Failure to Complete Timely Nutritional Assessments and Provide Required Supplements
Summary
The facility failed to ensure accurate and timely completion of nutritional assessments, weight monitoring, and provision of required nutritional supplements for multiple residents. For one resident, there was a significant delay in obtaining an initial weight after admission, with the first weight recorded seven days post-admission, showing a severe weight loss compared to hospital records. There was no documentation of re-weighing to confirm the loss, no investigation into the cause, and no evidence that the provider or resident representative was notified. The resident also reported not being involved in dietary decisions, and staff interviews revealed uncertainty about the reasons for weight refusals and lack of reconciliation of hospital and facility weights. Another resident with dialysis needs had orders for a specific nutritional supplement (Nepro) prior to dialysis, but documentation was inconsistent regarding administration and consumption. The resident reported disliking the supplement and instead consumed a different product brought from outside the facility. Staff were unaware of the resident's refusal and the substitution, and there was no documentation of the facility addressing the refusals or ensuring the prescribed supplement was provided as ordered. The dietary manager and nursing staff demonstrated a lack of clarity about the supplement's provision and documentation, and the registered dietitian was unaware of the resident's non-compliance with the prescribed supplement. Additional deficiencies included a resident with significant weight loss who did not receive a comprehensive nutritional assessment as required, and another resident with severe cognitive impairment and diagnoses of malnutrition and failure to thrive who experienced frequent meal refusals. The care plan for this resident lacked individualized interventions, and the nutritional assessment was completed late. There was no documentation of alternative interventions or communication with the resident's representative regarding preferences, and the dietary profile was missing from the record. Staff interviews confirmed delays in assessment and a lack of resident-specific interventions.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to employ a qualified director of food and nutrition services and to ensure education of dietary aides, affecting all 86 residents. A contract company assumed operation of the kitchen and promoted a former cook to Dietary Manager despite her lacking required certification and relevant educational background. The previously credentialed Dietary Manager stepped down due to the complexity of the new computer system and informed the company that the new Dietary Manager was not credentialed. Although the company indicated it would fund certification training, the new Dietary Manager had not begun any classes at the time of the survey, resulting in non-compliance related to food and nutrition services oversight.
The facility did not employ enough staff with the necessary competencies and skills in the food and nutrition service, including the absence of a qualified dietician.
A facility failed to ensure that a qualified dietitian conducted quarterly nutritional assessments, instead relying on a Certified Dietary Manager (CDM) without a bachelor's degree in nutrition. This affected a resident with complex medical conditions, including acute kidney failure and diabetes, who required a therapeutic diet. The CDM used a calculator to assess nutritional needs, contrary to the facility's contract and Ohio Medical Board guidelines, which require licensed dietitians for such evaluations.
The facility did not ensure the dietary manager was qualified, affecting meal services for 50 residents. The manager, promoted from a cook position, lacked formal training and certification. A dietitian was only present part-time, focusing on clinical work rather than kitchen oversight. The administrator confirmed the manager's lack of qualifications.
The facility employed an unqualified Dietary Manager, affecting all 115 residents receiving food from the kitchen. The Dietary Manager lacked necessary certifications or an associate degree in food service management, as confirmed by the RDO. The job description required registration as a Food Services Director in the state, which was not met.
The facility failed to employ a qualified dietary manager, as the current manager lacked formal training and had not passed the SERV Safe course. Additionally, the facility did not have a full-time dietitian, with the current dietitian working only seven to ten hours per week. This deficiency had the potential to affect all 94 residents receiving food from the facility kitchen.
