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F0803
E

Failure to Follow Menu and Resident Preferences

Pittsburgh, Pennsylvania Survey Completed on 04-18-2025

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 preplanned cycle menu and did not accommodate residents' food preferences and standing orders. On a specific date, residents were served pot pie for lunch instead of the expected chicken tenders, as indicated on the menu. The residents were not informed of this menu change in advance. Additionally, the facility's policy on menus and resident food preferences, which was last reviewed in March, outlines that menus should meet resident choices while following national nutritional guidelines and that individual food preferences should be assessed and communicated to the interdisciplinary team. Two residents were directly affected by these failures. One resident, who had a standing order for two cups of coffee, orange juice, and a boiled egg, received toast, a bagel, and only one cup of coffee, with no protein included. Another resident, who had a preference for a boiled egg and a dislike for scrambled eggs, was served a scrambled egg instead. The Dietary Services Director acknowledged making menu changes to gauge resident preferences but admitted difficulty in tracking these preferences due to limitations in the computer system. The Nursing Home Administrator confirmed the facility's failure to follow the preplanned menu and provide residents with their preferred food choices.

Plan Of Correction

The Dietary Director will ensure all menu changes are reviewed and approved at least 24 hours in advance by the Dietitian and Administrator. To notify residents in a simple and effective manner, the facility will implement a "Daily Menu Notice Board" in the facility, updated each morning by dietary staff. Any changes to the published menu will be clearly highlighted, and a brief explanation will be included. In addition, nursing aides will verbally inform residents of any substitutions at mealtime. To address errors in food preferences, the Dietary Services Director and Dietitian will jointly audit all resident food tickets for accuracy by June 9, 2025, and ensure corrections are entered into the dietary software. Staff responsible for tray preparation will receive re-training on reviewing food tickets and adhering to standing orders. A weekly audit of at least 10 meal trays will be conducted for 8 weeks to confirm compliance with resident preferences. The Administrator will monitor audit results and ensure follow-up for any deviations.

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