Failure to Follow Therapeutic Diet Menus and Portion Sizes
Summary
The facility failed to ensure that therapeutic diets were provided according to the prescribed menu and physician orders during lunch meals on two consecutive days. Specifically, three residents on a Consistent Carbohydrate (CCHO) diet received pineapple Bavarian cream square instead of the prescribed pineapple tidbits, and another resident on the same diet received pudding instead of the correct CCHO dessert. The facility's menu spreadsheet indicated that pineapple tidbits should have been served, and both the Certified Dietary Manager (CDM) and Registered Dietitian (RD) confirmed that the observed desserts did not comply with the menu requirements for CCHO diets. Additionally, during a meal service, fifteen residents on fortified diets did not receive the required super soup, which is intended to provide extra calories and nutrients for those unable to consume adequate amounts of food. The menu spreadsheet specified that super soup should be provided for fortified diets, but it was omitted during the meal service. Furthermore, two residents on large portion diets received only three ounces of meat instead of the four ounces specified in the menu spreadsheet. The RD explained that large portion diets are necessary for residents who need more protein or have specific preferences, and the correct portion size is essential to meet their nutritional needs. These failures were observed during direct dining and meal service observations, and were acknowledged by both the CDM and RD. The facility's own diet manual and job descriptions for dietary staff require strict adherence to menu specifications and portion sizes for therapeutic diets. The deficiencies had the potential to compromise the medical and nutritional status of a significant number of residents who received meals from the facility's kitchen.
Plan Of Correction
Corrective Action for Affected Residents: On 4/23/25, the Registered Dietitian reviewed the nutritional status of Residents 11, 21, 35, and 17 who received incorrect CCHO desserts, and Residents 1, 2, 3, 7, 15, 18, 20, 21, 25, 28, 30, 38, 39, 41, and 396 who did not receive super soup for fortified diets, and Residents 6 and 17 who received incorrect portion sizes. No adverse effects were identified. The Certified Dietary Manager immediately corrected portion sizes and therapeutic diet components for all affected residents. Identifying other Residents having the Potential to be Affected: On 4/23/25, the Registered Dietitian conducted a comprehensive review of all residents receiving therapeutic diets to ensure proper menu items and portion sizes were being provided. The CDM reviewed all current therapeutic diet orders against the menu spreadsheet to ensure alignment. Measures put into place or Systemic Changes: 1. The CDM will in-service all dietary staff: - Proper portion sizes for therapeutic diets - Following menu spreadsheets accurately - Importance of therapeutic diet compliance - Proper documentation of menu substitutions 2. Kitchen staff will measure protein portions using standardized serving utensils and scales to ensure accurate portions. Plan to Monitor Performance: 1. The CDM or designee will audit 10 therapeutic diet trays daily for 2 weeks, then 3x/week for 2 weeks, then weekly for 1 month to ensure compliance with menu spreadsheet and proper portions. 2. The RD will conduct weekly random audits of 5 therapeutic diet trays for 4 weeks, then monthly for 2 months. 3. Results of all audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee quarterly by the Food Service Director. The QAPI committee will analyze data for patterns and trends and make recommendations for continued monitoring or modification of plan as needed until substantial compliance is achieved and maintained. All corrective action to be completed by 5/26/25. 2. The Maintenance Supervisor will be in-serviced by the CDM on proper ice machine cleaning procedures per manufacturer's guidelines. 3. The Director of Nursing will in-service all nursing staff on proper temperature monitoring and documentation for resident unit refrigerators/freezers. Plan to Monitor Performance: 1. The CDM or designee will conduct weekly audits for 4 weeks, then monthly for 12 months of: - Ice machine cleanliness - Equipment condition - Food storage practices - Temperature logs - Food labeling compliance 2. The Director of Nursing or designee will audit resident unit refrigerator/freezer temperature logs daily for 4 weeks, then weekly for 12 months. 3. Results of all audits will be reported to the Quality Assurance Performance Improvement (QAPI) Committee quarterly for review and additional interventions as needed until substantial compliance is achieved and maintained for 3 consecutive months. All corrective action to be completed by 5/26/25.
