Inadequate Nutritional Oversight Due to Staffing Deficiencies
Summary
The facility failed to employ sufficient staff with the necessary competencies and skills to ensure appropriate nutritional oversight for residents. The full-time Director of Food and Nutrition Services (FSD) was not a qualified dietitian or clinically qualified nutrition professional and did not receive frequent consultations from a qualified dietitian. The facility's assessment did not indicate the necessity of a qualified dietitian to meet the nutritional needs of the residents, which is a requirement under federal regulations. The FSD, who is a Certified Dietary Manager, confirmed that she does not meet the minimum qualifications to be a qualified dietitian. Although the facility employs a part-time registered dietitian (RD) who works remotely, the FSD's interactions with the RD were limited to email and telephone communications. The FSD attended care plan meetings and documented residents' food preferences, but her scope of practice did not include clinical assessment and evaluation for medically related nutritional therapy. The part-time RD confirmed that she completes all job tasks remotely and does not conduct on-site consultations or oversight. She relies on input from the interdisciplinary team, including the FSD, to complete nutritional assessments. The RD has not been in the facility to observe residents' eating abilities or provide direct nutritional consultation, which limits her ability to fulfill her responsibilities effectively. The nursing home administrator could not provide documentation confirming the RD's on-site consultation or oversight role.
Plan Of Correction
1. A RD was hired to provide 10 hours/week of onsite dietary support and evaluation. 2. The facility will maintain an onsite RD. 3. The recruiter was re-educated on ensuring that an onsite RD was available to the facility for at least 10 hours/week. The NHA will report open positions to the recruitment department. 4. The NHA or designee will conduct an audit of RD onsite hours weekly x 4 weeks then monthly x 2 months to ensure onsite support is provided. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
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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