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
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Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
The facility failed to follow its posted menus and provide complete ordered meal items during two observed lunch services. On one day, residents did not receive all items listed on the menu, including finger foods, gelatin, milk, and prescribed nutritional supplements such as magic cups and peanut butter and jelly sandwiches, as confirmed by an LPN. On another day, instead of the planned entrée and sides, multiple residents were served alternate items without corresponding menu updates, and many trays were missing soup, vegetables, bread pudding, and nutritional supplements. Dietary staff and the dietary manager acknowledged that a different menu was served and that menu changes were not properly reflected.
Surveyors found that residents on pureed diets did not receive the same planned menu items as those on regular diets, despite orders for regular diets with pureed texture and, in some cases, nutritional supplements and adaptive equipment. During an evening meal, pureed plates contained generic green, orange, and beige purees and ice cream instead of the scheduled oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake, while other diners received the full regular-texture menu. Dietary staff reported that a broccoli blend was substituted for the listed asparagus and that no pureed cake was prepared, even though asparagus could have been pureed and facility policy required verification that each resident received the correct diet and consistency.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
The facility failed to follow dietitian-approved menus and recipes and did not consistently obtain RD approval for menu substitutions. A cook altered a planned ground beef stew and served canned stew instead, and residents complained when hamburger patties were used in place of corned beef for sandwiches. The Dietary Manager repeatedly substituted items when ingredients were missing or not ordered, including serving frozen pepperoni pizza instead of the planned menu item and using canned beef ravioli instead of a soup recipe, without reliably notifying the RD. These substitutions occurred despite residents having specific diet orders such as NAS, consistent carbohydrate, and small portions, and despite a facility policy requiring RD review of menus and documentation of any deviations.
A resident with multiple congenital conditions, a tracheostomy, and moderately impaired cognition, on a regular diet with pureed texture, did not receive all items listed on the facility’s lunch menu. The posted menu called for a turkey burger on a bun with lettuce, tomato, sweet potato fries, pea and cheese salad, chilled peaches, and 1% milk, but the meal card and tray contained only pureed turkey, peas, and peaches with water. The DS reported omitting the bun based on an undocumented belief that the resident did not like bread and admitted failing to provide lettuce, tomato, sweet potato fries, cheese in the peas, and milk because the menu was not checked while rushing, contrary to facility menu guidelines.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Follow Posted Menus and Provide Complete Ordered Meal Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its posted menus and ensure that meals met residents’ nutritional needs as required by facility policy and 28 Pa. Code 211.6(a)(b) on dietary services. The facility’s Food and Nutrition Services policy dated 10/29/25 required that each resident receive a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, considering resident preferences. The Tray Identification policy dated 10/29/25 required appropriate identification to distinguish various diets. On the lunch meal of 3/23/26, the written menu called for chicken and biscuits, carrots, cranberries, gelatin, and juice. During observation of this meal on the third floor, multiple residents did not receive all items ordered for them: one resident was missing finger foods, a magic cup, a peanut butter and jelly sandwich, and milk; three residents were missing magic cups; and three residents were missing gelatin. An LPN confirmed these missing food items at the time of the observation. On the lunch meal of 3/24/26, the written menu specified Salisbury steak, carrots, mashed chive potatoes, gravy, soup, and bread pudding. During observation of the trayline service in the main kitchen, 14 residents instead received hamburger or grilled cheese, mashed chive potatoes, and California vegetables. A dietary employee acknowledged serving a different menu, explaining that the morning cook had called off, carrots had been served two days in a row, and the correct food was not provided to the personal care area. The dietary manager confirmed that the facility failed to serve what was on the menu and to update the menu to reflect changes. Additional observations on the third floor that day showed multiple residents missing required items such as soup, vegetables, bread pudding, onions and mushrooms, and magic cups. An LPN again confirmed the missing items for these residents during interview.
