resident with Alzheimer’s disease, CAD, CHF, ESRD, type II diabetes, and anxiety had orders for a regular diet with pureed texture, use of a divided plate and sippy cup, and to be fed for all meals. A third resident with hypertension, insomnia, nontraumatic subarachnoid hemorrhage, and a history of repeated falls had orders for a regular diet with pureed texture and a magic cup with meals for weight loss. The daily menu for the observed evening meal listed oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake. Observation of a pureed meal showed mounds of green, orange, and beige purees and a nutrition supplement ice cream, while a regular-texture meal contained fried chicken, mashed sweet potatoes, and asparagus spears. Staff interviews revealed that the morning cook prepared a broccoli blend as the vegetable for the three residents on pureed diets instead of pureed asparagus, and that no pureed chocolate banana marble cake was prepared; ice cream was used as the pureed dessert instead. Dietary staff and another interviewee confirmed that residents on pureed diets were supposed to receive the same menu items as those on regular diets, except for preferences or allergies, and that asparagus could be pureed to an appropriate texture. The facility’s policy required staff to check trays before serving to ensure the correct diet and ordered consistency, but this was not followed for the affected residents on pureed diets.
Improper Portioning of Ground Chicken Salad on Diet Tickets
Penalty
Summary
The facility failed to ensure residents received proper portion sizes as specified on diet tickets during meal service. A resident with Alzheimer's disease and diabetes mellitus, admitted on 5/28/25, had an annual MDS assessment indicating moderate cognitive impairment and a need for setup assistance with eating. Physician orders for March 2026 specified a regular diet with dysphagia advanced texture and thin liquids. During observation of the lunch tray line on 03/19/26 at 12:15 P.M., the resident’s meal ticket indicated they were to receive ground chicken salad using a #10 scoop (3.75 oz). However, staff member #107 plated the ground chicken salad using a #16 scoop (2 oz), then completed the tray and placed it in the food cart. At 12:17 P.M., when Dietary Aide #109 pulled the tray from the cart, staff member #107 verified that the scoop used was a #16 (2 oz) instead of the required #10 (3.75 oz). In an interview at that time, staff member #107 acknowledged the serving size should have been three ounces and consulted the scoop chart, which confirmed the #16 scoop was only two ounces. The undated chicken salad recipe also specified that a #10 scoop of chicken salad should be placed between two slices of bread. In a later interview at 1:30 P.M., the Dietary Manager stated she believed staff member #107 was nervous and acknowledged she should have checked the serving utensils prior to tray service. This failure affected the identified resident and had the potential to affect eight other residents scheduled to receive ground chicken salad.
Failure to Maintain Adequate Food Supply and Follow Posted Menus
Penalty
Summary
The facility failed to ensure menus were followed and that an adequate food supply was maintained to meet residents' nutritional needs. Surveyors observed the dry stock area with the Dietary Manager and found a low stock of food, with the Dietary Manager confirming that food deliveries occurred once a week, that she shopped locally if food ran out, and that there was no emergency stock of food available, despite facility policy requiring a minimum seven-day supply. Review of the lunch meal service showed that the posted menu for that day called for beef and noodles, broccoli florets, and two baked cookies, but residents on regular diets received only one cookie, and residents on mechanical soft and puree diets received pudding instead of the listed dessert. The Dietary Manager confirmed there were not enough cookies prepared to follow the menu and acknowledged that the menu indicated residents should have received two cookies. Resident interviews further supported that the menu was not consistently followed. One resident reported not always receiving everything listed on their meal tickets, and another resident stated that the facility did not follow the meal tickets and that they felt they were not getting enough food to meet their daily calorie needs. Review of the substitution logs with the Dietary Manager showed that the log had not been filled out since July 2025, and the Dietary Manager verified that she did not keep a substitution log or documentation of meals served. This was inconsistent with the facility’s written menu policy, which required that menus be followed and that any deviations from the menu be recorded and archived. The deficiency affected 67 residents, with three residents identified as NPO and therefore not receiving food from the kitchen.
