F0803

D

Failure to Follow Posted Pureed Menu Items for Two Residents

Abilene, Texas Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow the posted Fall/Winter Week 5 Wednesday pureed menu for two residents on a pureed diet. The menu for that meal specified pureed beef stew, pureed garden salad with dressing, pureed cornbread, and pureed baked apple slices. Observations on the survey date showed that the dietary manager (DM) plated trays for two residents on pureed diets with pureed beef stew, pureed mixed vegetables, and pureed baked apples, but did not include the pureed cornbread listed on the menu. The trays were then sent out for service without the missing menu item being identified or corrected at the time of plating.

Resident #14 was an elderly female with dementia, history of stroke, weakness, reduced mobility, and coordination deficits, with a BIMS score indicating moderate cognitive impairment. Her care plan and nutrition assessment documented nutritional problems related to depression, a need for more calories than provided by meals alone, and risk for malnutrition due to a dysphagia pureed diet and a wound, with daily caloric needs of 1618 kcals and use of supplements to promote healing. Physician orders included a regular diet with dysphagia pureed Level 1 texture and nectar-thick liquids, with assistance for feeding. During the observed dinner meal, her tray did not contain the pureed cornbread that was on the menu, and she was no longer in the dining room when the omission was discovered. In a later interview, she stated she liked cornbread and would have eaten it if it had been on her tray.

Resident #79 was an elderly male with metabolic encephalopathy, diabetes mellitus, urologic conditions, dementia, and cognitive communication deficits, with an MDS BIMS score of 0 indicating he was unable to complete the interview. His care plan and nutrition documentation identified nutritional problems related to depression, goals for maintaining weight and adequate PO intake, and more recent notes showing poor intake with most meals at or below 50%, risk for unavoidable weight loss, dehydration, and skin decline related to disease progression, and a goal focused on comfort with house supplements offered. For the same pureed meal, his tray was prepared without the pureed cornbread and placed on a cart for room delivery. CNAs distributing trays reported they checked for correct diet texture but did not detect the missing cornbread. The DM later acknowledged she overlooked the cornbread because it was stored separately from other pureed foods and confirmed that all residents should receive all items listed on the menu. The facility’s policy stated that nursing staff are responsible for verifying meal accuracy against diet orders and that meals are to be prepared according to individual meal cards, but interviews with the DON, administrator, and dietitian confirmed that the residents were not provided all menu items as expected.