Failure to Provide Pureed-Diet Residents with Menu-Consistent Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that residents on pureed diets received the planned menu items in the prescribed texture, as required by facility policy and diet orders. Three residents with severe cognitive impairment and significant dependence for eating and ADLs were affected. One resident with Alzheimer’s disease, COPD, anxiety, dementia, and dysphagia had orders for a regular diet with pureed texture and nectar-thick liquids, plus a nutritional supplement before lunch and dinner. Another resident with Alzheimer’s disease, CAD, CHF, ESRD, type II diabetes, and anxiety had orders for a regular diet with pureed texture, use of a divided plate and sippy cup, and to be fed for all meals. A third resident with hypertension, insomnia, nontraumatic subarachnoid hemorrhage, and a history of repeated falls had orders for a regular diet with pureed texture and a magic cup with meals for weight loss. The daily menu for the observed evening meal listed oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake. Observation of a pureed meal showed mounds of green, orange, and beige purees and a nutrition supplement ice cream, while a regular-texture meal contained fried chicken, mashed sweet potatoes, and asparagus spears. Staff interviews revealed that the morning cook prepared a broccoli blend as the vegetable for the three residents on pureed diets instead of pureed asparagus, and that no pureed chocolate banana marble cake was prepared; ice cream was used as the pureed dessert instead. Dietary staff and another interviewee confirmed that residents on pureed diets were supposed to receive the same menu items as those on regular diets, except for preferences or allergies, and that asparagus could be pureed to an appropriate texture. The facility’s policy required staff to check trays before serving to ensure the correct diet and ordered consistency, but this was not followed for the affected residents on pureed diets.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Unapproved Menu Substitutions and Failure to Follow Dietitian-Approved Recipes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that menus and recipes were followed and that meal substitutions were approved by the Registered Dietitian (RD) to meet residents’ nutritional needs. Facility records showed that a cook changed the menu and did not prepare ground beef stew according to the recipe, instead serving canned beef stew. Resident council later complained that hamburger patties were used to make sandwiches in place of corned beef, and this complaint was confirmed. The Dietary Manager also made substitutions to the menu without consulting the RD and made unauthorized food purchases, including frozen pepperoni pizzas when the facility lacked pizza crust to prepare the planned menu item. Interviews with staff revealed that menu substitutions occurred due to last-minute changes, missing items from food deliveries, or ordering errors by the Dietary Manager, and that the RD was not consistently notified when these substitutions occurred. The Social Services Director reported that menu substitutions happened about every other week and that she did not believe the RD was always informed. The Dietary Manager acknowledged that when ingredients were missing or not ordered, the kitchen would “switch it up,” including using frozen pizza instead of making pizza per the approved menu and recipe, and serving canned beef ravioli instead of following a soup recipe. The RD reported concerns that the Dietary Manager was not ordering the correct amount of food, was purchasing other products, and was not informing her regularly of menu substitutions, despite prior meetings to clarify expectations for RD notification. The RD specifically cited the frozen pizza substitution as problematic due to residents with weight loss goals and fluid retention, and noted that simply removing pepperoni from the pizza for a resident on a no added salt (NAS) diet was not ideal. Review of facility documents showed that on the date pepperoni pizza was on the menu, there were residents on NAS, consistent carbohydrate, and small portion diets, and the facility’s own menu policy required RD review and approval of menus and documentation of deviations from posted menus, including reasons for substitutions, which was not consistently followed.
Failure to Follow Menu and Provide All Planned Food Items for a Pureed Diet
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to follow the planned menu and provide all menu items to a resident receiving a regular diet with pureed texture. The resident had diagnoses including septo-optic dysplasia of the brain, multiple congenital malformations, and a tracheostomy, and an MDS showing moderately impaired cognition with a need for staff assistance with eating and oral hygiene. The facility’s weekly menu for the relevant lunch meal listed a turkey burger on a hamburger bun with lettuce leaf, tomato slices, sweet potato fries, pea and cheese salad, chilled peaches, and 1% milk. However, the resident’s meal card for that lunch only listed turkey burger, peas, peaches, and water. During kitchen observations, the Dietary Supervisor (DS) prepared and pureed a turkey patty, peas, and peaches, and then assembled the resident’s tray with only those three pureed items. When the tray was later observed in the resident’s room, it did not include a hamburger bun, lettuce leaf, tomato slices, sweet potato fries, pea and cheese salad (including cheese), or 1% milk as specified on the menu. In interview, the DS stated she did not serve the bun because she believed the resident did not like bread, but acknowledged there was no documentation of this preference in the resident’s nutritional assessment and that the bun should have been served because it was on the menu. The DS further stated she did not serve the lettuce, tomato slices, sweet potato fries, or cheese with the peas because she had not checked the menu and was in a rush, despite facility policy requiring foods to be prepared according to the menu and the DFNS to supervise meal preparation and service to assure the menu is followed and diet orders are implemented.
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