Failure to Provide Sugar-Free Syrup to Residents on LCS Diet
Summary
The facility failed to provide sugar-free pancake syrup to residents on a low concentrated sweets (LCS) diet, as per their dietary orders. This deficiency affected three residents who were observed to have received regular syrup instead of the prescribed diet syrup. The residents involved had pertinent diagnoses such as type two diabetes mellitus, chronic kidney disease, and cognitive impairments, which necessitated adherence to their therapeutic diet orders. Resident #74, who was cognitively intact and required setup for eating, was observed to have an empty container of regular syrup on their breakfast tray, despite the tray ticket indicating a requirement for diet syrup. Similarly, Resident #25, who was severely cognitively impaired but independent in eating, was also found to have consumed regular syrup instead of diet syrup. Resident #26, with a history of diabetes and chronic kidney disease, was observed with regular syrup on their tray, contrary to their LCS diet order. Interviews with staff, including the Regional Director of Dietary Services and CNAs, confirmed that regular syrup was mistakenly provided on LCS diet trays. The facility's dietary staff had been educated on providing meal items per tray ticket, yet the issue persisted. The facility's policy required the use of a tray card identification system to ensure residents received their diets as ordered, but this system failed to prevent the error, leading to non-compliance with dietary orders.
Penalty
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During a multi-day power outage, the facility relied only on a gas stove, leaving kitchen equipment such as the food processor unusable and resulting in residents on pureed diets receiving limited items like mashed potatoes, stuffing, tomato soup, and cream of wheat without clear protein sources. Several residents with dysphagia, protein-calorie malnutrition, significant weight loss, COPD, and other chronic conditions had orders for pureed diets and nutritional supplements, but documentation in progress notes, intake records, and MARs did not show that any additional supplementation beyond routine orders was provided during the outage. Dietary staff could not specify what protein foods were served, no records were kept of the actual foods provided, tray tickets did not list what was served, and one resident reported not getting enough to eat or receiving extra items such as shakes or ice cream. The DON and RD could not verify that residents on pureed diets received well-balanced, protein-adequate meals during this emergency period.
A resident with impaired cognition, blindness, and multiple conditions including Type II DM, hypothyroidism, hypokalemia, and adult failure to thrive was care planned to require feeding assistance, meal setup using a clock system, and monitoring of nutritional intake. During an observed lunch meal service, meal trays were delivered on the hall and to rooms, but the resident did not receive a lunch tray over an extended period. A CNA, unfamiliar with the facility and residents, did not verify that all residents had trays, and an RN reported that the resident typically refused meals and preferred Cheerios, confirming that no lunch tray was offered.
Staff failed to provide consistent food portions and palatable meals, with some residents receiving smaller servings as food ran low and others receiving food at inappropriate temperatures. Food temperature logs were not properly maintained, and staff were unsure of correct serving temperatures, resulting in meals that did not meet facility policy for nutrition and palatability.
A resident did not receive their lunch meal as scheduled, despite requesting food from the alternative menu. Both the resident and the DON confirmed that the meal was not provided, which was not in accordance with the facility's policy requiring three daily meals at regular times.
Two residents did not receive meals consistent with their prescribed diets and meal tickets. One resident on a mechanical diet was served the wrong vegetable, while another on a pureed diet received only part of the required meal, with several pureed items missing at the time of service. Staff confirmed the discrepancies and were unable to provide reasons for the omissions, despite facility policy requiring adherence to the menu and meal tickets.
A resident with multiple medical conditions did not receive her ordered meal and was instead given a peanut butter sandwich without being consulted, as kitchen staff failed to discuss alternative options when the requested item was unavailable. The resident confirmed this was a recurring issue, and facility policy requiring support of dietary choices was not followed.
