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F0803
E

Failure to Follow Standardized Pureed Diet Recipe

Chicago, Illinois Survey Completed on 05-30-2025

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 follow standardized recipes during the preparation of pureed diets for eight residents who required this diet texture. During observation, the cook prepared pureed beef lasagna by adding unmeasured amounts of water to the blender, resulting in a watery and thin consistency. The cook admitted to not measuring the water and instead filled the blender container halfway or until the food was covered, then added food thickener to adjust the consistency. This process was repeated for two batches, both resulting in diluted pureed lasagna. The standardized recipe required that liquid be added gradually, starting with the smallest amount, and only adding more if needed, with a specific total amount for ten portions. The facility's policies also required the use of standardized recipes and careful addition of liquids and thickeners to maintain nutrient density. Interviews with the Regional Director of Kitchen Operations and the Registered Dietitian confirmed that recipes should be followed to ensure residents receive the correct nutrition, and that adding excessive liquid can dilute the nutritional value of the food. The job description for the cook position also required preparation of food according to standardized recipes and special diet orders. Physician orders and menu extensions confirmed that the affected residents were prescribed pureed diets and were to receive pureed skillet lasagna. The failure to follow the standardized recipe and preparation procedures had the potential to affect the nutritional intake of the residents receiving pureed diets.

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