F0803

D

Failure to Follow Planned Menu and Portion Sizes Resulting in Substitute Entrées Without Resident Choice

Highwood, Illinois Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow the planned noon meal menu and portion sizes, resulting in two residents not receiving the scheduled turkey casserole meal. During observation of the noon meal service, the cook used a white 6 oz scoop to plate turkey casserole and chopped carrots while staff verbally requested meal textures. The administrator went behind the steam table and also began plating, using heaping scoop portions that created a mound over the flat of the scoop. As the last room cart was being plated, the cook scraped the metal tray to fill the scoop and ran out of turkey casserole, despite believing the correct serving ladle was used. Staff informed the cook that two more plates were needed, and the cook plated hot dogs with carrots for those two meals instead of the planned entrée.

The dietary manager later confirmed that the facility ran out of turkey casserole and that two residents did not receive the regular meal, stating that the scoop sizes had been too large and should have been flat. One of the affected residents reported receiving a tray with a hot dog, believing it was the normal meal being served, and stated that a female staff member with long black hair, described as someone higher up, later told him they had accidentally given him the hot dog. The resident said he would have preferred the regular meal and felt he should have been given a choice of an alternative and informed that the facility had run out of the planned meal. The administrator confirmed that this resident was not informed of the shortage of turkey casserole and was not offered a choice from the alternative menu. The facility’s diet spreadsheet menu documented the turkey casserole portion size as 6 oz, with 4 oz soft chopped carrots and bread pudding as part of the planned meal.