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.
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.
Staff did not follow standardized recipes or correct portion sizes when preparing and serving meals, resulting in altered nutritional content for residents on pureed diets. The Dietary Manager confirmed the wrong scoop was used and could not verify that the nutritional needs of residents were met, as the intended recipe and serving sizes were not followed.
A resident with diabetes was not served cereal at breakfast as specified on their tray slips and the facility's planned menus. Despite clear documentation and staff acknowledgment that cereal should have been provided, the resident did not receive it on multiple occasions, and staff confirmed the omission. This failure to follow the planned menu could have affected the nutritional needs of all residents receiving meals from the kitchen.
The facility did not follow established menus and failed to notify the RD of meal substitutions, affecting residents on mechanical soft ground and puree diets. Instead of the posted menu, residents received meals with unapproved substitutions, such as brown gravy on chicken and mashed potatoes instead of puree cabbage. The RD was not informed of these changes, contrary to facility policy.
The facility failed to serve the meal listed on the cycled menu, affecting 115 residents. Instead of the listed ham and California vegetable blend, residents received a sloppy joe. Interviews and a photo confirmed the deviation, and the Administrator acknowledged the issue, noting sufficient ingredients were available.
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