Failure to Follow Menus and Dietary Preferences for Residents
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received meals in accordance with their prescribed diets, preferences, and portion sizes. Observations revealed that a resident on a pureed diet did not receive pureed green beans as specified on the menu, and only received them after staff intervention. Additionally, kitchen staff did not serve the correct portion sizes for certain menu items, as evidenced by the use of incorrect scoop sizes for Korean menu items. The facility also failed to prepare and serve the Korean pureed menu for residents who had documented preferences for Korean food, instead providing them with American pureed menu items. Multiple residents who preferred Korean food and required pureed diets were served American menu pureed items rather than the Korean menu purees indicated in their care plans and nutrition progress notes. In one instance, a resident who preferred the American menu was served pureed kimchi instead of pureed bread, contrary to the menu and her preferences. The dietary staff acknowledged these errors, attributing them to mistakes made by the cook and a lack of awareness regarding the preparation of specific menu items. Further, a resident was served carrots that were not included on the menu for the day, despite her stating she did not like carrots due to an adverse reaction. Staff confirmed that the carrots were not part of the planned menu and that food trays were not checked for accuracy before being distributed. These failures affected the majority of residents receiving food from the kitchen and had the potential to result in unmet nutritional needs.
Plan Of Correction
F803 Menus Meet Resident Needs/Prep in Advance/Followed Corrective action for residents found to have been affected by this deficiency: - DS provided Resident 65 with the pureed green beans that were found missing from the meal tray, immediately on 6/16/25. - DS in-serviced dietary staff on 6/17/25, including the Lead Cook and Cook 2, on P&P "Standardized Menus" and "Food Preparation Guidelines," emphasizing the importance of following recipes, using proper measuring utensils, and correct portion sizes according to the menu spreadsheets, to ensure residents receive adequate nutrition by providing all food items on the menu, including both the American and cultural Korean menus. - DS conducted resident satisfaction surveys and visited all residents on a puree textured diet, or who were not served the correct food items, initiated on 6/17/25 and completed on 7/7/25, including Residents 79 and 40, and residents who preferred the Korean menu, including Residents 27 and 96, to ensure residents are content with the meals provided. Corrective action for residents that may be affected by this deficiency: - DS, RD, or trained designee will conduct daily round audits during food preparation 3 times per week for 3 months to ensure all standardized menus and spreadsheets are followed. - DS, RD, or trained designee will conduct test tray and tray line audits, 3 times per week for 3 months, ensuring both the American and Korean menus and spreadsheets are followed, including all pureed foods and cultural food preferences. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - DS or RD will report their findings regarding standardized menus and food preparation compliance to the QA committee for discussion and further recommendations. The QA will continue monitoring for a minimum of 3 months or until substantial compliance is achieved. Date of compliance: 7/7/25