Penalty
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The facility did not follow its menu and portion control procedures for residents on mechanically altered diets, as a dietary aide served mechanically altered beef stroganoff using a #12 scoop and provided only one scoop instead of the required portion. The diet extension sheet and scoop size chart showed that a larger #6 scoop, or two #12 scoops, was needed to meet the planned serving size, but three residents on mechanically altered diets received less than the specified amount of meat. The regional dietary manager and the dietary aide confirmed the incorrect scoop size and portion used, contrary to facility policy requiring appropriate portions to ensure nutritional adequacy.
Staff did not follow the RD-planned renal diet menu when preparing meals for multiple residents on renal diets. During a lunch meal service, a staff member served pasta salad in a self-selected portion size and prepared grilled cheese sandwiches using American cheese instead of the Swiss cheese required for renal diets. The menu for the renal diet included pasta salad but did not specify a portion size, and facility policy stated that renal diet residents were allowed Swiss cheese and should avoid American cheese. The Diet Manager confirmed that the pasta portion size should have been clarified by the RD and that the incorrect cheese type was used.
Surveyors found that dietary staff were inaccurately measuring food portions because they misunderstood scoop sizes and lacked appropriate measuring tools. One staff member consistently used a size 16 scoop, believing it provided three ounces of meat for mechanical soft diets, when it actually provided only two ounces, contrary to the written menu and a posted scoop chart. Additionally, potato portions for both regular and modified diets were served using a spaghetti-style utensil or by hand with gloves, without any measurement to ensure the ordered four-ounce portions. These practices affected multiple residents on mechanical soft and regular diets and showed that prescribed menu portions were not being followed.
Surveyors found that residents with orders for large meal portions were not consistently receiving 1.5 times the standard portions as required by facility policy. Over multiple Resident Council meetings, residents repeatedly complained about not getting enough food, not receiving what was ordered, and menus not matching what was served. During an observed lunch service, the Dietary Manager provided two servings of the main entrée for large-portion diets but only standard 4 oz servings of side dishes, and two residents on large-portion diets were seen receiving only single portions of sides. The Regional Dietary Manager confirmed these meals did not meet the ordered large-portion requirements, and the Dietary Manager admitted she misunderstood the policy, thinking it meant only a double entrée rather than increased portions of all components. A diet order report showed that this practice had the potential to affect 34 residents receiving large portions.
Surveyors found that residents on pureed diets did not receive the same planned menu items as those on regular diets, despite orders for regular diets with pureed texture and, in some cases, nutritional supplements and adaptive equipment. During an evening meal, pureed plates contained generic green, orange, and beige purees and ice cream instead of the scheduled oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake, while other diners received the full regular-texture menu. Dietary staff reported that a broccoli blend was substituted for the listed asparagus and that no pureed cake was prepared, even though asparagus could have been pureed and facility policy required verification that each resident received the correct diet and consistency.
A resident with Alzheimer's disease and DM, on a regular diet with dysphagia-advanced texture and thin liquids, was served an incorrect portion of ground chicken salad when dietary staff used a #16 scoop (2 oz) instead of the #10 scoop (3.75 oz) specified on the diet ticket and in the recipe. During lunch tray line service, the staff member plated the smaller portion and sent the tray to the cart, and the error was only recognized when the tray was later pulled. The dietary manager later acknowledged that serving utensils had not been checked before tray service, and this error had the potential to affect multiple residents receiving the same menu item.
Incorrect Portion Sizes for Mechanically Altered Meat
Penalty
Summary
The facility failed to ensure that menus were followed and that residents on mechanically altered diets received the correct portion size of meat as planned on the menu. During observation of the lunch tray line, a dietary aide was seen serving mechanically altered beef stroganoff using a green-handled #12 scoop and providing only one scoop per meal to residents on mechanically altered diets. The diet extension sheet specified that mechanically altered meat was to be served with a #6 scoop, and the facility’s scoop size chart showed that a #12 scoop provides 2.78 ounces while a #6 scoop provides 4.66 ounces. The regional dietary manager confirmed that when using a #12 scoop, two scoops should have been given to meet the required portion size, and the dietary aide acknowledged that only one scoop had been provided to each resident receiving mechanically altered beef. Record review confirmed that three residents were on mechanically altered diets at the time, and facility policy on portion control required that residents receive appropriate food portions to ensure nutritional adequacy. This deficiency represents non-compliance investigated under the cited complaint numbers related to failure to provide correct serving sizes for mechanically altered meat for three residents receiving mechanically altered diets.