Failure to Ensure Adequate Pureed Diet Nutrition During Power Outage
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received a nourishing, palatable, well‑balanced diet that met daily nutritional and special dietary needs during a prolonged power outage. The facility experienced a power outage from the evening of 03/13/26 until the morning of 03/15/26, during which only the gas stove functioned in the kitchen because there were no generator-connected (red) outlets. As a result, staff could not use the food processor to prepare pureed foods and instead served items that could be made with boiling water. Dietary staff reported that residents on pureed diets were given mashed potatoes, stuffing, tomato soup, and cream of wheat, and no record was kept of the specific foods served during this period. Tray tickets for affected meals did not indicate what foods were actually provided. Four residents with orders for pureed diet textures were specifically reviewed. One resident had dementia, type 2 diabetes mellitus, dysphagia oral phase, and was care planned as at risk for nutritional decline, with interventions including pureed diet with thickened liquids and house supplements twice daily. Another resident had protein calorie malnutrition, muscle wasting and atrophy, diverticulosis, and a history of significant weight loss, and was also care planned for pureed texture and house supplements twice daily. A third resident had dysphagia oropharyngeal phase, respiratory failure, intellectual disabilities, adult failure to thrive, and was ordered a pureed diet with nectar thick liquids and a daily house supplement. The fourth resident had COPD, GERD, mild cognitive impairment, major depressive disorder, significant weight loss, and was ordered a pureed diet with nectar thick liquids, Magic Cup with meals, and house supplements with meals for weight loss. For all four residents, review of progress notes, nurse aide intake tracking, and MARs showed no documentation that any additional supplementation beyond the routinely scheduled supplements was provided during the power outage dates. Dietary staff, including the Dietary Supervisor and Dietary Director, were unable to identify what protein sources were served to residents on pureed diets during this time. A DTR and a Regional RN asserted that residents on pureed diets received nutritional supplements and that items such as tomato soup provided some protein, but the RD could not confirm whether additional supplementation was actually provided during the outage. One cognitively intact resident reported not getting enough to eat during the outage and stated that, although some food was provided, it was not enough to satisfy hunger and no additional items like ice cream or health shakes were offered. The DON confirmed that tray tickets did not specify what foods were served during the power outage, and there was no documentation to substantiate that residents on pureed diets received balanced meals or adequate protein during this emergency period. The deficiency affected four reviewed residents with pureed diet orders and had the potential to affect all eight residents in the facility who required pureed diet textures. The lack of a system to ensure well‑balanced, nutritionally adequate pureed meals during the power outage, combined with the absence of documentation of what foods and supplements were actually provided, led to the finding that the facility did not meet the requirement to provide each resident with a diet that met daily nutritional and special dietary needs during the emergency event.
Failure to Provide Ordered Lunch Meal to Dependent, Visually Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a nourishing, palatable, well‑balanced diet that met the resident’s nutritional needs. The resident had multiple diagnoses including Type II DM, hypothyroidism, hypokalemia, adult failure to thrive, and anxiety disorder, and was blind with impaired cognition (BIMS score of eight). The care plan documented ADL self‑care performance deficits related to impaired vision and arthritis, required staff assistance with meals, and specified that staff should help the resident eat, encourage self‑feeding when possible, and use the clock system to describe plate setup. The resident was also care planned as being at risk for nutrition and hydration deficits due to multiple medical conditions and diuretic use, with interventions including providing ordered supplements and monitoring intake and weight. Facility documentation identified the resident as requiring feeding assistance. On the observed lunch meal service date, surveyors noted that the resident was in her room at 11:39 A.M. with no meal tray present. Hall trays were delivered to the hallway at 11:52 A.M., and to resident rooms by 11:58 A.M., yet from 12:02 P.M. through 12:40 P.M. the resident still did not have a lunch tray. A CNA interviewed at 12:45 P.M. stated she was unaware the resident had not received a lunch tray, explained she was unfamiliar with the residents and the facility’s lunch tray process because it was her first time in the facility, and confirmed she did not check to ensure all residents had their lunch trays. An RN interviewed at 12:49 P.M. stated the resident always refuses meals and was not offered a tray because the resident likes Cheerios, further stating the resident would not allow a plate to sit on the tray table and again confirming that lunch was not offered to the resident.
