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F0803
F

Failure to Follow Pre-Approved Menu and Recipes

Johnstown, Pennsylvania Survey Completed on 12-19-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its pre-approved planned menu and recipes for a lunch meal on December 19, 2024. The posted menu indicated that residents were to receive chicken vegetable stew, spaghetti noodles, dinner roll, pineapple tidbits with cream, two-percent milk, coffee/tea, and margarine. However, during the lunch tray delivery, it was observed that the residents did not receive the dinner roll or margarine, and the pineapple tidbits were served without cream. Additionally, the chicken vegetable stew served did not contain several ingredients listed in the facility's recipe card, including chopped ham, lima beans, crushed tomatoes, diced celery, and minced garlic. Interviews with the Dietary Manager and another staff member revealed that the missing cream was due to a delay in the supply truck's arrival, and the staff attempted to make the stew as hearty as possible with the available ingredients. There was no documented evidence that the changes in the menu were discussed with the resident council president, indicating a lack of communication and planning to address the shortfall in ingredients. This failure to follow the planned menu and recipes constitutes a deficiency in meeting the nutritional needs of the residents as required by the facility's dietary services regulations.

Plan Of Correction

1. There were no ill effects noted to residents in the facility due to menu change. 2. Dietary Manager educated on regulation of the notification to residents of menu changes. 3. Dietician or designee will audit to ensure lunch meal is accurate to communicated menu weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.

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