Failure to Provide Ordered Fortified Foods to Residents at Nutritional Risk
Summary
The facility failed to provide ordered fortified foods to six residents who had recommendations and care plan interventions for fortified foods to address nutritional risk, weight loss, or inconsistent intake. During meal service observations on the 2nd floor dining room, residents identified as R18 and R95 had meal tickets indicating "fortified pudding" but did not receive it, and R78’s meal ticket indicated "magic cup" but she did not receive it. During meal service observations on the 3rd floor dining room, residents identified as R35, R45, and R64 had meal tickets indicating "fortified pudding" but did not receive it. The Registered Dietitian (V17) stated that when she recommends fortified foods, she enters these recommendations into the kitchen platform so they appear on the facility meal tickets, and that fortified foods do not appear on the Physician Order Sheet but should be provided if they appear on the meal ticket. The Assistant Dining Service Director (V6) stated that the facility no longer has magic cup, that residents are to receive fortified pudding instead, and that servers are supposed to plate fortified pudding in bowls and place them on the tray with the rest of the meal. Despite this, the fortified items indicated on the meal tickets were not served to the identified residents. Care plans for all six residents documented nutritional concerns and included interventions to provide fortified foods: R18 and R95 were noted to be at increased nutritional risk or at risk for unintentional weight loss related to advanced age, impaired cognition, and variable intake; R35, R45, and R64 had histories of inadequate intake and weight loss; and R78 had inadequate intake related to early satiety with observed 50% meal consumption. The Registered Dietitian confirmed that she recommended fortified pudding or magic cup for these residents due to either past significant weight loss or inconsistent intake, and that if fortified foods appear on the meal ticket, the resident should receive them.
Penalty
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A resident meal service issue involved food being served at improper temperatures, with dry fish, room-temperature fruit, and missing beverages on trays. Staff and family reported cold, flavorless meals, tray-ticket mismatches, substitutions, and occasional missing items, while the Unit A2 kitchenette had limited snack stock compared with stated par levels. Interviews also described budget-driven food ordering problems, back orders, and inconsistent oversight of tray accuracy and menu service.
A resident was observed not eating breakfast after being served cornflakes and two boiled eggs, despite a tray card indicating Fruit Loops, no eggs or pork, and assorted fruit juices. The resident stated she disliked the items served, and an RN confirmed the tray card and the meal that was delivered.
Dietary Preference Not Followed for Resident Breakfast: A resident stated that bacon was wanted with breakfast, but the meal served did not include it. Record review showed ST had cleared the resident for bacon cut into bite-sized pieces and a diet slip indicated bacon was allowed, yet the dietary director was not aware of the diet change. The resident's care plan directed staff to serve the diet as ordered, and facility policy required nursing to notify FNS of diet changes and food preferences.
Failure to provide nutritious and palatable meals: During a meal observation, the menu listed fruit but none was served until a CNA provided fruit cups after a resident asked for them. The DNM reported no substitution log was maintained, residents complained in council about the dining room being closed, menus being incorrect, food items running out, and poor food quality, and a dietary aide said staffing cuts and shortages led to frequent missing items such as milk and cereal.
Meal service failed to match ordered dietary needs for two residents during breakfast. One resident ordered double protein portions and reported sometimes not getting enough to eat, yet was served a tray that did not reflect the double portions or his no-bacon preference. Another resident had an order for an extra egg when eggs were on the menu, but was served only one egg. The Dietary Manager stated the cook had missed giving double or extra portions and staff needed to read meal tickets better.
A resident with DM and a physician order for a heart healthy regular diet, double portions, and an extra sandwich was repeatedly served incorrect lunch trays. Observations showed meals labeled for large protein portions but lacking the ordered sandwich and, on another occasion, containing only a single meat patty similar to other residents’ trays. The resident said this happened frequently and was frustrating, and the DSM confirmed one tray was prepared incorrectly.
Meals Served at Improper Temperatures and Incomplete Snack Availability
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met daily nutritional needs during two meals and in one kitchenette. During the lunch meal observation, a resident’s tray was tested and found to contain fish at 118 degrees Fahrenheit, mashed potatoes at 121 degrees Fahrenheit, mixed vegetables at 134 degrees Fahrenheit, fruit cup at 70 degrees Fahrenheit, and coffee at 128 degrees Fahrenheit. The fish was described as dry with a jerky-like texture, and the fruit cup was room temperature. Staff also stated that beverages were normally served on trays, but they were not served on the lunch trays that day. During the dinner and lunch-related interviews, staff and family described repeated problems with meal quality and tray accuracy. A resident’s family stated meals were late, not palatable, and hot meals were always cold, with few options available. An LPN stated hot food was served cold, cold food was served at room temperature, meal tickets did not usually match the meal tray, and missing items were usually condiments. A CNA stated residents complained that food was cold when it should be hot, lacked flavor, and that meal tickets sometimes did not match what residents received. The LPN also stated that pureed diets were sometimes sent as regular consistency trays, diabetic residents received sugary items, and the kitchen sometimes substituted menu items when it did not have the ordered food. The Unit A2 kitchenette was also observed to have limited snack availability compared with the facility’s stated snack par levels. On one observation, the kitchenette contained graham crackers, peanut butter crackers, mini marshmallows, pudding cups, peanut butter, bread, English muffins, hot chocolate packets, tea, condiments, and several refrigerated and frozen items including thickened liquids, milks, shakes, sandwiches, sherbert, and ice cream. On a later observation, the kitchenette contained only a small amount of ice cream/sherbert, graham crackers, and peanut butter. Staff interviews stated snacks were limited, sometimes unavailable, or still frozen when brought to the unit, and that residents had complained they never had snacks. The Food Service Director, former Food Service Director, Administrator, and Registered Dietitian all described ordering and menu issues, including budget-driven reductions, back orders, substitutions, and lack of oversight of tray accuracy and meal service.
