Incorrect Meal Portions and Missing Sandwich for Resident with Diabetes
Summary
The facility failed to ensure Resident #3 received a nourishing, palatable, well-balanced diet that met his daily nutritional and special dietary needs. Resident #3 was a male with type 2 diabetes mellitus with hyperglycemia and intact cognition, and his physician ordered a heart healthy regular diet with regular texture and consistency, double portions plus an additional sandwich for all meals, and avoidance of carb-heavy meals due to diabetes. The facility diet roster also noted diabetic diet and large protein portions for him. During observation and interview, Resident #3’s lunch tray on 5/12/2026 arrived with a ticket reading "lg protein" and appeared to have a larger portion of meat than other residents, but it was not served with a sandwich. Resident #3 stated his meals were frequently served with incorrect portion sizes and without a sandwich, and he said he felt frustrated by the errors. On 5/14/2026, another lunch tray arrived with a ticket reading "lg protein," but the meal contained only a single slice of meat patty similar in size to other residents’ trays and did not reflect the ordered large protein portion. The DSM stated the tray was prepared incorrectly and did not contain a large protein portion, and the Admin stated residents should be served trays with double portions if ordered by the physician and that nursing staff should check trays before service.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Delayed dietary communication caused a resident with severe cognitive impairment and feeding assistance needs to miss meal service. Staff said the kitchen could not serve the resident without a dietary card, the admission order was not delivered in time, and the resident did not receive a tray until a family member raised concern.
Failure to communicate a dialysis dietary recommendation for a resident with DM2, CKD stage 5, and elevated phosphorus. Dialysis labs showed a phosphorus level of 7.8 and noted to encourage avoiding ice cream, but the resident continued receiving dairy items such as ice cream, yogurt, and milk. The UM described a process for sharing new diet orders via a communication slip, yet the Dietary Mgr could not find one and the Dietary Tech said the recommendation was never communicated or entered into the system.
A cook served diced fried potatoes using the same larger scoop for both CCHO and regular diet trays, resulting in twice the intended potato portion for CCHO meals. The RD stated a smaller scoop should have been used for the therapeutic diet, and the facility menu and policy specified different portion sizes for regular versus CCHO diets.
A facility failed to provide proper meat portions for residents on regular diets and for a resident ordered double portions. During lunch, a resident with malnutrition said the meat portions were not large enough and was observed with only one thin slice of pork loin, while another resident with nutritional deficiency and an order for double portions received three thin slices totaling about 4.5 oz instead of 6 oz. Meal tickets specified 3 oz pork roast loin, but the DM weighed a slice at 1.5 oz and said the pork had been cut in-house.
A resident with liver and colon cancer had a physician order for a regular diet, but the RN’s communication slip sent to dietary indicated a clear liquid diet, and the resident was served clear liquids instead of the ordered diet. The tray card also did not include the resident’s preferred or disliked foods, and the DS and DON verified the mismatch between the order and what was provided.
Double Portion Meal Orders Not Met: The facility failed to serve lunch trays in accordance with ordered double portions for multiple residents with conditions including DM, ESRD on dialysis, CKD, malnutrition, dementia, and obesity. Surveyors observed the tray line serving only 15 raviolis to residents ordered double portions, while the regular portion was 10 raviolis and the large portion was 12. The Dietary Manager and RD confirmed the servings did not equal twice the regular portion, and the Administrator stated there was no diet formulary defining diet parameters.
Delayed Dietary Order Caused Missed Meal Service
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs when Resident #1 did not receive timely dietary communication to the kitchen after admission. Resident #1 was admitted with unspecified dementia, restlessness and agitation, and muscle wasting and atrophy, and his MDS showed severely impaired cognition with a BIMS score of 1. He required supervision or touching assistance with eating and substantial to maximum assistance with toileting hygiene. The care plan identified an ADL self-care performance deficit and included staff assistance with eating. During the admission process, the dietary order was not communicated to the kitchen in time, and the resident’s dietary card was not delivered before meal service. The DM stated the kitchen could not serve a resident without a dietary card because staff would not know any diet restrictions, and she acknowledged two instances where dietary cards were not turned in timely, including one that resulted in a missed meal. Staff interviews confirmed the resident was admitted in the afternoon after kitchen staff had gone home, the kitchen did not know he was in the facility until a family member asked about the missing tray, and he did not receive breakfast. The facility policy stated that nursing service transcribes the diet order and sends forms to Dietary Service prior to meal service.
Failure to Communicate Dialysis Dietary Recommendation
Penalty
Summary
The facility failed to ensure communication and coordination between staff and all departments regarding a special dietary recommendation for one resident with type 2 diabetes, disorders of phosphorus metabolism, stage 5 chronic kidney disease, and a Monday, Wednesday, Friday dialysis schedule. Dialysis nutrition labs showed a phosphorus level of 7.8, and the dialysis note requested that the resident be encouraged to avoid ice cream. The resident’s record showed that after this recommendation was sent to the facility, the resident continued to partake in dairy products, including ice cream, yogurt, and milk. The resident’s orders and care plan did not reflect the dialysis recommendation. During interview, the Unit Manager stated that residents returning from dialysis have a dialysis book for new orders or recommendations, and that staff communicate dietary changes through a Diet Order and Communication slip for new diet orders, recommendations, or short-term diet adjustments. The Dietary Manager was unable to locate a Diet Order or Communication slip for the resident for the month of June. The Dietary Tech stated that she was not aware of the dialysis recommendation and that it had not been communicated to dietary staff. She confirmed that the recommendation was not in the system and should have been entered.
