F0803

E

Failure to Follow Dietician-Approved Menus and Provide Ordered Diet Textures and Preferences

West Salem, Wisconsin Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its planned menus and ensure meals met residents’ nutritional needs and preferences as written and approved. Surveyors reviewed the facility’s week three menus and observed multiple meals where items listed on the menu were not served. For one dinner, the posted menu included minestrone soup, grilled cheese, French fries, lettuce, tomato, onion, apple slices, ketchup, margarine, and 2% milk and/or coffee, but residents actually received minestrone soup, grilled cheese, canned pears, and a choice of 2% milk, coffee, or juice, with no French fries, lettuce, tomato, onion, or apples provided. For a lunch meal, the menu listed chili with beans, baked potato, sweet potato cornbread, red grapes, sour cream and chives, margarine, and 2% milk, coffee, or tea, but residents received chili with beans, baby baked potatoes, sweet potato cornbread or a dinner roll, red grapes, and beverages, with no sour cream and chives served. For a supper meal, the menu listed corn dogs, creamy coleslaw, banana, margarine, and beverages, but residents received corn dogs, tater tots, coleslaw, sugar cookies, and beverages, with no banana served.

Staff interviews confirmed that menus were routinely altered without adherence to the written, dietician-approved menu and without appropriate substitutions being reviewed. A cook reported that the facility did not usually order regular baking potatoes because of their size and instead used baby baked potatoes, and that sour cream and chives were usually not included. The Administrator stated that the facility relied on a whiteboard as the working menu and that it was labeled as subject to change. The Dietary Manager stated that menu items varied based on supply and ordering issues and acknowledged being unaware that a registered dietician needed to approve menu adjustments to ensure residents received appropriate amounts and types of food within the same food groups. Residents in a group interview reported they were not provided with the actual facility menu, only what was written on the dry erase board, and that alternates were not posted. They stated they were unaware that French fries and lettuce, tomato, onion, and ketchup were supposed to be part of a prior dinner meal, expressed that they liked French fries and would have wanted them, and noted that pears were served frequently and that no alternate fruit was offered when they did not like pears.

The deficiency also included failure to provide an individual resident with meals consistent with her ordered diet texture, care plan, and preferences. One resident with dementia, chronic and acute kidney disease, cellulitis, and a severely impaired BIMS score was care planned as being at risk for significant weight loss and ordered a regular chopped diet with thin liquids, with all foods to be served in bite-sized pieces and requiring setup/cleanup assistance and indirect supervision during meals. Her tray card indicated a soft and bite-sized regular diet with no recorded dislikes. During a lunch observation, the posted whiteboard menu listed chili with beans, baby baked potato, cornbread/dinner roll, and grapes. The resident was served chili, a whole bread roll, and whole grapes; after refusing chili, she was given chicken noodle soup but did not receive any potatoes. She ate the whole roll and whole grapes quickly and independently without staff interaction. In a subsequent interview, the Dietary Manager, DON, and Administrator agreed that the roll should have been cut into bite-sized pieces, the resident should have received bananas instead of grapes, and potatoes should have been served, and confirmed that the facility was expected to provide a diet meeting the resident’s needs and that dislikes or allergies should be documented on the tray card.