Failure to Follow Physician-Ordered Diets for Diabetic Residents
Summary
The facility failed to adhere to physician-ordered diets for two residents, R4 and R9, both of whom have Diabetes Mellitus Type II. R4 was admitted with a hospital discharge instruction to receive a Diabetic diet, but due to a transcription error, the dietary department was instructed to serve a regular diet instead. This error persisted from R4's admission, as confirmed by the Certified Dietary Manager and the Director of Nurses, who acknowledged the incorrect entry of R4's diet order. Similarly, R9, who also has Diabetes Mellitus, was ordered a Consistent Carbohydrate diet with pureed texture and thin liquids. However, R9 was served a regular diet with a full portion of dessert, contrary to the physician's order, as observed by a Certified Nurse Aide and confirmed by an Agency Registered Nurse. The Regional Registered Dietician noted that the facility should have ensured the correct transcription of hospital discharge orders into the Electronic Medical Record (EMR) and communicated the correct diet to the dietary department. The Director of Nurses admitted that R4's diet order was entered incorrectly, and R9's diet was served incorrectly despite being transcribed correctly into the EMR. These failures in following physician-ordered diets could have led to adverse health outcomes for the residents, such as high blood sugar or hospitalization, as stated by the Regional Registered Dietician.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents with impaired cognition and swallowing needs did not receive their prescribed therapeutic diets and thickened liquids. One resident ordered a puree diet with thickened liquids and extra gravy at all meals was repeatedly fed without the required extra gravy and was given unthickened water at the bedside. Another resident ordered a dysphagia advanced diet with nectar thickened liquids, and allowed only regular texture foods for pleasure, was repeatedly given an unthickened dark soda. Staff, including CNAs, an RN, and a speech therapist, confirmed that the liquids were not thickened and that the orders did not permit regular liquids for pleasure, contrary to the facility’s therapeutic diet policy.
Several residents with physician-ordered therapeutic diets, including renal and gluten/lactose-free diets, were served foods and beverages not compliant with their dietary restrictions. Staff, including CNAs, LPNs, and dietary personnel, demonstrated a lack of knowledge about specific diet requirements and failed to follow meal tickets and orders. One resident requiring thickened liquids and no straws due to dysphagia was observed using straws and consuming regular liquids, with staff unaware of the restrictions. Facility policies for verifying diet accuracy were not followed, resulting in residents not receiving prescribed diets.
A resident with severe cognitive impairment and multiple diagnoses did not receive a physician-ordered nectar thick liquids and puree diet. Instead, the resident was fed regular thin milk by a family member without staff supervision, contrary to the care plan. The resident exhibited a slight cough after consuming the thin milk, and staff confirmed that the milk was not thickened as required.
A resident with end stage renal disease, CHF, and diabetes was not provided with the prescribed renal diet, including limits on juice, milk, and sugar intake. Despite clear physician orders and meal ticket instructions, the resident was repeatedly served and consumed excessive amounts of milk and juice, as well as regular sugar syrup, due to errors by dietary and nursing staff. Interviews confirmed the resident was unaware of dietary restrictions and consistently received incorrect items.
A resident with multiple neurological and cognitive diagnoses was not provided with nectar thick liquids as ordered, receiving thin consistency juice instead. Staff recognized the error after the resident had already consumed most of the unthickened beverage.
The facility failed to provide physician-ordered carbohydrate-controlled diets to 17 residents, serving buttered peas instead of the prescribed sauteed spinach. This discrepancy was confirmed by the Regional Director of Dietary Services and the Dietary Manager, who acknowledged that the correct dietary substitutions were not followed, affecting residents with specific dietary needs.
