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F0803
F

Failure to Prepare and Serve Therapeutic Diets According to Menu and Recipe Requirements

Sandwich, Illinois 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 properly prepare and serve pureed and mechanical soft diets according to prescribed recipes and menu requirements for all 97 residents. Specifically, for residents requiring pureed diets, the Dietary Manager did not follow the facility's pureed chicken nugget recipe, instead using unmeasured amounts of hot water and bread crumbs rather than the specified chicken broth and thickener. The Dietary Manager also failed to provide the correct portion size, pureeing only 21 chicken nuggets for 11 residents instead of the required 55, resulting in each resident receiving less than the intended amount of protein. Additionally, no pureed bread was served, despite it being listed on the menu, due to the Dietary Manager forgetting to include it. For residents requiring mechanical soft diets, the facility did not prepare the chicken nuggets according to the mechanical soft recipe, which required the nuggets to be ground with gravy. Instead, residents on mechanical soft diets were served whole chicken nuggets, not in the required texture. The Dietician confirmed that recipes and menus were not followed, and that water and bread crumbs should not have been used unless specified in the recipe. The facility's policy states that menus are to meet nutritional needs and be prepared as planned, but these procedures were not followed, resulting in residents not receiving meals consistent with their dietary requirements.

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