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F0803
E

Failure to Follow Standardized Menus and Diet Orders During Meal Service

Los Angeles, California Survey Completed on 05-22-2025

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 ensure that standardized recipes and menus were followed during lunch service, resulting in multiple dietary errors. Seven residents on fortified diets did not receive the required calorie-enriched foods as indicated on their meal tickets, because the dietary aide did not communicate the fortified diet orders during tray line service and the cook did not add the additional food items per the fortified menu. The dietary aide admitted to forgetting to read the fortified diet orders, resident food preferences, and specific diet requirements, which led to residents not receiving the appropriate meals. Additionally, 14 residents on regular diets did not receive the seasoned peas as specified on the menu, and residents on renal diets received three-bean salad instead of the prescribed wheat roll with margarine. Both the cook and dietary aide were unfamiliar with the menu and did not review the spreadsheet or meal tickets properly, resulting in incorrect food items being served. Observations confirmed that residents on regular diets received plates missing vegetables, and those on renal diets received inappropriate items. Facility policy required menus to be served as written unless substitutions were made for preferences or unavailability, but this was not followed during the observed meal service.

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