Failure to Provide Ordered Nutritional Supplements
Summary
The facility failed to provide nutritional supplements to four residents according to physician orders. During lunch observations on 7/29/25, 7/30/25, and 7/31/25, R42, R33, R26, and R6 were observed in the dining room or, in one case, still asleep in bed, and the ordered supplements were not provided as directed. V15, the Activity Aide serving lunch, stated she used laminated tray cards to determine what each resident should receive, and the tray cards listed the ordered supplements for each of the four residents. R42 had an order for Magic Cup twice daily with lunch and dinner, but was observed receiving regular pudding instead of the ordered Magic Cup at lunch on 7/31 and did not receive Magic Cup at lunch on 7/29 or 7/30. R33 had orders for Magic Cup twice daily and Mighty Shake twice daily, both to be given with lunch and dinner/lunch, but did not receive either supplement at lunch on 7/29, 7/30, or 7/31. R26 had orders for Magic Cup twice daily and Mighty Shake three times daily with meals, but did not receive either supplement at lunch on 7/29 or 7/30, and was not in the dining room on 7/31 because he remained asleep in bed after staff attempted to get him up. R6 had an order for Mighty Shake with breakfast, lunch, and dinner, but did not receive the lunch supplement on 7/29 or 7/31. The Registered Dietician documented that these supplements were intended to support nutritional status, appetite, wound healing, and protein/calorie intake, and noted weight loss and decreased appetite for some of the residents. The facility policy stated that a physician order is required for a dietary supplement and that nursing maintains the physician order in the MAR for commercially prepared liquid supplements.
Penalty
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Failure to honor a resident’s food preferences: a resident with HTN, hx of falls, and adult failure to thrive reported an egg allergy and said she was served eggs multiple times after telling staff. The food preference log showed eggs were added as an allergy, later removed, and only afterward was a no-eggs breakfast preference documented; the DM confirmed the resident continued to receive eggs during that period and that her documented preferences were not being honored.
Meals were not served according to residents’ meal tickets and dietary needs. A resident who was supposed to receive chocolate pudding did not get it, a resident with a milk allergy and dislike of fresh vegetables was served raw vegetables and a milk-containing supplement, another resident did not receive the ordered water with lunch, and a resident did not receive the listed sandwich toppings. The Dietary Mgr and Regional Dietary Mgr acknowledged the meal ticket mismatches.
A resident on a physician-ordered gluten-free diet was not given adequate dietary education or menu choices, and the menus did not list gluten-free substitutes for items crossed out as allergies. Staff also did not provide an early breakfast or a ready-to-eat meal before the resident left for a morning medical appointment. The resident had recently returned from a hospital stay for a small bowel obstruction, and the RD and dietary manager documentation did not show that his diet change, food preferences, or education needs were fully addressed.
A resident with ESRD on HD and a renal diet was not provided an individualized meal plan because his food preferences were not assessed or entered into the meal system. He reported receiving the same breakfast daily without meat, disliked meals such as cheese lasagna, and often ordered food from outside because he remained hungry. Staff confirmed no preference interview had been completed, no preferences were listed on the meal ticket, and the RD had not discussed preferences with the resident.
Failure to communicate a dialysis dietary recommendation for a resident with DM2, CKD stage 5, and elevated phosphorus. Dialysis labs showed a phosphorus level of 7.8 and noted to encourage avoiding ice cream, but the resident continued receiving dairy items such as ice cream, yogurt, and milk. The UM described a process for sharing new diet orders via a communication slip, yet the Dietary Mgr could not find one and the Dietary Tech said the recommendation was never communicated or entered into the system.
Delayed dietary communication caused a resident with severe cognitive impairment and feeding assistance needs to miss meal service. Staff said the kitchen could not serve the resident without a dietary card, the admission order was not delivered in time, and the resident did not receive a tray until a family member raised concern.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of one resident who was admitted with diagnoses of high blood pressure, history of falling, and adult failure to thrive. The resident was her own health care decision maker. During an interview, the resident stated she had an egg allergy and reported that she was served eggs multiple times after informing facility staff of the allergy, and she was unsure why she continued to receive eggs after speaking with staff on several occasions. A review of the resident’s food preference activity log showed that eggs were added as an allergy on 5/27/26, then the allergy was removed on 6/4/26, and later the log indicated a preference for no eggs for breakfast on 6/23/26. During a concurrent interview and record review, the Dietary Manager confirmed that the resident continued to receive eggs during the period after the allergy was removed and before the no-eggs preference was documented, and stated that the resident’s documented food preferences were not being honored during that period.
Meals Not Served According to Meal Tickets and Dietary Needs
Penalty
Summary
The facility failed to ensure that residents’ meals were served according to their nutritional needs, special dietary needs, and preferences for 4 of 6 residents reviewed for dietary services. Resident #R4’s dinner meal ticket indicated that he was to receive chocolate pudding with all meals, but observation of the dinner tray showed that chocolate pudding was not served. In an interview, the Dietary Manager stated that Resident #R4 should have received chocolate pudding with the dinner tray. Resident #R5’s lunch meal ticket indicated a milk allergy and a dislike of fresh vegetables, yet the lunch tray included fresh/raw lettuce and tomatoes with the fish po-boy and also included a mighty shake containing milk. Resident #R6’s lunch meal ticket indicated that she was to receive chocolate milk and one other beverage/water, but observation showed that only chocolate milk was served. Resident #R7’s lunch meal ticket indicated a regular diet with no likes or dislikes listed, but the lunch tray did not include lettuce or tomatoes with the fish po-boy. The Dietary Manager acknowledged that Resident #R5 should not have received fresh vegetables or a mighty shake, Resident #R6 should have received water in addition to chocolate milk, and Resident #R7 should have been served lettuce and tomatoes. The Regional Dietary Manager confirmed that residents should be served meals in accordance with their meal tickets.