Failure to Follow RD-Planned Menus and Provide Appropriate Nutritional Substitutions at Breakfast
Penalty
Summary
The deficiency involves the facility’s failure to follow menus planned by the Registered Dietitian (RD) and to provide the specified foods and nutritionally appropriate substitutions to residents. Menu spreadsheets for multiple days showed that all diets were to receive two ounces of scrambled eggs at breakfast, with residents on cardiac diets to receive an egg substitute product and no bacon. Review of temperature guides and menu spreadsheets showed either no notation of substitutions or inaccurate documentation of substitutions. Observations and interviews confirmed that on several days residents did not receive eggs or egg products as planned, and there was no documentation of appropriate substitutions. Multiple residents reported not receiving eggs on the specified days and instead receiving small portions of toast and bacon, with one resident stating the portion was not enough food and that he wanted some type of protein. A resident on a cardiac diet reported receiving bacon, which he was not supposed to have, and stated he should have received an egg substitution product when eggs were on the menu. Staff interviews, including a CNA and a housekeeper, corroborated that residents on the skilled unit did not receive eggs or milk on certain days and instead received limited portions of toast and bacon, with no other protein on the breakfast trays. Dietary staff confirmed that there were no eggs in the kitchen to prepare and that bacon was used as a substitute for eggs, and that only about half of the residents received milk on one of the days because the kitchen ran out. Dietary staff, including diet aides, a diet manager, and another kitchen staff member, stated they did not have a listing of appropriate protein substitutes and believed bacon was a protein substitute for eggs. They also reported that the specialized diet spreadsheet was not used during meal service as a reference, and that the meals were not served from the spreadsheet of specialized diets. The RD verified that bacon was not a nutritionally equivalent substitution for egg protein and that cooks should follow the approved spreadsheet for specialized diets. Additionally, on another day, the menu spreadsheet indicated that all diets were to receive mandarin oranges at breakfast, but observations showed that no residents received mandarin oranges except those on pureed diets, who received applesauce. Dietary staff confirmed there were no mandarin oranges available, no time to prepare another substitute, and that no other fruit was provided in place of the mandarin oranges for most residents, despite facility policy requiring menu changes and substitutions when items are not available for service.
Failure to Honor Resident Dietary Preferences and Assist With Menu Selection
Penalty
Summary
The deficiency involves the facility’s failure to honor and manage residents’ dietary preferences and menu choices in accordance with its own policies and physician/dietary orders. For one resident with Alzheimer’s disease and severe cognitive impairment, records showed orders for a regular mechanical soft diet with thin liquids and ice cream at lunch and dinner, along with a low BMI and moderate assistance needed for eating. Despite this, there was no documentation of updated dietary preferences, no evidence of family involvement in nutrition assessments, and no changes to the nutrition care plan over several months. The resident’s son reported that, due to her cognitive impairment, she could not remember to request alternative food items and that the family had not been asked to update preferences or informed they could complete weekly menus. Another resident, admitted with a fracture, anxiety disorder, morbid obesity, and intact cognition but dependent for all ADLs, had a physician order for a regular diet with thin liquids. The nutrition assessment and care plan noted a regular diet, set-up assistance, and some meal refusals, but did not document specific dietary preferences. This resident reported telling staff on the first day that chicken was disliked and being told the kitchen would be informed, yet continued to receive chicken. The resident also stated that daily menus were provided but staff did not consistently assist with filling them out. Review of the diet ticket confirmed a regular diet with no listed preferences or chicken dislike, and the RD acknowledged the absence of documented preferences and uncertainty about whether staff consistently passed out and assisted with daily menus. A third resident with unspecified dementia and a regular diet order had a care plan intervention to review food likes, dislikes, and meal preferences as needed. During a breakfast observation, the resident received a tray containing items such as a hard-boiled egg, oatmeal, hash brown, and a pastry, while the ticket listed cereal, hard-boiled egg, blueberry muffin, hash brown, milk, coffee, and juice. The resident appeared upset and stated only frosted flakes, coffee, and milk had been requested. A CNA confirmed the tray was incorrect and commented that dietary staff frequently made errors with residents’ orders. After the correct items were brought, the resident expressed ongoing dissatisfaction and confusion about why meals were always wrong. The RD later acknowledged awareness of this concern and stated that dietary staff were having difficulty knowing what each resident wanted. Review of facility policies showed that diets were to be determined in accordance with residents’ informed choices, preferences, treatment goals, and wishes, and regularly reviewed by the dietitian, nursing staff, and physician.
Failure to Follow Posted Lunch Menu and Provide Planned Food Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned lunch menu for all 63 residents receiving meals from the dining room. The written menu for a specific date listed corn dog, cheesy mashed potatoes, mixed vegetables, white bread, and yellow cake for lunch. During observation of the meal service, staff were instead serving corn dogs, regular mashed potatoes without cheese, mixed vegetables, and vanilla pudding, and no bread was provided. The yellow cake specified on the menu was not served. In an interview, the cook serving the meal acknowledged that the mashed potatoes were not prepared as cheesy potatoes and stated there was no particular reason for this change. The cook also stated that yellow cake was not available because it had not been made, so pudding was served instead, and confirmed that bread had been forgotten entirely. Later, the Corporate Dietary Manager reported she was not aware that cheesy potatoes and bread were not served, but she did know that pudding was substituted for yellow cake because the cake had not been prepared the night before, despite the facility having yellow cake in stock. Facility policy on menus required that menus meet residents’ nutritional needs, that appropriate substitutions be made and recorded when items were not available, and that substitutions be similar in nutritional value to the planned items.
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