Pureed meals were prepared without standardized recipes or measured ingredients for eight of eight residents on a pureed diet. A cook blended chicken salad with unmeasured water, bouillon seasoning, and thickener, then added more water while checking consistency by sight. The cook stated she had never used a recipe in eight years at the facility, and the Dietary Manager confirmed recipes were not used for puree meal preparation.
A facility failed to follow puree recipes for meals served to residents receiving pureed diets. Staff used a yellow scoop that was too small for pureed mashed potatoes, meat, and mixed vegetables, resulting in portions that were smaller than the recipe specifications, and a Cook/Dietary Aide added water to pureed cinnamon rolls instead of following the recipe calling for milk and commercial thickener with chilling to 41 degrees F or below. The RD and CDM confirmed the portion sizes and preparation did not match the recipes.
A resident with severe cognitive impairment and a diagnosis of protein calorie malnutrition was not served the lunch meal as written on the facility menu or tray slip. Instead of chicken parmesan, the resident received plain steamed chicken, despite staff and family confirming the discrepancy. Both the Administrator and DOD acknowledged the resident should have received chicken parmesan without sauce, as is the usual practice for residents preferring no sauces.
A facility failed to follow the puree menu for all residents receiving a puree diet, with dietary staff preparing Chicken and [NAME] Casserole by pureeing a large pan of the item and adjusting consistency during meal prep. The facility also failed to follow one resident’s ordered NAS/renal diet with no potatoes or bananas; the resident reported receiving restricted foods and not getting large portions, and an observed breakfast tray included one-half banana despite the diet order.
Pureed Diet Menus Not Followed: Staff did not serve pureed meals as listed on the menu for residents on pureed diets. During breakfast observations, DAs served items such as pureed eggs, cream of wheat, and pureed oatmeal instead of the menu items called for, and the DM stated she was unaware the menus were not being followed.
Puree Diet Menu Not Followed: Dietary staff did not follow the posted puree recipes when preparing meals for five residents on a puree diet. An LPN-equivalent dietary staff member prepared Philly steak filet and dinner rolls using amounts and serving sizes that did not match the menu, and the DKM confirmed the kitchen reduced the number of servings to equal seven residents instead of following the recipe directions.
The facility did not ensure menus were prepared in advance with required details such as serving sizes and diet-specific modifications. After a kitchen fire, staff relied on emergency menus but failed to provide clear documentation or guidance for dietary modifications and portion sizes. Residents received meals that did not match planned menus, and dietary staff lacked instructions for preparing meals according to individual diet orders, placing all residents at risk of nutritional issues and dissatisfaction.
Surveyors found that the facility did not consistently follow prescribed menus or provide adequate menu variety. A resident with severe cognitive impairment and a pureed diet order was served meals with incorrect textures and items not matching the menu. Multiple residents reported receiving repetitive side dishes, especially vegetables and potatoes, over several days. Dietary staff and the RD demonstrated a lack of oversight and communication regarding menu adherence, and the facility lacked a written menu policy.
A resident with intact cognition and a documented dislike for broccoli was served broccoli at lunch, despite the facility's policy to honor food preferences. The resident reported not being asked about menu choices and regularly receiving unwanted foods.
Several residents with intact cognition reported not being offered meal choices when eating in their rooms, receiving only the meal provided or a peanut butter and jelly sandwich as an alternative. Observations showed discrepancies between posted menus, tray tickets, and actual meals served, with residents not informed of their options. The Dietary Manager and Administrator confirmed these practices did not align with facility policy.
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