N0181

Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets

Boca Raton, Florida Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide residents with appropriate menu choices that matched their physician-ordered diets, thereby not assuring residents’ rights to knowledge of available choices and independent personal decisions. One resident with severe cognitive impairment was admitted with multiple medical diagnoses and had a physician’s order for a controlled diet with pureed texture and honey-thick liquids. During a lunch observation, this resident’s meal ticket was found stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were compatible with the resident’s ordered pureed diet. The Registered Dietitian and the Dietary Manager confirmed that Daily Menu printouts for the Regular Menu were provided to all residents, including those on mechanically altered diets, and acknowledged that residents on such diets would be offered items like fresh fruit that could not actually be provided according to their prescribed diet consistency.

Another resident with moderate cognitive impairment and multiple medical diagnoses, including failure-related conditions, had a physician’s order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray was observed with a meal ticket stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s meal ticket was again stapled to a Regular Menu that listed fresh fruit as a choice. The resident had circled fresh fruit as her preference but instead received canned peach halves on her tray and verbally expressed that she wanted her chosen item rather than the peaches, reiterating her food preferences before the surveyor left the room. These observations, along with staff interviews, showed that residents on modified diets were routinely given Regular Menus with options that could not be honored due to their diet orders.

Plan Of Correction

Resident Rights/Exercise of Rights Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required N0181

1. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on [R] . Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified.

2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets. On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes.

3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits. Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders.

The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served.

4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] and resolving any variances that may occur.