Failure to Provide Correct Diet Texture and Document Allergies on Diet Slips
Summary
The facility failed to ensure that a resident with a history of dysphagia and at risk for choking received the correct physician-ordered diet texture. The resident was supposed to receive an IDDSI Level 6 Soft and Bite-Sized diet with specific restrictions, including no bread, no coleslaw, no straws, and line of sight supervision. However, the diet slip did not include these restrictions, and the resident was served an IDDSI Level 7 regular textured breakfast, including sausage patty and toast, without dentures in place. The speech therapist observed the resident eating the incorrect diet unsupervised, which led to coughing, regurgitation, and a subsequent aspiration event requiring emergency intervention and hospitalization. Interviews with staff revealed that the process for updating and communicating diet changes was inadequate. The Food and Nutrition Services supervisor was responsible for updating diet slips, but if not present, changes were only written in a communication book, and the diet slips were not updated in a timely manner. Dietary staff relied solely on the diet slips for meal preparation and were unaware of the resident's specific dietary restrictions. Nursing staff also assumed dietary staff would provide the correct meals based on the slips, and there was no consistent supervision in the dining room during meals. Additionally, the facility failed to include a severe peanut allergy on the diet slip for another resident with a history of anaphylaxis. Although the allergy was posted in the kitchen and known to staff, it was not documented on the diet slip, which was the primary reference for dietary staff when preparing and serving meals. This omission was confirmed during interviews with dietary staff and the Food and Nutrition Services supervisor.
Removal Plan
- Complete a dining assessment on all residents who have not had one recently and review recent assessments for accuracy.
- Educate nursing staff that someone from nursing must always be in the dining room during meal service.
- Educate dietary staff on diet slips and re-educate on the process of how diets are communicated.
- Place a binder with all of the IDDSI diets in all kitchenettes for staff reference to ensure appropriate foods are served to residents.
- DON and nurse managers will work with the interdisciplinary team to review new diet changes and update the diet slips.
- Audit all processes.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Posted Pureed Lunch Menu: A pureed lunch meal was served without all items listed on the approved menu. Observations showed pureed trays included catfish, cowboy beans, and carrots, but no pureed hush puppies or approved substitute. The dietary employee stated she forgot to puree the hush puppies, and the DM, DON, and ADM stated all menu items were required to be served as listed or replaced with an approved substitution.
Menus and Recipes Not Followed: A resident reported that orange juice and milk were not consistently served and that potatoes were sometimes too hard to eat. During meal observations, residents were served items that did not match the posted menu, including a cold tuna sandwich instead of a tuna melt and missing listed sides such as coleslaw and mandarin oranges. The DON and RD stated the kitchen was selecting only one of the listed menu items in some meal categories and that the tuna melt recipe required toasted bread and heating until the cheese melted, which was not done.
A Dietary Helper was observed pouring Liquid Whole Eggs with Citric Acid into a pan without measuring it for a resident’s eggs with veggies order. The DS stated ingredients must be measured, and the DCH acknowledged he did not measure the egg despite handling instructions showing the portion control amount. The DON reviewed the Menu policy and stated menus are to be followed and ingredients measured for therapeutic diets to ensure proper nutrition and resident choices are met.
Dietician-approved pureed menu not followed for two residents with pureed diet orders. Staff served pureed eggs, pureed pork breakfast sausage patties, and grits instead of the approved pureed pancakes and hash browns with thickened gravy, and the Dietary Manager stated the menu changes had not been approved by the dietician.
Outdated Daily Menu Posted on Locked Unit: The facility failed to keep the posted menu current in a locked unit dining area, where the same Saturday menu remained displayed for several days instead of the correct daily menu. CNA, LVN, DM, and ADM all confirmed the menu should have been updated daily by dietary staff, and staff noted residents became frustrated when the meal served did not match the posted menu.
Meal service did not follow posted menus and tray cards for several residents. A resident did not receive milk, two residents did not receive poultry gravy, one resident on a pureed diet was served a regular roll instead of the ordered item, and another resident’s cereal tray was missing a serving and milk. An LPN, nurse aide, and account manager confirmed the missing or incorrect items during the dining observation.
Failure to Follow Posted Pureed Lunch Menu
Penalty
Summary
The facility failed to follow the posted Week 5 Tuesday lunch menu for pureed meals by not serving all food items listed on the menu. The menu for the lunch meal included mustard fried catfish, cowboy beans, steamed baby carrots, hush puppies, a lemon wedge garnish, and ambrosia, but the pureed lunch trays observed in the dining room contained mustard fried catfish, cowboy beans, and steamed baby carrots only. No pureed hush puppies were observed on the trays, and no substitute item was served for the missing menu item. During observation, pureed lunch trays were seen in the dining room at 12:15 PM and again at 1:05 PM on the secured unit, and both observations showed the same missing item. In interview, the dietary employee stated she prepared and served the pureed lunch meals and should have served pureed hush puppies with the meal. She stated she realized the hush puppies were missing when she served the last couple of trays and forgot to puree them after getting nervous. She also stated she was responsible for ensuring the hush puppies were served on the pureed trays. The DM stated all food items listed on the meal tickets must be served because the menu was approved by the dietitian and based on residents' requirements. The DON stated all food listed on the meal tickets must be served and match the correct texture for each resident, and that the person serving the tray was responsible for ensuring all food listed on the meal ticket was on the tray before it was given to the resident. The ADM also stated dietary staff must follow the menu and serve all items listed. The facility's Menu Planning Guideline stated menus will be served per the posted menus and, if not available, temporary changes will be noted on the menu substitution sheets.
