Failure to Address Significant Weight Loss
Summary
The facility failed to ensure adequate dietary services were provided to prevent significant weight loss for one resident who had diagnoses including pneumonia, cerebral infarction, diabetes mellitus, severe morbid obesity, dementia, chronic pain syndrome, dysphagia, psychosis, and adjustment disorder with anxiety. The resident’s care plan identified her as at risk for altered nutritional status related to diabetes mellitus and a mechanically altered/therapeutic diet. Her weight declined from 323.6 pounds to 271.5 pounds in about one month, and the record documented a 13.15% weight loss. The registered dietitian noted the significant weight loss and attributed it to fluid shifts, with no further nutritional interventions documented at that time. Speech therapy later evaluated the resident because of difficulty taking medications and decreased oral intake and recommended a puree diet, which was then ordered by the physician. After the diet change, nursing notes documented that the resident’s meal intake decreased because she did not like the puree diet and that she refused to eat pureed food. The resident’s husband stated she had not been eating since the diet was changed. The resident continued to lose weight, with documented weights showing further decline to 258 pounds and then 246.8 pounds, totaling 21.05% weight loss from the earlier baseline and 23.73% over six months. The record showed delayed and limited dietary intervention after the significant weight loss was identified. The dietitian did not document ongoing monitoring or recommendations to prevent further weight loss until later, when Boost glucose control twice daily was ordered and the diet was eventually upgraded to mechanical soft with chopped meats after the resident and her husband agreed. The medical record also showed no laboratory tests were performed to evaluate nutritional status during the period of continued weight loss. Interviews with the RD, DON, NP, and Medical Director confirmed the resident’s weight loss was significant and unplanned, that the Boost twice daily was not enough to sustain her weight, and that the resident’s weight loss had not been adequately addressed when first identified.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unqualified Culinary Manager Overseeing Food and Nutrition Services: The facility failed to ensure its Culinary Manager met the required qualifications to direct food and nutrition services when a full-time qualified dietician was not employed. The CM stated she had worked at the facility since August 2025, had only cook and kitchen manager experience, and no certification documentation was provided. The CEO confirmed the CM did not have the required qualifications and was in the process of getting certified.
Failure to employ a qualified Food Service Director. The Dietary Supervisor stated he was the manager but was not certified, the RD stated she provided clinical services only and did not manage the dietary department, and the NHA confirmed there was no Certified Dietary Manager. The facility also did not provide documentation showing that any staff met the qualifications for the Food Service Director role.
The facility failed to ensure a qualified individual was designated as the director of food and nutrition services, affecting 65 of 76 residents who ate in the dietary dept. Surveyors observed no training certificates in the kitchen or office, and the DM stated they had been in the role for about two months without any certifications. The Administrator confirmed the current DM was not certified and said a CDM had been hired but had not yet started.
An unqualified Dietary Supervisor directed the facility’s Food Service/Dietary Department without meeting the minimum qualifications for a CDM or director of food and nutrition services. Although she completed a UF nutrition and foodservice training pathway, she told surveyors she had not taken or scheduled the CDM exam and had no degree in Nutrition, Hospitality, or Food Service. The deficiency affected 84 of 84 residents receiving meals from the department.
The facility failed to maintain a qualified dietary manager. The Dietary Director was not a certified dietary manager or certified food service manager, had no related degree or prior nursing facility dietary leadership experience, and the employee file showed no evidence of qualifications for managing the dietary program. HR confirmed he did not meet the role requirements, and the overseeing dietician was not in the facility full-time.
The facility failed to employ a qualified Food Service Director to manage Dietary operations for 12 of 12 months. The Dietary Supervisor stated she was the manager and was still working on CDM certification, while the RD said she only comes to the facility about once a week and works at multiple facilities. The Dietary Supervisor and RD confirmed there was no CDM and no full-time RD, and the facility did not show evidence that any staff met the qualifications for the Food Service Director role.
