F0805

G

Failure to Provide Ordered Pureed Diet Resulting in Aspiration Pneumonia

Richmond, Virginia Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

Facility staff failed to provide a provider-ordered pureed/mechanically altered diet to a resident with dysphagia and severe cognitive impairment, resulting in pneumonia requiring antibiotic treatment. The resident’s diagnoses included dysphagia, vascular dementia, stridor, and cerebral infarction, and the hospital discharge summary specified a pureed diet. The admission MDS documented severe cognitive impairment (BIMS score 2/15) and a mechanically altered diet, and the comprehensive care plan identified dysphagia requiring a puree diet. Although an initial order on 12/19/25 was for a regular diet with dysphagia advanced texture and thin liquids, this was changed on 12/22/25 to a pureed diet per hospital recommendations. Despite these orders, the resident was observed on 02/11/26 with a lunch tray containing chicken that the dietician and SLP determined was a mixture of mechanically altered and pureed textures; the SLP stated it would not be safe for this resident to consume. The tray ticket listed the entrée as puree crispy chicken thigh, indicating a discrepancy between the ordered/printed diet and the actual food consistency served.

In addition, the resident’s family reported multiple occasions when the resident did not receive the correct diet, including being provided a milkshake containing Oreo cookies and Reese’s Pieces on Super Bowl Sunday and receiving wrong meal trays on three occasions. Facility emails related to this incident showed a CNA first acknowledging giving an Oreo milkshake to a resident on a puree diet, then later stating the milkshake given was safe and that the Oreo milkshake was not provided. Another resident reported ordering a cookies and cream milkshake for the resident via a delivery service and instructing that the pieces be ground up because the resident was on a puree diet, and confirmed the resident consumed it. The provider documented that a chest radiograph on 02/11/26 showed infiltrate consistent with recurrent aspiration pneumonia and noted it was reported the resident recently received a milkshake containing candy pieces, which likely contributed to this aspiration episode. Documentation from the DON also indicated the resident had previously been served the wrong diet over the weekend of 12/20/25–12/21/25, which the resident ate, followed by chest X-ray findings of bilateral perihilar atelectasis/infiltrate and initiation of antibiotic therapy for pneumonia on 12/24/15.