F0656

D

Failure to Include Ordered Diet Textures and Divided Plates in Comprehensive Care Plans

Victoria, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement comprehensive person-centered care plans that included all ordered dietary interventions and adaptive equipment for two residents. For one resident with type II diabetes mellitus, major depressive disorder, hemiplegia and hemiparesis, moderate intellectual disability, and cerebral palsy, the comprehensive care plan dated 07/16/2025 identified a focus on potential risk for malnutrition with an RCS/LCS/NSOT diet, but did not include the ordered use of a divided plate. The resident’s active diet order, in place since 10/04/2024, specified an RCS/LCS/NSOT diet with regular texture and consistency, a divided plate, and only pink sugar, yet the divided plate was omitted from the care plan despite being part of his ongoing care.

Surveyor observations on 02/06/2026 showed this resident consistently received meals on a plastic divided plate in both the assisted feeding dining room and his room. The resident exhibited involuntary muscle contractions and hand deformities related to cerebral palsy, and the speech therapist reported having evaluated him months earlier and recommending a divided plate due to his hand deformities and need for assistance. During an interview, the resident stated it was easier to eat with a divided plate. Despite these clinical needs and the standing physician order, the divided plate intervention was not reflected in the resident’s comprehensive care plan.

For a second resident with Alzheimer’s disease, major depressive disorder, dementia, and anxiety, the quarterly MDS indicated he could usually understand and be understood, required setup and supervision for eating, and was on a therapeutic diet. His comprehensive care plan dated 07/11/2025 included a focus on ADL self-care performance deficit with supervision for eating as needed and noted that he was on a regular diet, but did not document his ordered mechanical soft texture diet or the need for a divided plate. Active orders dated 10/15/2025 specified a regular diet with mechanical soft texture, regular consistency, a divided plate, drinks in coffee cups, and double liquids. Observations confirmed he was receiving mechanical soft texture food, and his meal ticket reflected mechanical soft texture, yet these requirements were not incorporated into the care plan. The MDS nurse, DON, and interim administrator each acknowledged in interviews that the comprehensive person-centered care plan should accurately reflect the care and services the residents require.