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F0803
E

Failure to Follow Planned Menu for Pureed Baked Fish

Johnstown, Pennsylvania Survey Completed on 12-12-2024

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 their planned menu, which was designed to meet the nutritional needs of residents. The written and posted menu for a lunch meal specified that residents were to receive baked fish, prepared with margarine, salt, and white pepper. However, during a test tray observation, it was found that the pureed version of the baked fish was snow white in color and lacked the seasonings present in the regular diet portion. This resulted in the pureed fish being bland and not as flavorful as intended. An interview with the Corporate Dietary Director confirmed that the pureed fish should have been prepared with the same ingredients as the regular portion, indicating a failure to follow the planned menu and recipe guidelines.

Plan Of Correction

1. The facility cannot retroactively address the findings. 2. Baseline audit of menus completed. 3. Dietary manager to educate dietary staff on menus, production sheets and recipes. Nursing staff to be educated on resident menus. 4. Weekly audits completed by contract Certified Dietary Manager or designee for 4 weeks then monthly for 2 months to ensure menus, spreadsheets and recipes are followed. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.

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