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F0805
D

Resident on Puree Diet Served Incorrect Food Consistency

Spencer, West Virginia Survey Completed on 08-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a physician order for a puree diet was served crackers on her plate during a meal service. The incident occurred when a kitchen aide placed crackers on the resident's plate, which was verified by the Regional Dietary Manager. The resident then crumbled the crackers and added them to her soup, preparing to eat the mixture before a surveyor intervened. Documentation from speech therapy indicated that only residents on a Dysphagia Advanced diet may have crackers with soups, but this resident was on a puree diet, which does not permit crackers. The facility failed to ensure that food was prepared and served in the correct consistency as ordered by the physician.

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