F0803

E

Failure to Follow Planned Menu for Mechanically Altered Diets

Concord, North Carolina Survey Completed on 02-27-2026

Penalty

Fine: $44,925

Summary

The facility failed to follow the planned menu for residents prescribed mechanically altered diets during two observed lunch meals. A resident with protein calorie malnutrition, lipoprotein deficiency, dysphagia, and severe cognitive impairment was ordered a mechanically altered diet with thin liquids. The facility’s diet spreadsheet for therapeutic diets showed that residents on mechanically altered diets were to receive specific soft, cooked, fork-mashable vegetables and designated desserts for the lunch meals observed. However, during the first lunch observation, the resident’s tray ticket listed a regular mechanically altered diet, but the actual meal included broccoli with mixed vegetables and tropical fruit instead of the planned seasoned sautéed zucchini and applesauce. There was no evidence of the menu-specified vegetable or dessert on the tray.

During the second lunch observation, the diet spreadsheet indicated that residents on mechanically altered diets, including this resident, should receive ground turkey cutlet with gravy, mashed potatoes, cut green beans, and cherry cobbler. Instead, the resident was served chopped turkey cutlet with gravy, red whole sliced potatoes, broccoli, and a cookie for dessert. The Dietary Manager acknowledged awareness of the resident’s mechanically altered diet and confirmed that the resident received the wrong vegetables and dessert, and that all 24 residents on mechanically altered diets received incorrect vegetables and desserts on both observed days. The Regional Dietary Manager stated the facility had run out of food, leading to menu changes, and confirmed that 24 residents on mechanically altered diets did not receive the correct vegetables or desserts. The Administrator stated her expectation that dietary staff follow the planned menu and log and communicate any menu changes to residents.