Resident Served Breakfast Contrary to Documented Preferences
Penalty
Summary
The facility failed to ensure that a resident was provided a diet that reflected her stated food preferences. Resident #22 was observed in the dining room on 05/19/26 not eating breakfast and stated she received cornflakes, which she did not like, and that she disliked hard boiled eggs. Her tray card indicated 2 bowls of Fruit Loops with "out" handwritten, no eggs or pork, and assorted fruit juices, but she was served cornflakes, two boiled eggs, and no juice. After surveyor intervention, the resident received two bowls of Fruit Loops because the delivery truck had just run. Registered Nurse #5 confirmed the tray card and the food the resident was served.
Dietary Preference Not Followed for Resident Breakfast
Penalty
Summary
The facility failed to ensure that a resident's dietary preferences were taken into consideration for breakfast. Resident #12 stated that he/she did not get what he/she wanted for breakfast and wanted bacon with breakfast each day. On observation, the resident's breakfast consisted of fried eggs, oatmeal with syrup, and pancakes, and the resident stated that bacon was not served and that he/she was not allowed to have bacon. Record review showed that the speech therapist screened the resident during lunch and documented that the resident requested bacon be added back to the diet. The note stated the resident was educated on current diet texture implications and was agreeable to bacon cut into bite-sized pieces, and the diet order was clarified. Additional record review showed a diet order and diet slip dated 5/10/26 indicating a texture change to bite size and that bacon was allowed. Staff interviews revealed that the dietary director was not aware of the diet change, while the director of rehabilitation and an RN stated that the updated diet slip had been provided to nursing and delivered to the kitchen. The resident's care plan directed staff to provide and serve the diet as ordered, and the facility policy required nursing to notify food and nutrition services of diet orders and changes, including food preferences.
Failure to Provide Nutritious and Palatable Meals
Penalty
Summary
The facility failed to provide food that was nutritious and palatable. During an observation at lunch, the menu indicated fruit, but no residents were served fruit. One resident requested fruit, and a CNA provided oranges and applesauce in individual cups; the CNA then obtained three additional fruit cups and offered them to other residents. The Dietary Manager stated the facility did not maintain a substitution log for meal changes and presented a binder containing only blank substitution log forms. At the Resident Council meeting with the Administrator present, multiple residents reported frequent closure of the dining room, the kitchen running out of food items, incorrect menus, and poor food quality, stating these concerns had been repeatedly reported without resolution. A Dietary Aide reported the dining room was closed most days at lunch and dinner, five dietary workers left in March 2026 and were not replaced, staffing cuts were ordered, and the kitchen often ran out of items such as milk and cereal without buying replacements. Food Committee minutes from February 2025 through January 2026 documented ongoing complaints about palatability, including food being too spicy, tough meat, overly salty food, poor presentation, and soup that was too salty.
Meal trays did not match ordered dietary supplements
Penalty
Summary
The facility failed to serve meals that met physician-ordered dietary needs for 2 residents during breakfast service. Resident #9 had diagnoses including hip fracture, left tibia fracture, other fractures, and anemia, and his care plan and physician orders directed a consistent carbohydrate diet with double protein portions at meals. During interview, he stated he was not getting enough to eat and reported that his meal tickets said he was supposed to get double portions, but sometimes he received them and sometimes he did not. On the observed breakfast tray, he was served one egg, cold cereal with milk, hot cereal, and 2 pieces of bacon, despite the ticket indicating double protein portions and a line through bacon because he did not like it. Resident #16 had diagnoses including low back pain, weakness, and spinal stenosis, and her care plan and physician order directed an extra egg when eggs were on the menu. During the breakfast observation, she was served one egg, 2 ounces of mechanically ground sausage, cold cereal with milk, and a muffin. Her meal ticket identified that she had requested extra eggs, but the tray did not reflect the ordered extra egg. The Dietary Manager later stated the cook had missed giving double or extra portions during breakfast service for some residents that morning and that staff needed to read the meal tickets better.
Incorrect Meal Portions and Missing Sandwich for Resident with Diabetes
Penalty
Summary
The facility failed to ensure Resident #3 received a nourishing, palatable, well-balanced diet that met his daily nutritional and special dietary needs. Resident #3 was a male with type 2 diabetes mellitus with hyperglycemia and intact cognition, and his physician ordered a heart healthy regular diet with regular texture and consistency, double portions plus an additional sandwich for all meals, and avoidance of carb-heavy meals due to diabetes. The facility diet roster also noted diabetic diet and large protein portions for him. During observation and interview, Resident #3’s lunch tray on 5/12/2026 arrived with a ticket reading "lg protein" and appeared to have a larger portion of meat than other residents, but it was not served with a sandwich. Resident #3 stated his meals were frequently served with incorrect portion sizes and without a sandwich, and he said he felt frustrated by the errors. On 5/14/2026, another lunch tray arrived with a ticket reading "lg protein," but the meal contained only a single slice of meat patty similar in size to other residents’ trays and did not reflect the ordered large protein portion. The DSM stated the tray was prepared incorrectly and did not contain a large protein portion, and the Admin stated residents should be served trays with double portions if ordered by the physician and that nursing staff should check trays before service.
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