Failure to Provide Physician-Ordered Therapeutic Diets and Thickened Liquids
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received their physician-ordered therapeutic diets. One resident with impaired cognition, few teeth, and a need for maximum assistance with feeding was ordered a regular puree diet with thickened liquids and extra gravy with all meals. Review of the resident’s meal ticket confirmed the extra gravy requirement. On multiple observed meal times, CNAs were feeding this resident without any extra gravy on or near the tray, and a bedside water pitcher contained liquids that were not nectar thickened as ordered. Staff verified that the extra gravy was not provided and that the water in the pitcher was not thickened, despite acknowledging that the resident sometimes needed additional gravy to ensure a smooth swallow. Another resident with diagnoses including hemiplegia, convulsions, cerebral infarction, dementia, and aphasia, and who was totally dependent on staff for feeding, had a physician order for a regular dysphagia advanced diet with nectar thickened liquids, with permission for regular texture foods for pleasure only. During observations, this resident was repeatedly provided a dark soda poured into a cup with a straw that was not thickened. A CNA confirmed the liquid was not thickened. Later, an RN and a speech therapist both verified that the physician’s order allowed regular texture foods for pleasure but did not include regular consistency liquids for pleasure. The facility’s own therapeutic diet policy stated that therapeutic diets are ordered by the physician to increase nutrients or provide foods residents are able to eat, yet the ordered diet consistencies were not followed for these residents.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to ensure that therapeutic diets were provided as ordered by physicians for four residents reviewed. Residents with specific dietary needs, such as those on renal diets or requiring gluten and lactose-free diets, were observed receiving foods and beverages that were not in accordance with their prescribed diets. For example, residents with renal diet orders received foods such as milk, cheese, sausage, ham, and vegetable soup, all of which were listed as restricted items for renal diets according to the facility's own therapeutic diet definition sheet. Additionally, residents reported receiving high-sodium snacks and orange juice, which were also restricted. Staff interviews revealed a lack of knowledge regarding the specific dietary restrictions for residents on therapeutic diets. Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPNs), and dietary staff were unable to identify which foods were restricted for residents on renal diets or gluten and lactose-free diets. Meal tickets and dietary orders were not consistently followed, and staff confirmed that residents were regularly served foods that were not compliant with their dietary restrictions. One resident with gluten and lactose sensitivity reported abdominal pain after consuming a supplement containing milk protein and stated that she routinely received inappropriate foods, leading her to rely on food brought in by her family. Another resident with an order for a mechanically altered diet and thickened liquids due to dysphagia was observed using straws and consuming unthickened liquids, contrary to physician orders. Staff were unaware of the order prohibiting straws and had not been thickening the resident's liquids. Documentation showed that the resident had been non-compliant with the diet order, but staff had not consistently documented refusals or set up care conferences as required by facility policy. Facility policies required meals to be checked against therapeutic diet spreadsheets and meal tickets, but these procedures were not followed, resulting in residents not receiving diets as ordered.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including hypertension, dementia, obesity, and cancer, did not receive a therapeutic diet as ordered by the physician. The resident, who was severely cognitively impaired and totally dependent on staff for eating, had a physician order for a nectar thick liquids and puree diet, with thin liquids and pleasure foods allowed only under staff supervision. Despite these orders, observations on two separate occasions revealed that the resident's family representative fed the resident regular milk from the original carton using a straw, which was not thickened to nectar consistency. The resident exhibited a slight cough after consuming the thin milk, and there was no staff present to supervise or assist with feeding during these meals. Interviews confirmed that the milk provided was not thickened and that fluids from the kitchen were typically thickened into serving glasses, not left in original cartons. The family representative acknowledged feeding the resident thin milk and noted the resident's cough. The registered dietitian verified that the resident should have received nectar thickened milk unless thin liquids were given under staff supervision, which was not the case during the observed incidents. The facility was unable to provide a policy regarding therapeutic diets and fluid consistencies.
Failure to Provide Physician-Ordered Renal Diet
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, congestive heart failure, and diabetes mellitus, who was prescribed a renal diet with low concentrated sugar and a fluid restriction, was not provided with the specified foods according to physician's orders. Medical record review and meal ticket documentation indicated the resident was to receive limited amounts of juice and milk, as well as a low concentrated sugar diet. However, observations revealed the resident was served and consumed six ounces of orange juice and eight ounces of milk at breakfast, exceeding the prescribed limits. The resident also received and consumed regular sugar syrup instead of the required sugar-free syrup. Interviews with the resident, dietary manager, and registered nurse unit manager confirmed that the resident was not provided with the correct diet as ordered. The dietary manager acknowledged that both the CNA and kitchen staff made errors in serving the incorrect items. The resident was unaware of the dietary restrictions and consistently received and consumed the wrong items. Facility policy required therapeutic diets to be prescribed by the physician to support the resident's treatment plan, but this was not followed in this instance.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide thickened liquids as ordered for a resident with multiple diagnoses, including dementia, cerebral infarction, and Alzheimer's disease. The resident was admitted with a physician's order for a regular, mechanical soft texture diet with nectar consistency liquids. During a breakfast observation, an agency CNA provided the resident with two glasses of thin consistency apple juice, despite the meal ticket being highlighted for nectar thick liquids. Another CNA confirmed the resident required thickened liquids and removed the drinks, but the resident had already consumed most of one glass. The deficiency was identified through observation, medical record review, and staff interviews.
Failure to Provide Physician-Ordered Carbohydrate-Controlled Diets
Penalty
Summary
The facility failed to provide physician-ordered carbohydrate-controlled diets to 17 residents, affecting all residents who were supposed to receive this specific dietary regimen. During an observation of the lunch tray line service, it was noted that residents ordered a Carbohydrate Controlled Diet (CCD) were served buttered peas instead of the prescribed sauteed spinach. This discrepancy was confirmed by the Regional Director of Dietary Services and the Dietary Manager, who acknowledged that the spreadsheet indicating the correct dietary substitutions was not followed. The facility's diet and nutritional manual for a consistent carbohydrate diet, intended for individuals with diabetes or difficulty controlling blood glucose levels, was not adhered to, as evidenced by the failure to provide the correct vegetable substitution. The facility's policy on menus, which should meet the nutritional needs of residents in accordance with established national guidelines, was not implemented correctly, leading to the dietary oversight.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
Trusted by long-term care providers and associations.
