F0803

F

Failure to Follow RD-Planned Menus and Provide Appropriate Nutritional Substitutions at Breakfast

Springfield, Ohio Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow menus planned by the Registered Dietitian (RD) and to provide the specified foods and nutritionally appropriate substitutions to residents. Menu spreadsheets for multiple days showed that all diets were to receive two ounces of scrambled eggs at breakfast, with residents on cardiac diets to receive an egg substitute product and no bacon. Review of temperature guides and menu spreadsheets showed either no notation of substitutions or inaccurate documentation of substitutions. Observations and interviews confirmed that on several days residents did not receive eggs or egg products as planned, and there was no documentation of appropriate substitutions.

Multiple residents reported not receiving eggs on the specified days and instead receiving small portions of toast and bacon, with one resident stating the portion was not enough food and that he wanted some type of protein. A resident on a cardiac diet reported receiving bacon, which he was not supposed to have, and stated he should have received an egg substitution product when eggs were on the menu. Staff interviews, including a CNA and a housekeeper, corroborated that residents on the skilled unit did not receive eggs or milk on certain days and instead received limited portions of toast and bacon, with no other protein on the breakfast trays. Dietary staff confirmed that there were no eggs in the kitchen to prepare and that bacon was used as a substitute for eggs, and that only about half of the residents received milk on one of the days because the kitchen ran out.

Dietary staff, including diet aides, a diet manager, and another kitchen staff member, stated they did not have a listing of appropriate protein substitutes and believed bacon was a protein substitute for eggs. They also reported that the specialized diet spreadsheet was not used during meal service as a reference, and that the meals were not served from the spreadsheet of specialized diets. The RD verified that bacon was not a nutritionally equivalent substitution for egg protein and that cooks should follow the approved spreadsheet for specialized diets. Additionally, on another day, the menu spreadsheet indicated that all diets were to receive mandarin oranges at breakfast, but observations showed that no residents received mandarin oranges except those on pureed diets, who received applesauce. Dietary staff confirmed there were no mandarin oranges available, no time to prepare another substitute, and that no other fruit was provided in place of the mandarin oranges for most residents, despite facility policy requiring menu changes and substitutions when items are not available for service.