Improper Portioning of Ground Chicken Salad on Diet Tickets
Penalty
Summary
The facility failed to ensure residents received proper portion sizes as specified on diet tickets during meal service. A resident with Alzheimer's disease and diabetes mellitus, admitted on 5/28/25, had an annual MDS assessment indicating moderate cognitive impairment and a need for setup assistance with eating. Physician orders for March 2026 specified a regular diet with dysphagia advanced texture and thin liquids. During observation of the lunch tray line on 03/19/26 at 12:15 P.M., the resident’s meal ticket indicated they were to receive ground chicken salad using a #10 scoop (3.75 oz). However, staff member #107 plated the ground chicken salad using a #16 scoop (2 oz), then completed the tray and placed it in the food cart. At 12:17 P.M., when Dietary Aide #109 pulled the tray from the cart, staff member #107 verified that the scoop used was a #16 (2 oz) instead of the required #10 (3.75 oz). In an interview at that time, staff member #107 acknowledged the serving size should have been three ounces and consulted the scoop chart, which confirmed the #16 scoop was only two ounces. The undated chicken salad recipe also specified that a #10 scoop of chicken salad should be placed between two slices of bread. In a later interview at 1:30 P.M., the Dietary Manager stated she believed staff member #107 was nervous and acknowledged she should have checked the serving utensils prior to tray service. This failure affected the identified resident and had the potential to affect eight other residents scheduled to receive ground chicken salad.
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