Unqualified Culinary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to ensure the designated Culinary Manager met the required professional qualifications for overseeing food and nutrition services. The SOM, Appendix PP, stated that when a qualified dietician or other clinically qualified nutrition professional is not employed full-time, the facility must designate a director of food and nutrition services who meets specified qualifications, including certification or education and experience requirements. The facility’s Culinary Manager position description also required ServSafe Food Safety Certification and one of several additional credentials, such as a Certified Dietary Manager, Certified Food Protection Professional, Dietetic Technician, Registered, or certification with the American Culinary Federation. During interview, the Culinary Manager stated she had worked at the facility since August 2025 and was overseen by the facility’s RD, who worked one day per week. Documentation of the Culinary Manager’s certification was requested, but no certification was provided on multiple occasions. When asked about her background, the Culinary Manager stated she had two years of experience as a cook and one year of experience as a kitchen manager at a boarding school. The CEO later confirmed the Culinary Manager did not have the required qualifications and was in the process of getting certified.
Failure to Employ a Qualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months, from June 2025 through July 2026. During interviews, the Dietary Supervisor stated that he was the manager and was not certified, the Registered Dietician stated that she worked 4 days a week and provided clinical services only and did not manage the dietary department, and the Nursing Home Administrator confirmed that the facility did not currently have a Certified Dietary Manager. The facility also failed to provide documented evidence that any staff met the qualifications for the Food Service Director position.
Unqualified Dietary Manager Designated as Food and Nutrition Director
Penalty
Summary
The facility failed to ensure a qualified individual was designated to serve as the director of food and nutrition services, affecting 65 of 76 residents who consumed food in the dietary department. During surveyor observation of the kitchen, no certificates of training were seen in the kitchen or office area. When asked for the Dietary Manager job description on multiple occasions, the facility did not provide it. The Dietary Manager stated that they had been in the position for about two months and did not have any certifications. The Administrator also stated that the current Dietary Manager did not have any certifications and that a Certified Dietary Manager had been hired but had not yet started.
Unqualified Dietary Supervisor Directed Food Service Department
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietitian. Survey findings showed that the Dietary Supervisor in charge of the Food Service/Dietary Department did not meet the minimum qualifications to serve as the director of food and nutrition services. The facility’s Certified Dietary Manager job description required the person in that role to be a Certified Dietary Manager in good standing with the State of Alabama or to be in training to satisfactorily complete the requirements to become a Certified Dietary Manager. The Dietary Supervisor had a certificate of completion for Nutrition and Foodservice Professional Training Pathway III(b) from the University of Florida, but she told surveyors that she had not taken the CDM test yet, had not scheduled it, and had no Associate’s or Bachelor’s degree in Nutrition, Hospitality, or Food Service. She also stated that she had completed the CDM course in September 2025 and had worked in the position for eight years managing the Food Service Department. The Administrator acknowledged that the Dietary Supervisor had been in training but had not completed it, and said she had followed up and encouraged completion of the training. The report states that this affected 84 of 84 residents receiving meals from the facility’s Food Service/Dietary Department while it was under the direction of an unqualified individual.
Unqualified Dietary Director
Penalty
Summary
The facility failed to maintain a qualified dietary manager. Interview with Dietary Director #601 revealed that he was not a certified dietary manager or certified food service manager, had no other certification specific to managing a food service program, had no associate degree or higher in food service or hospitality, and had no prior experience as a dietary director in a nursing facility. He also stated that the overseeing dietician was not in the facility full-time. Review of his employee file showed no evidence of previous experience managing a dietary department in a nursing home and no certifications or degrees related to managing a nursing home dietary program. The Dietary Director was hired on 04/19/26, and Human Resources confirmed that he lacked the qualifications for the role.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months, from July 2025 through June 25, 2026. During an interview on 6/23/26, the Dietary Supervisor stated that she was the manager and was currently working on her certification to become a CDM. During an interview on 6/24/26, the RD stated that she comes to the facility usually once a week and works at a few facilities. The Dietary Supervisor and RD later confirmed that the facility did not have a Certified Dietary Manager and that the RD was not employed by the facility full time. The facility failed to show evidence that any staff met the qualifications for the position of Food Service Director.
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