N0407

Failure to Follow Therapeutic Diet Orders and Provide Ordered Nutritional Supplements

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

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to follow physician-ordered therapeutic diets and provide ordered supplements. One resident on a controlled pureed diet with honey-thick liquids, who had severe cognitive impairment and was care planned for risk of compromised nutritional status, was not served a vegetable at lunch; her tray contained only pureed chicken, a pureed starch, and possibly a pureed bread covered in gravy, despite the menu listing a pureed vegetable (broccoli on one day and peas on another). During tray line observation, no pureed vegetables were present on the line even though the pureed menu specified a pureed vegetable. The Dietary Manager and Registered Dietitian were informed of the missing pureed vegetable and acknowledged the absence.

The facility also failed to provide physician-ordered Magic Cup nutritional supplements as specified. One resident with varying dietary intake and a care plan for compromised nutritional status had an order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner, but during a breakfast observation the Magic Cup was listed on the meal ticket and not provided. Another resident observed at the same breakfast also had a Magic Cup ordered but did not receive it. A third resident with moderate cognitive impairment had an order for a 4 oz Magic Cup with lunch; during lunch observations, this resident’s ticket read Magic Cup, but she was given a chocolate ice cream cup and ate coconut cream pie for dessert instead of the ordered supplement, while the MAR documented 100% consumption of a Magic Cup on consecutive days. The RD and Dietary Manager stated that dietary staff were responsible for providing Magic Cups but could not explain why residents in the dining room did not receive them.

Plan Of Correction

Dietary Services CFR(s): 400.141(1)(i), FS 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 N0407 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents.

2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on by

Certified Dietary Manager.

3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R] . RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months.

4. The Certified Dietary Manager/Designee will report on the 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.