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F0803
E

Failure to Follow Menu Extensions and Recipes for Resident Meals

Colorado Springs, Colorado Survey Completed on 08-27-2025

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 recipes and menu extensions were followed to meet residents' nutritional needs during meal preparation and service. Observations during a dinner meal revealed that residents on regular diets were served only half of a baked Italian sub sandwich instead of the two halves specified in the menu extensions. Additionally, a resident prescribed a pureed diet was served pureed barley soup and a pureed hamburger patty, rather than the required pureed Italian grinder sub and pureed potato salad. The menu extensions also indicated that a pureed brownie should have been served for dessert, but the resident received a pureed chocolate chip cookie and ice cream instead. Record review confirmed that the menu extensions detailed specific portion sizes and food items for both regular and pureed diets, which were not adhered to during meal service. Staff interviews revealed that the dietary manager did not use or follow recipes, was unable to locate them in the dining manager RD program, and acknowledged that dietary aides were not properly trained on portion sizes. The nursing home administrator confirmed that recipes should be followed and recognized the potential concerns related to not doing so, including issues with allergies, safety, and nutritional values.

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