Failure to Serve Dietician-Approved Pureed Menu and Portions
Penalty
Summary
The facility failed to serve the Dietician-approved menu to all five residents on pureed diets, as required. Observations revealed that staff did not consistently follow the approved menu or portion sizes, resulting in residents receiving incorrect amounts and, in some cases, burned or insufficient food. Specifically, staff prepared only the exact number of portions needed, did not account for food loss during preparation, and did not always use heaping measurements as expected. On one occasion, a resident received less than the required serving of peas and rice, with some food containing burned pieces, after staff ran out of pureed food. Staff interviews confirmed that running out of pureed food was a recurring issue, and there was inconsistency in following the portioning process and menu requirements. One resident affected by this deficiency had a documented significant weight loss, dropping from 129 pounds to 102.5 pounds over six months, without being on a physician-prescribed weight loss regimen. The facility's policies and procedures lacked clear direction for staff to follow the Dietician-approved menu, and staff did not consistently prepare extra servings to ensure all residents received the correct portions. The Consulting Dietician and Certified Dietary Manager both expected staff to prepare extra portions and use heaping measurements, but these expectations were not consistently met.