F0803

E

Failure to Follow Therapeutic Diet Menus and Spreadsheets for RCS and Pureed Diets

Steubenville, Ohio Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and the approved menu/spreadsheet for residents, particularly those on reduced concentrated sweets (RCS) and pureed diets. Surveyors observed the lunch tray line and found that multiple residents with orders for RCS diets, including those with morbid obesity, type 2 diabetes mellitus, chronic kidney disease, and severe protein-calorie malnutrition, were served high-sugar desserts that were inconsistent with their diet orders and the facility’s RCS policy. For several cognitively intact or moderately impaired residents who required setup or cleanup assistance and were care planned as being at nutritional risk, tray tickets specified chilled peaches as the dessert for RCS diets, yet staff placed large portions of white cake with cherry topping and whipped topping on their trays. Fruit was available and had been placed on other residents’ trays, but was not used for these RCS diet trays.

Additional observations showed that residents on RCS mechanical soft diets were also served inappropriate desserts. Residents with diagnoses including type 2 diabetes with neuropathy, dementia, Parkinson’s disease, COPD, and dysphagia, and who were ordered RCS, no salt packet, mechanical soft diets, received chocolate cake with white frosting or fruit shortcake. The tray tickets for these residents indicated RCS mechanical soft diets, and in at least one case specified fruit shortcake, but the facility’s RCS spreadsheet indicated that RCS diets should receive chilled peaches instead of fruit shortcake. The registered dietitian and dietary technician later confirmed that chocolate cake with icing and fruit shortcake were not appropriate dessert choices for residents on RCS mechanical soft diets and that a glitch in the tray card system meant there was no spreadsheet breakdown for combination diets such as RCS mechanical soft.

Surveyors also identified that the facility did not follow the puree diet spreadsheet for residents ordered pureed texture diets. The facility’s fall and winter menu and corresponding spreadsheet specified that residents on pureed diets were to receive pureed fish of the day, pureed vegetables, pureed dinner roll with margarine, and pureed fruit shortcake for lunch. However, during observation of the tray line, no pureed fruit shortcake was present, and residents on pureed diets were instead given small plastic bowls of vanilla pudding. The dietary director confirmed that the cook had not prepared the pureed fruit shortcake and that these residents were therefore receiving vanilla pudding in place of the menu-specified dessert. A registered dietitian and dietary technician confirmed that the spreadsheets needed to be followed and that residents on pureed diets should have received pureed fruit shortcake. The facility’s own policies on RCS diets and on menus and adequate nutrition required that meals be prepared consistent with RCS guidelines and that menus be followed, but these were not adhered to during the observed meal service.

A registered nurse supervisor acknowledged during interview that menus were not always followed and stated that diabetic residents were receiving desserts they should not be getting, noting that everybody got cake for lunch that day. Across the cited examples, residents’ medical records consistently showed therapeutic diet orders, MDS assessments documenting therapeutic or mechanically altered diets, and care plans identifying nutritional risk with interventions to provide diet and fluids as ordered and to honor preferences as able. Despite this, the lunch service on the observed day did not follow the written menus, diet spreadsheets, or physician orders for RCS and pureed diets, resulting in desserts being served that were inconsistent with the residents’ prescribed diets and the facility’s written policies.