F0800

D

Failure to Follow Therapeutic Diet Orders for Two Residents

Gainesville, Texas Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide prescribed therapeutic diets consistent with physician orders for two residents. One male resident with intact cognition, muscle wasting and atrophy, hypothyroidism, hypotension, and type 2 diabetes was admitted on 1/9/26 and had an order dated 1/23/26 for a Fortified Food Plan Diet with regular texture and liquids. His Initial MDS documented a therapeutic diet on admission and while a resident. However, his breakfast ticket dated 2/16/26 listed a Low Concentrated Sugar/Consistent or Controlled Carbohydrates diet instead of the ordered fortified food plan. On 2/17/26, surveyors observed an untouched breakfast tray in his room containing sausage, an egg-like item, oatmeal, French toast with syrup, and juice, with the tray ticket again reflecting a Low Concentrated Sugar/Consistent or Controlled Carbohydrate diet rather than the ordered fortified diet.

The Dietary Manager stated on 2/17/26 that she had been providing this resident a Low Concentrated Sugar diet and only then noticed that the physician had changed the diet to a Fortified Food Plan requiring larger portions and more calories. She reported she did not recall receiving notification of the diet change from nursing or the dietitian and acknowledged that the Low Concentrated Sugar diet provided smaller portions and fewer calories than the ordered fortified plan. The DON later stated that it was the dietitian’s responsibility to notify the Dietary Manager of changes in therapeutic diets and believed the diet for this resident was not changed timely because a new dietitian had sent an incomplete spreadsheet of residents on therapeutic diets.

A second female resident with intact cognition, hypertension, renal failure, diabetes mellitus, and irritable bowel syndrome was admitted on 1/30/26 with an order dated 1/30/26 for a Controlled Carbohydrate (Low Concentrated Sugar) diet, and her Initial MDS also documented a therapeutic diet. Her lunch tickets dated 2/9/26 and 2/10/26 showed a Regular Diet instead of a controlled carbohydrate/diabetic diet. She told surveyors she had been receiving regular portions of carbohydrates, regular sugar, and desserts, and produced saved meal tickets labeled Regular Diet. On 2/17/26, her lunch tray ticket finally reflected a Low Concentrated Sugar/Controlled Carbohydrate Diet, and the observed meal contained smaller portions and sugar substitutes. The Dietary Manager confirmed that when a ticket reflects “regular” there are no dietary restrictions, that diabetic residents should receive a Low Concentrated Sugar diet, and that this resident’s orders had always reflected a Low Concentrated Sugar diet, but she had been receiving regular meals. The ADON stated that diet orders from the speech therapist, dietitian, or physician should be given to the Dietary Manager as soon as they are changed. The facility’s Therapeutic Diets policy required that therapeutic diets be prescribed by the attending physician or delegated dietitian and that diet orders match the terminology used by food and nutrition services.