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:
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that for an extended period the facility did not employ a full-time qualified dietitian and also lacked a qualified director of food and nutrition services. An interim Dietary Manager, hired originally as a GN awaiting RN licensure, assumed the dietary manager role despite having an expired CDM credential. The RD functioned only as a consultant and was present on-site one day per week, and the NHA confirmed there was no full-time dietitian, no qualified dietary manager in place, and no job description for the RD position.
Surveyors identified that the facility did not employ a full-time registered dietitian and also lacked a qualified dietary services manager to oversee food and nutrition services in the dietitian’s absence. During an interview, the Administrator confirmed that no full-time dietitian was onsite and no qualified dietary manager had been designated, resulting in noncompliance with management requirements for staffing the dietary department.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
Surveyors found that the facility failed to employ a qualified director of food and nutrition services and to ensure education of dietary aides, affecting all 86 residents. A contract company assumed operation of the kitchen and promoted a former cook to Dietary Manager despite her lacking required certification and relevant educational background. The previously credentialed Dietary Manager stepped down due to the complexity of the new computer system and informed the company that the new Dietary Manager was not credentialed. Although the company indicated it would fund certification training, the new Dietary Manager had not begun any classes at the time of the survey, resulting in non-compliance related to food and nutrition services oversight.
Surveyors identified that the facility did not employ a full-time qualified dietitian and also lacked a qualified full-time dietary services manager to oversee food and nutrition services. In an interview, the DON confirmed the absence of both a full-time dietitian and a qualified dietary manager, resulting in noncompliance with regulatory requirements for qualified dietary staff.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Employ Qualified Dietary Leadership in Absence of Full-Time Dietitian
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time qualified dietitian or a qualified director of food and nutrition services for a 25-day period, as required by federal regulations. Surveyors reviewed the job description for the Dietary Manager position, which outlined responsibilities such as managing daily dietary operations, working closely with a registered dietitian to implement meal plans, maintaining food safety standards, supervising dietary staff, and overseeing food quality and inventory. During this time, the facility did not have a full-time dietitian on staff, and the registered dietitian functioned only as a consultant, present at the facility one day per week. Employee file review and staff interviews showed that the individual serving as interim Dietary Manager, identified as Employee E12, did not meet the qualification requirements for the role. E12 had been hired as a Graduate Nurse while awaiting RN licensure and later signed the Dietary Manager job description, but she reported that her Certified Dietary Manager (CDM) license had lapsed after a previous employer closed and she changed career paths. The Nursing Home Administrator confirmed that there was no full-time dietitian employed, that the RD was only a consultant without a facility job description, and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian during the identified period.
Plan Of Correction
The facility will employ a full-time qualified Dietary Manager. The interim Dietary Manager will be taking CDM renewal on 05/08/2026 The Administrator educated the governing body for the requirement for the Dietary Manager have a CDM certification The Administrator will audit compliance of the requirement that the Dietary Manager maintains a CDM certification.
Lack of Qualified Dietary Leadership in Absence of Full-Time Dietitian
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager when there was no full-time registered dietitian onsite. During an interview on March 31, 2026, at 2:45 p.m., the Administrator confirmed that the facility did not have a full-time dietitian present and also did not employ a qualified dietary manager in the dietitian’s absence. This deficiency was cited under 28 Pa. Code 201.18(b)(3) related to management requirements for employing sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service, including a qualified dietitian.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Unqualified Dietary Manager and Lack of Dietary Staff Education
Penalty
Summary
The deficiency involves the facility’s failure to employ a qualified director of food and nutrition services and to ensure appropriate education of dietary aides, affecting all 86 residents. The Administrator reported that a contract company, Health Care Services Group (HCSG), had been brought in to run the kitchen, using the facility’s existing kitchen staff while the facility retained oversight. Personnel credential review showed that the individual serving as Dietary Manager, identified as #217, did not meet the qualifications for the role: she was not certified and her degrees were not in fields that would qualify her as a Dietary Manager, despite her years of kitchen experience. Interviews with Dietary Manager #217 revealed that she had originally been employed as a cook and was promoted to manage the kitchen after HCSG took over operations. She stated that a previously credentialed Dietary Manager, identified as #100, stepped down from the role when the contract company assumed control, citing the complexity of the computer system, and recommended her, while informing HCSG that she was not credentialed. HCSG indicated they would pay for her to take classes to become a Certified Dietary Manager, but she confirmed she had not started any classes and believed the company might be waiting to see if she could handle the position before investing in her training. The survey identified this as a failure to employ a qualified Dietary Manager and to provide education to dietary aides, constituting non-compliance under Complaint Number 2701233.
Lack of Qualified Full-Time Dietary Leadership
Penalty
Summary
The facility failed to employ sufficient qualified dietary leadership staff, specifically a full-time qualified dietitian or, in the absence of such, a full-time qualified dietary services manager. During a staff interview on March 21, 2026, at 10:44 a.m., the Director of Nursing confirmed that there was no full-time dietitian employed and that the facility did not employ a qualified dietary manager to oversee the food and nutrition service. This deficiency was cited under 28 Pa. Code 201.18(b)(3) regarding management and 42 CFR §483.60(a)(2) concerning qualified dietary staff, and it had been previously cited on June 6, 2025.
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