A resident with significant wt loss was served lunch without the ordered extra sandwich and fruit. Her tray did not include the physician-ordered items intended to support her nutritional needs, and kitchen staff said they were unaware of the order. A recent nutritional assessment documented that she was underweight and had ongoing significant wt loss.
Residents were served lunch without items listed on their trays, including fortified pudding, mandarin oranges, and key lime pie, and staff had to obtain the missing foods after the omissions were identified. Another resident stated she continued to receive mixed vegetables despite telling staff she did not like them, even though she had a BIMS of 15.
Meals were not consistently served as ordered or in a palatable manner. During dining observations, several residents reported pork was too tough to chew and that gravy listed on the meal ticket was missing, while others said chicken was bland, tough, and served too often. Residents also reported that food preferences and alternate selections were not reliably updated or honored, and a DMFN confirmed the gravy should have been on the pork per recipe and ticket.
A resident was observed not eating breakfast after being served cornflakes and two boiled eggs, despite a tray card indicating Fruit Loops, no eggs or pork, and assorted fruit juices. The resident stated she disliked the items served, and an RN confirmed the tray card and the meal that was delivered.
A resident with a physician’s order for double entrée portions at meals was observed receiving only a single BBQ sandwich, despite the tray ticket specifying a double entrée. During the meal, the NA assisting the resident left the table briefly, during which time the resident consumed almost the entire sandwich and ate meat that had fallen onto their clothing. When the NA returned and was informed of the double-entrée order, the NA stated they were unaware of the order. Record review confirmed the active order for double entrées, and the observation showed the meal served did not match the ordered diet.
The facility failed to follow a resident’s diet order for double vegetable portions and large breakfast portions, despite a policy requiring menus and meals to meet residents’ nutritional needs and be served as written. A resident with a consistent carbohydrate diet order did not have the double vegetable portion instruction printed on tray tickets, and was observed receiving the same number of potato wedges as other residents. The Dietary Manager confirmed that extra portion orders should appear on tray tickets and acknowledged that this resident’s tickets previously included, but no longer showed, the extra portion instructions.
A resident with a diet order for consistent carbohydrate, regular, thin, no added salt, and no beef or pork was served ham on the tray. After surveyor intervention, staff confirmed the tray card listed a milk allergy and no beef or pork. Staff stated only pork was available, the resident’s acceptance of pork depended on her mood, and the resident was then given a PB&J sandwich. The account manager said the facility does not provide an alternate menu, but residents may choose from an always available menu.
Failure to Provide Ordered and Preferred Beverages: Two residents did not receive beverages listed on their tray cards. One resident’s tray card listed apple juice, but the resident reported never receiving it and said preferences were asked for but not honored; an admin staff member confirmed the resident instead asked for punch. Another resident’s tray card listed chocolate milk, but milk was not on the tray, and an admin staff member confirmed it was missing.
A resident’s care plan noted a caffeine-free diet due to religious beliefs, but the dietary order only reflected a lacto-ovo vegetarian diet. Dietary slips listed coffee and tea at lunch and dinner, and the FSD confirmed the facility’s coffee and tea contained caffeine. The resident’s MPOA stated that avoiding caffeine was an absolute religious requirement.
A resident on a consistent carbohydrate diet reported meals were often cold, inconsistent, and frequently substituted. The resident received a 3-week menu labeled for a regular diet instead of the required diet, and the meal ticket showed handwritten changes to items. The Dietary Account Manager confirmed the menu was not the correct diet for the resident.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.