Incorrect CCHO Portioning During Meal Service
Penalty
Summary
The facility failed to provide 24 of 68 residents with the correct Carbohydrate-Controlled (CCHO) diet portion when kitchen staff served twice the amount of potatoes required for the therapeutic diet. During lunch tray line observation, a cook used a scoop with a grey-colored handle to plate potatoes for a tray marked for a CCHO diet order and then continued using the same scoop for both CCHO and regular diet orders. In interview, the RD stated that a smaller scoop with a blue-colored handle should have been used for CCHO portions and confirmed that the larger portion size would nullify the intended therapeutic effect of the CCHO diet. The facility’s Summer Menus specified diced fried potatoes should be served with a number 8 scoop for regular diets and a number 16 scoop for CCHO diets, and the Therapeutic Diets policy stated the DS and RD will observe meal preparation and serving to ensure portions match written portion sizes.
Inadequate Pork Portion Sizes Served at Lunch
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met nutritional needs for 2 of 5 residents reviewed for dietary needs. Resident #1 had diagnoses including cerebrovascular disease and protein-calorie malnutrition, and his care plan indicated he was on a regular diet and at nutrition and hydration risk, with interventions to provide and serve diet as ordered. Resident #2 had diagnoses including postoperative surgical aftercare, nutritional deficiency, and moderate protein-calorie deficiency, and his care plan indicated he was on a regular diet with thin liquids and was to receive double portions, with interventions to provide and serve diet as ordered. During lunch observation, residents on regular diets were served appropriately portioned sides and one thin slice of pork loin with gravy. Resident #1 stated the food portions were not large enough and specifically said the meat portions were not large enough, while the sides were fine. He was observed with only 1 small thin slice of pork loin on his plate and said he only received 1 slice. At the same time, the dietary staff were observed plating resident meals and placing one thin slice of pork loin on each plate for residents who received regular portions and wanted pork loin. Meal tickets on the tray cart specified Pork Roast Loin Garlic Herb - 3 oz. for the regular meal, and Resident #2’s ticket specified Double Portions with the same 3 oz. pork roast loin. Resident #2 was observed with 3 thin pork loin slices on his plate, approximately 4.5 oz. total instead of 6 oz. The DM stated he sliced the pork loin and believed each slice was 3 oz., but when he weighed a slice on the kitchen’s only mechanical scale, it weighed 1.5 oz. He said the pork loin was typically precut when ordered, but this time the staff had to cut it themselves. The RD stated she had observed a test tray earlier in the month with no portion-size issues and later said she would audit how much protein residents were getting with each meal. The facility menu and nutritional adequacy policy stated menus are planned to meet the average resident’s nutritional needs and that the meal planning guide uses 5 oz. of meat or equivalent as the minimum daily serving.
Diet Order Not Followed and Food Preferences Omitted
Penalty
Summary
The facility failed to provide one resident with the diet ordered by the physician and did not include the resident’s preferences and dislikes on the dietary tray card. The resident was admitted with diagnoses of liver and colon cancer and had a physician order for a regular diet to be served three times per day. However, the nursing communication slip completed by the RN indicated a no added salt, controlled carbohydrate, clear liquid diet, advance as tolerated, and the dietary tray card later reflected no added salt and controlled carbohydrate without identifying the diet type or texture or listing the resident’s preferred and disliked foods. During interview and record review, the Dietary Supervisor verified the resident was served a clear liquid diet throughout the stay instead of the ordered regular diet. The Dietary Supervisor stated the nurse was responsible for communicating the diet order to dietary staff and that the tray card should include the resident’s preferences and dislikes, but she did not verify the diet order against the communication slip and relied on the nurse’s information. The Director of Nursing also verified the resident had orders for a regular diet and received a clear liquid diet during the stay, and stated she was not sure why the communication slip indicated a clear liquid diet. The facility policy stated residents will have a written diet order on admission and diets will be served as ordered by the physician.
Double Portion Meal Orders Not Met
Penalty
Summary
The facility failed to serve meals that met the nutritional needs of residents who were ordered double portions at lunch. Record review identified 24 residents with orders for double entree, double protein, or double portion meals, including residents with diagnoses such as diabetes mellitus, end stage renal disease on dialysis, severe protein calorie malnutrition, chronic kidney disease, morbid obesity, dementia, depression, and other chronic conditions. Their records and dietary assessments documented that they were supposed to receive increased meal portions as part of their diet orders and nutritional care plans. During observation of the lunch meal tray line on 05/19/26, surveyors observed [NAME] #405 using a #16 scoop to serve cheese ravioli and counting portions to ensure residents received 10 raviolis. Residents with orders for double portions were served 15 raviolis. At the time of observation, [NAME] #405 stated the production sheet indicated a #16 scoop was to be used for ravioli and that a portion size was 10 raviolis. [NAME] #405 confirmed that residents with double portion orders received 15 raviolis. Review of the production sheet with the Dietary Manager showed the #16 scoop was intended for the sauce on top of the ravioli, the regular portion was 10 raviolis, and the large portion was 12 raviolis. The Administrator stated the facility did not have a diet formulary defining what each diet meant or the parameters for each diet. The Registered Dietitian confirmed that double portions meant residents should receive twice the regular portion, not the large portion listed on the production sheets or the one-and-a-half portions that were served at lunch.
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