Failure to Provide Consistent, Palatable, and Appropriately Portioned Meals
Penalty
Summary
The facility failed to ensure that food portions were appropriate and that meals served were palatable for residents, with the exception of one resident who did not consume meals from the kitchen. Observations during a lunch tray line revealed inconsistencies in portion sizes, with residents on pureed diets receiving different amounts of food compared to those on regular diets, and the last group of residents served receiving smaller portions as food supplies ran low. Additionally, food items such as pureed spaghetti, salad, and garlic bread were not kept within the steam tables, and some food temperatures were not recorded or were recorded incorrectly. The temperature log was not consistently updated, and not all required food temperatures were obtained prior to meal service. Further observations showed that as meal service continued, the quality of the food deteriorated, with spaghetti noodles hardening and becoming crusty. Staff confirmed they were attempting to stretch limited food supplies to serve all residents, resulting in inconsistent portion sizes that did not match the recommended amounts listed on the facility's spreadsheet. A test tray revealed that some food items were served at inappropriate temperatures, and staff were unsure of the correct serving temperatures. Review of facility policy indicated that meals should be nourishing, palatable, well-balanced, and served at safe and appetizing temperatures, but these standards were not met during the observed meal service.
Failure to Provide Timely Lunch Meal to Resident
Penalty
Summary
The facility failed to provide a resident with three meals a day as required by policy. On observation, a resident had not received their lunch by 2:10 P.M., despite having requested a ham sandwich and a bowl of soup from the alternative menu. The resident confirmed in an interview that they had not received lunch at that time. The DON also confirmed that the resident did not receive their lunch. Review of the facility's policy indicated that lunch should be served daily at 12:30 P.M., but this was not followed in this instance.
Failure to Provide Prescribed and Complete Meals per Menu and Meal Tickets
Penalty
Summary
The facility failed to provide residents with meals that met their prescribed dietary needs and preferences as outlined in their meal tickets and the facility menu. For one resident with hemiplegia, vascular dementia, and other conditions, the meal ticket specified a mechanical diet including glazed ham, green beans, rice pudding, au gratin potatoes, and a wheat dinner roll. However, the resident was served brussels sprouts instead of green beans, and the green beans were not prepared at all. Staff confirmed the discrepancy and were unable to explain why the correct vegetable was not provided, despite the meal ticket indicating otherwise. Another resident, with Alzheimer's disease, dementia, and dysphagia, was ordered a regular diet with puree texture. The meal ticket and menu called for pureed glazed ham, brussels sprouts, au gratin potatoes, rice pudding, and bread. At the time of service, only pureed ham and brussels sprouts were available and served; the other pureed items were not prepared. The kitchen manager acknowledged the missing items and stated that the equipment needed to prepare them was unavailable at the time. The diet technician confirmed that all items on the meal ticket should have been served. Facility policy requires that menus be followed as written unless changed for preference or unavailability, but no such changes were documented.
Resident Meal Preferences Not Honored
Penalty
Summary
A deficiency occurred when a cognitively intact resident with multiple diagnoses, including a left humerus fracture, PTSD, depression, and glaucoma, did not receive her ordered meal. The resident had ordered a hot dog, mashed potatoes, and fruit for lunch, but instead received mashed potatoes, fruit, and a peanut butter sandwich. The resident confirmed that she often did not receive what was listed on the menu and would instead be given a peanut butter and jelly sandwich. Observation during lunch service confirmed the resident received a peanut butter sandwich instead of the hot dog she had ordered. The Director of Nutritional Services verified that the kitchen did not have hot dogs available and that staff did not discuss alternative menu options with the resident. Instead, staff assumed the resident would want a peanut butter sandwich without confirming her preference. Facility policy stated that residents' rights to make personal dietary choices would be supported, but this was not followed in this instance.
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