Unqualified Dietary Manager and Lack of Dietary Staff Education
Penalty
Summary
The deficiency involves the facility’s failure to employ a qualified director of food and nutrition services and to ensure appropriate education of dietary aides, affecting all 86 residents. The Administrator reported that a contract company, Health Care Services Group (HCSG), had been brought in to run the kitchen, using the facility’s existing kitchen staff while the facility retained oversight. Personnel credential review showed that the individual serving as Dietary Manager, identified as #217, did not meet the qualifications for the role: she was not certified and her degrees were not in fields that would qualify her as a Dietary Manager, despite her years of kitchen experience. Interviews with Dietary Manager #217 revealed that she had originally been employed as a cook and was promoted to manage the kitchen after HCSG took over operations. She stated that a previously credentialed Dietary Manager, identified as #100, stepped down from the role when the contract company assumed control, citing the complexity of the computer system, and recommended her, while informing HCSG that she was not credentialed. HCSG indicated they would pay for her to take classes to become a Certified Dietary Manager, but she confirmed she had not started any classes and believed the company might be waiting to see if she could handle the position before investing in her training. The survey identified this as a failure to employ a qualified Dietary Manager and to provide education to dietary aides, constituting non-compliance under Complaint Number 2701233.
Insufficient Qualified Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. This included not having a qualified dietician as required. The deficiency was identified based on the facility's staffing and qualifications in the food and nutrition department.
Unqualified Staff Conducting Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the nutritional staff member responsible for completing quarterly reviews was qualified to assess the nutritional status of residents. This deficiency was identified through a review of records, staff interviews, and the Ohio Dietetics website, which revealed that a Certified Dietary Manager (CDM), who is a non-licensed professional without a bachelor's degree in nutrition, was conducting these assessments. The CDM was responsible for all quarterly nutritional reviews, while a Registered Dietitian, Licensed Dietitian (RDLD) handled annual, new or readmission, and significant change assessments. The CDM confirmed that she used a calculator to determine if there had been a significant change in residents' nutritional needs and whether their dietary intakes were meeting those needs. The deficiency specifically affected one resident, who had multiple complex medical conditions, including acute kidney failure, COPD, morbid obesity, type two diabetes mellitus, heart failure, a history of malignant neoplasm of the large intestine, and major depressive disorder. The resident was cognitively intact, required assistance with eating, and was on a therapeutic diet. The facility's contract with the consulting dietetics company stipulated that a nutritionist/dietitian with a minimum of a bachelor's degree in nutrition or dietetics and relevant experience should be provided, yet the CDM did not meet these qualifications. The Ohio Medical Board's guidelines state that unlicensed personnel can collect and record nutritional data but cannot evaluate or interpret it, which is considered the practice of dietetics.
Unqualified Dietary Manager in Facility
Penalty
Summary
The facility failed to ensure that the dietary manager was qualified to oversee dietary service operations, potentially affecting all 50 residents receiving meals from the kitchen. The dietary manager, who was promoted from a cook position in May 2024, lacked formal certified dietary manager training and had not completed the SERV Safe course. Interviews revealed that there was no full-time dietitian on-site, with a dietitian only scheduled to be present one day a week for six hours and two hours remotely, focusing on clinical work rather than kitchen oversight. The facility's administrator confirmed that the dietary manager did not meet the required qualifications for the position and was not certified, although efforts were being made to obtain certification.
Unqualified Dietary Manager Employed
Penalty
Summary
The facility failed to employ a qualified Dietary Manager, which had the potential to affect all 115 residents receiving food from the kitchen. During an interview, the Dietary Manager revealed she did not possess a certified dietary manager certificate, certified food service manager certificate, a national certification for food service management and safety from a national certifying body, or at least an associate degree in food service management. This was confirmed by the Regional Director of Operations, who verified that the Dietary Manager did not meet the minimum qualifications required for the position. The job description for the Director of Food Service indicated that the individual must be registered as a Food Services Director in the state and assist in planning, developing, organizing, implementing, evaluating, and directing the Food Services Department and its activities. This deficiency was investigated under Complaint Number OH00157178.
Lack of Qualified Dietary Manager and Full-Time Dietitian
Penalty
Summary
The facility failed to employ a qualified dietary manager to oversee the food service department, which had the potential to affect all 94 residents receiving food from the facility kitchen. The dietary manager, identified as DM #574, had no formal certified dietary manager training and had not passed the SERV Safe course. DM #574 had been in the position for about four months without any additional formal training to qualify her as the dietary manager. Additionally, the facility did not employ a full-time dietitian, as Dietitian #664 only worked seven to ten hours per week. The facility census was 97, and three residents were identified as receiving nothing by mouth.
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.
Trusted by long-term care providers and associations.
