F0803

E

Failure to Follow Ordered Consistent Carbohydrate Diets and Menu Specifications

Sister Bay, Wisconsin Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that ordered consistent carbohydrate (CCHO) diets were accurately implemented and that menus met residents’ prescribed nutritional needs. The facility’s Controlled Carbohydrates policy states that carbohydrates should be balanced consistently at each meal, providing 70–80 grams of carbohydrates, and that these diets can be used for diabetic residents with glucose control concerns. However, for one resident with type 2 diabetes, hospital discharge orders specified a carb-controlled diet of 60 grams of carbohydrates per meal, while the facility’s medical record contained an order for a CCHO, no added salt diet providing 90 grams of carbohydrates per meal. The Dietary Manager was unaware that this resident’s diet order specified 90 grams of carbohydrates and did not know how many grams of carbohydrates were provided on the facility’s CCHO menu. The Registered Dietitian stated that a carb-controlled diet is usually 55–70 grams of carbohydrates per meal, that higher carbohydrate orders should be followed by providing additional carbohydrates, and that specific carbohydrate orders should be communicated to the Dining Director so meal tickets can be adjusted, but was also unsure how many carbohydrates per meal the facility’s menu provided.

Additional residents with diagnoses including type 2 diabetes and stroke had active orders for CCHO or CCHO no added salt diets, yet reported or demonstrated that they did not consistently receive meals aligned with those diets. One cognitively intact resident with type 2 diabetes reported preferring to follow a CCHO diet but stated they did not always receive it and were served a lot of potatoes and bread, which they would prefer to avoid. Another cognitively intact resident with type 2 diabetes reported preferring to follow a CCHO diet but stated they did not always receive it and therefore chose to eat smaller portions or avoid items they felt did not fit a CCHO diet. Several other residents with CCHO or CCHO no added salt diet orders had varying levels of cognitive impairment, including severe impairment, and were dependent on staff and the facility’s systems to ensure their prescribed diets were followed.

During an observation of lunch service, the surveyor reviewed the lunch menu for residents on a CCHO diet, which specified 3 oz baked ham, 4 oz scalloped potatoes, 4 oz buttered green beans, 1 dinner roll, and a half slice of Boston cream pie. When observing the trays prepared in the kitchen, the surveyor noted that each tray, including those for residents on CCHO diets, contained a slice of pie that appeared to be the same size, rather than a half slice as indicated on the menu. The Dietary Manager acknowledged noticing that residents on CCHO diets did not receive a half piece of pie and confirmed that they should have received a half slice according to the menu. These observations, combined with staff interviews and record review, showed that residents with CCHO diet orders did not consistently receive meals that matched their prescribed diets or the facility’s stated carbohydrate-controlled menu.