Non-Compliance with Menu and Nutritional Adequacy Requirements
Penalty
Summary
Heritage Ridge Senior Living at Johnstown was found to be non-compliant with the requirements for menus and nutritional adequacy as per 42 CFR Part 483, Subpart B. The facility failed to ensure that dietary staff served the planned portion sizes and provided condiments according to resident preferences. The facility's policy stated that menus should meet resident choices, including religious, cultural, and ethnic needs, while following national guidelines for nutritional adequacy. However, deviations from the posted menus were not properly recorded or followed. On January 23, 2025, several residents reported receiving breakfast meals that did not match the written menu or their tray tickets. For instance, one resident received a single pancake instead of two, and another resident did not receive the banana or grits as indicated on their tray ticket. Additionally, residents expressed dissatisfaction with the lack of condiments and snacks, with some stating they felt hungry and had to rely on personal snacks. The Dietary Manager confirmed that the breakfast served did not follow the written menu, citing issues such as green bananas and residents' dislike for grits as reasons for the deviations. During the lunch meal on the same day, residents also reported discrepancies between the written menu and what was served. One resident noted the absence of tartar sauce with their fish, while another received chicken tenders instead of fish and expressed a desire for ketchup. Interviews with staff revealed that condiments were not consistently available with meal carts or on resident trays, and the Dietary Manager acknowledged the oversight. The facility's failure to adhere to the planned menus and provide necessary condiments and snacks was evident in the observations and interviews conducted during the survey.
Plan Of Correction
Menus were reviewed for accuracy of portion sizes and specifications. All residents have the potential to be affected. Dietary staff educated on the importance of adhering to portion sizes and menu specifications. Condiments are now available in the nutrition room and can be provided upon request in addition to being provided on the meal tray. Dietary manager or designee to audit for compliance with portion sizes and menu specifications. Audits will be conducted 4 times weekly for 4 weeks, then 2 times weekly for 2 weeks, and periodically thereafter. Results of the audits will be provided to the Administrator by dietary manager and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.