Menus and Recipes Not Followed
Penalty
Summary
The facility failed to ensure residents received nutritionally adequate meals and that standardized recipes were followed. During observation and interview, residents on regular diets were served meals that did not match the menu items listed. At lunch, residents received tuna sandwiches with cheese, potato chips, tomato soup, and chocolate pudding, but none were served creamy coleslaw. The sandwiches were not heated or toasted, and the cheese was not melted. The dietary supervisor stated she chose to serve only one of the listed side items at meals, rather than both items shown on the menu. The dietary supervisor also stated that the menu listed a protein side and a fruit or cold side for breakfast every day, and a vegetable and salad or cold side at lunch and dinner every day, but she selected only one item from those categories to serve. She stated residents were not served orange juice or cereal every day, only when listed on the menu. During breakfast observation, residents were served biscuit with sausage gravy, hot cereal, and hardboiled egg, and none received mandarin oranges even though they were listed on the menu. A resident stated orange juice was not served every day, milk was only served at breakfast when available, and potatoes were sometimes so hard they were inedible. A CNA stated residents complained that potatoes were not cooked through and were crunchy, and she sometimes had to separate out the soft parts when setting up trays. The registered dietitian stated the hard potatoes suggested the cooks were not following the recipe and that the food should be cooked properly and served as listed on the menu. She stated if tuna melt was listed, residents should receive a tuna melt, not a cold tuna fish sandwich. She also stated the menus were not being followed in a way that met nutritional requirements, including adequate servings of fruits or vegetables, starches, and dairy. The facility’s policy stated cycle menus are planned to meet nutritional needs and standardized recipes are to be used in food preparation. The tuna melt recipe provided required toasted bread and heating until the cheese melted and the internal temperature reached 165 degrees F, but the sandwiches observed were prepared cold and stored in the refrigerator without being heated.
Unmeasured Egg Ingredient Used in Resident Meal
Penalty
Summary
The facility failed to accurately measure Liquid Whole Eggs with Citric Acid on 7/31/2026 for one sampled resident who received eggs with veggies. Resident 1 was admitted with diagnoses of abnormalities of gait and a history of falling, and the H&P dated 6/17/2026 indicated the resident had the capacity to understand and make decisions. The resident’s meal ticket dated 7/31/2026 listed preferences for dry cereal and milk, and eggs with veggies. During observation at 6:55 AM in the kitchen, the Dietary Helper was seen pouring Liquid Whole Eggs with Citric Acid from the box into the pan without measuring it. During interview, the Dietary Supervisor stated ingredients are not supposed to be estimated and must be measured using appropriate equipment to ensure proper nutrition and palatability. The Dietary Helper later reviewed the handling instructions and stated that for portion control, 1 large egg liquid equals three tablespoons, and acknowledged he only poured the egg and did not measure it. The DON also reviewed the facility’s Menu policy, which states menus meet residents’ nutritional needs and are developed and prepared to meet residents’ choices and needs, and stated menus are supposed to be followed and ingredients measured for therapeutic diets.
Dietician-Approved Pureed Menu Not Followed
Penalty
Summary
The facility failed to serve the dietician-approved pureed menu for dinner for 2 residents with pureed diet orders. The Week 2 menu specified pureed buttermilk pancakes with margarine and syrup, pureed breakfast sausage, and pureed hash browns with thickened gravy for 07/30/2026 dinner, but observation at 5:36 PM showed one resident served pureed eggs, pureed pork breakfast sausage patties, and grits instead of the ordered pureed pancakes and hash browns. A second observation at 6:01 PM showed another resident served the same alternate meal of pureed eggs, pureed pork breakfast sausage patties, and grits rather than the approved menu items. During interview, the Dietary Manager stated that all residents with pureed diet orders were not served the dietician-approved pureed dinner menu and that the menu changes to pureed eggs and grits had not been approved by the dietician.
Outdated Daily Menu Posted on Locked Unit
Penalty
Summary
The facility failed to ensure current daily menus were posted in the locked unit dining area. During observations on 07/28/26 and 07/29/26, the posted menu continued to display Saturday, July 25, 2026, including a lunch item of ham, instead of the current day's menu. The menu remained unchanged for 4 consecutive days in the locked unit dining area. During interviews, CNA D stated the menu did not reflect the correct day and should have displayed Wednesday's menu, and that residents would not know what meals were being served if menus were not updated daily. LVN E, the charge nurse for the locked unit, confirmed the menu remained on Saturday's menu and stated residents had become frustrated because they expected ham as posted and could become fixated on the menu and upset when the meal served did not match. The DM and ADM both acknowledged dietary staff were responsible for updating menus daily, and the ADM stated residents relied on the posted menu and expected to receive the meal listed. Record review showed the facility's menu planning policy required current menus to be posted during the appropriate time period.
Meal trays did not match posted menus and tray cards
Penalty
Summary
The facility failed to ensure menus were prepared in advance and followed to meet residents’ nutritional needs. During a dining observation, the posted menu for Monday listed Chicken Stir Fry with vegetables, broccoli florets, steamed rice, a buttered dinner roll, and pear crisp, and the dysphagia advanced menu extension also included poultry gravy. The facility’s meal distribution policy stated that dining services staff, under the supervision of the licensed nurse, would assemble meals in accordance with the individual meal card and present them for delivery to the resident or care staff. Several residents did not receive items listed on their tray cards or menu extensions. One resident did not receive 8 ounces of milk and stated she never gets milk at supper; an LPN confirmed the milk and cup were not provided. Another resident did not receive poultry gravy or the two rolls listed on the tray card, and a nurse aide confirmed the omissions. A resident on a pureed diet received a regular buttered dinner roll instead of the pureed roll listed on the tray card, and the surveyor intervened before the resident ate it. Two other residents also did not receive poultry gravy as listed, and one resident’s cereal tray was missing the second serving and milk. Staff members confirmed the tray card and meal discrepancies as they were observed.
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