Gluten-Free Diet Education, Menu Substitutions, and Early Breakfast Not Provided
Penalty
Summary
The facility failed to provide dietary staff with initial and ongoing education related to a physician-ordered gluten-free diet for a resident who had been hospitalized in April 2026 for treatment of a small bowel obstruction likely due to dietary indiscretion. After the resident returned from the hospital, the registered dietitian documented that the diet order had been changed to gluten-free, but there was no indication that the resident was met with to discuss the change. The former dietary manager completed a post-hospital Food and Nutrition Data Collection assessment on 4/15/26, but the section for resident-specific food likes, dislikes, and preferences was left blank, and the education section did not show that the resident had been instructed about the new diet order. No follow-up assessments were completed after that date. During meal observations and menu review, the resident was given menus labeled gluten restricted, but the menus did not provide gluten-free alternatives for items the resident could not have. At breakfast, pancakes were listed on the main menu and were crossed out with the word “ALLERGY,” but no gluten-free substitute was listed. At lunch, sweet potato fries were crossed out in the same way, again without a gluten-free replacement on the menu. At dinner, breaded cauliflower was crossed out and marked “ALLERGY,” with no gluten-free option listed. The resident stated he did not understand the pancake restriction because he had made and eaten pancakes during a therapy session, and the occupational therapist confirmed that a gluten-free pancake mix had been used in therapy after the resident’s hospital discharge. The resident also did not receive an early breakfast before a morning medical appointment. On the morning of the appointment, he was observed leaving in his wheelchair, and neither kitchen staff nor a caregiver had offered him breakfast early or provided a ready-to-eat breakfast item to take with him. Food service staff stated they relied on the former dietary manager or receptionist to notify them of appointment schedules, and they were not aware of the resident’s appointment. The senior director stated that appointment information was discussed daily in interdisciplinary meetings and that staff were expected to use that information to meet residents’ nutritional needs on appointment days.
Failure to Individualize Renal Diet to Resident Preferences
Penalty
Summary
The facility failed to provide an individualized therapeutic renal diet for a cognitively intact resident with ESRD on hemodialysis by not assessing and incorporating his food preferences into his meal plan. The resident had orders for hemodialysis and a renal diet with regular texture and thin liquids. Facility policy required food preferences to be identified, entered into the menu management system, and used by the RDN or other qualified nutrition professional to adjust the meal plan after consultation with the resident. During interview and observation, the resident stated he was receiving the same breakfast every morning, including scrambled eggs, oatmeal or cream of rice, and plain bread that was not toasted or buttered, and that he never received meat with breakfast. He said he was dissatisfied with the meals, often ordered food from outside restaurants, and had meals delivered because he was not satisfied and remained hungry. At lunch, he was served cheese lasagna, buttered toast, salad, and apples, voiced dislike for the meal, and requested chicken tenders from the alternate menu. An LPN stated the kitchen probably did not have any and that the resident had to choose the alternate menu early in the morning, which was difficult because he liked to sleep in. Record review and staff interviews showed no evidence that the resident’s preferences had been assessed or entered on the meal ticket. The Dietary Accounts Manager confirmed she had not yet interviewed residents about meal preferences and that no preferences were listed for the resident. She also stated the facility used a preplanned renal diet and that the resident would have to sign a waiver with the DON to get preferred foods. The facility RD stated she had not discussed preferences with the resident and had not evaluated him since April, despite routine monitoring notes. The dialysis RD stated she was not opposed to the resident having meat with breakfast and was not aware he was having meals delivered to the facility.
Failure to Communicate Dialysis Dietary Recommendation
Penalty
Summary
The facility failed to ensure communication and coordination between staff and all departments regarding a special dietary recommendation for one resident with type 2 diabetes, disorders of phosphorus metabolism, stage 5 chronic kidney disease, and a Monday, Wednesday, Friday dialysis schedule. Dialysis nutrition labs showed a phosphorus level of 7.8, and the dialysis note requested that the resident be encouraged to avoid ice cream. The resident’s record showed that after this recommendation was sent to the facility, the resident continued to partake in dairy products, including ice cream, yogurt, and milk. The resident’s orders and care plan did not reflect the dialysis recommendation. During interview, the Unit Manager stated that residents returning from dialysis have a dialysis book for new orders or recommendations, and that staff communicate dietary changes through a Diet Order and Communication slip for new diet orders, recommendations, or short-term diet adjustments. The Dietary Manager was unable to locate a Diet Order or Communication slip for the resident for the month of June. The Dietary Tech stated that she was not aware of the dialysis recommendation and that it had not been communicated to dietary staff. She confirmed that the recommendation was not in the system and should have been entered.
Delayed Dietary Order Caused Missed Meal Service
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs when Resident #1 did not receive timely dietary communication to the kitchen after admission. Resident #1 was admitted with unspecified dementia, restlessness and agitation, and muscle wasting and atrophy, and his MDS showed severely impaired cognition with a BIMS score of 1. He required supervision or touching assistance with eating and substantial to maximum assistance with toileting hygiene. The care plan identified an ADL self-care performance deficit and included staff assistance with eating. During the admission process, the dietary order was not communicated to the kitchen in time, and the resident’s dietary card was not delivered before meal service. The DM stated the kitchen could not serve a resident without a dietary card because staff would not know any diet restrictions, and she acknowledged two instances where dietary cards were not turned in timely, including one that resulted in a missed meal. Staff interviews confirmed the resident was admitted in the afternoon after kitchen staff had gone home, the kitchen did not know he was in the facility until a family member asked about the missing tray, and he did not receive breakfast. The facility policy stated that nursing service transcribes the diet order and sends forms to Dietary Service prior to meal service.
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