F0803

D

Failure to Follow Menu and Provide All Planned Food Items for a Pureed Diet

Sun Valley, California Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in which the facility failed to follow the planned menu and provide all menu items to a resident receiving a regular diet with pureed texture. The resident had diagnoses including septo-optic dysplasia of the brain, multiple congenital malformations, and a tracheostomy, and an MDS showing moderately impaired cognition with a need for staff assistance with eating and oral hygiene. The facility’s weekly menu for the relevant lunch meal listed a turkey burger on a hamburger bun with lettuce leaf, tomato slices, sweet potato fries, pea and cheese salad, chilled peaches, and 1% milk. However, the resident’s meal card for that lunch only listed turkey burger, peas, peaches, and water.

During kitchen observations, the Dietary Supervisor (DS) prepared and pureed a turkey patty, peas, and peaches, and then assembled the resident’s tray with only those three pureed items. When the tray was later observed in the resident’s room, it did not include a hamburger bun, lettuce leaf, tomato slices, sweet potato fries, pea and cheese salad (including cheese), or 1% milk as specified on the menu. In interview, the DS stated she did not serve the bun because she believed the resident did not like bread, but acknowledged there was no documentation of this preference in the resident’s nutritional assessment and that the bun should have been served because it was on the menu. The DS further stated she did not serve the lettuce, tomato slices, sweet potato fries, or cheese with the peas because she had not checked the menu and was in a rush, despite facility policy requiring foods to be prepared according to the menu and the DFNS to supervise meal preparation and service to assure the menu is followed and diet orders are implemented.