Failure to Follow RD-Planned Renal Diet Menu and Portion Specifications
Penalty
Summary
The facility failed to implement the renal diet menu as planned by the Registered Dietitian (RD) for 15 residents on renal diets. During a lunch meal service, a staff member plated pasta salad for residents on renal diets using a #16 scoop and prepared grilled cheese sandwiches for these residents using American cheese. The Diet Manager confirmed that residents on renal diets should have received Swiss cheese instead of American cheese, in accordance with facility policy stating that residents on renal diets were allowed Swiss cheese and should avoid American cheese. The lunch menu for the renal diet included pasta salad but did not specify a portion size, and described a grilled cheese sandwich made with two slices of bread and three slices of Swiss cheese. Because the menu did not indicate a portion size for the pasta salad for the renal diet, the staff member chose a portion size based on personal judgment, and the Diet Manager acknowledged that the appropriate renal pasta portion should have been clarified by the RD. This deficiency affected 15 facility-identified residents receiving renal diets out of a total facility census of 119 residents. The observations, staff interviews, and review of the facility menu and policy showed that the menu lacked specific renal diet portion guidance and that staff did not follow the renal cheese type specified by policy and the RD-planned menu.
Inaccurate Portion Control and Lack of Measuring Tools in Dietary Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure menus were followed with accurate portion sizes due to inadequate staff training and lack of proper measuring tools. During an evening meal service, a dietary staff member used a size 16 scoop for mechanical soft meat, repeatedly identifying it as three ounces, while a chart on the wall and the Dietary Manager confirmed that a size 16 scoop equaled only two ounces. The menu required three ounces of meat for residents on mechanical soft diets, but a three-ounce scoop could not be located. The staff member reported she had worked at the facility for 4.5 years and had always believed, based on prior instruction, that the size 16 scoop was three ounces. This error directly conflicted with the posted scoop chart and the written menu requirements. Further observations showed that residents on regular diets were ordered four ounces of red skin potatoes, while residents on mechanical soft and low concentrated sweet diets were to receive four ounces of potato wedges, but no accurate measuring was performed for the potato portions. For the first tray, a utensil shaped like a spaghetti scoop was used to serve potato wedges, and for all other trays (except pureed diets), potato wedges were picked up by hand with a gloved hand without any measurement. The Dietary Manager stated she attempted to locate tongs for serving the wedges but could not find any. These practices affected residents receiving mechanical soft diets and those receiving regular texture food, as identified by the facility, and demonstrated that menus were not being followed with respect to prescribed portion sizes due to staff misunderstanding of scoop sizes and the absence of appropriate measuring tools.
Failure to Provide Ordered Large Meal Portions to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents ordered large portions received meals consistent with those diet orders and the facility’s own portion policy. Resident Council minutes over several consecutive months documented repeated resident complaints about not getting what they were supposed to get, not having enough food on their plates, and menus not matching what was served. During a lunch meal observation, the Dietary Manager served two servings of the main entrée for large portion diets but only one 4-ounce serving of each side item (baked beans and vegetables or rice and green beans), despite the facility policy defining a large portion as 1.5 times the standard portion for all components. Review of the diet order report showed that 34 residents were ordered large portions at meals. Surveyors observed that a resident on a large portion renal diet received one hamburger on a bun and single 4-ounce servings of rice and green beans, and another resident on a large portion regular diet received one sausage on a bun and single 4-ounce servings of baked beans and California blend vegetables. The Regional Dietary Manager confirmed these residents did not receive large portions as ordered. The facility’s policy on large, small, and double portions specified that large portions are a modest increase above the standard portion (1.5 times) and should be measured consistently using predetermined guidelines, such as 1.5 scoops instead of one scoop. The Dietary Manager acknowledged misunderstanding the policy, believing it meant a double entrée while still providing only standard portions of side items. The Activity Director, who began in December, confirmed that residents consistently complained in Resident Council about not receiving enough food. This deficiency was investigated under two complaint numbers and had the potential to affect 34 residents receiving large portions.
Failure to Provide Pureed-Diet Residents with Menu-Consistent Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that residents on pureed diets received the planned menu items in the prescribed texture, as required by facility policy and diet orders. Three residents with severe cognitive impairment and significant dependence for eating and ADLs were affected. One resident with Alzheimer’s disease, COPD, anxiety, dementia, and dysphagia had orders for a regular diet with pureed texture and nectar-thick liquids, plus a nutritional supplement before lunch and dinner. Another resident with Alzheimer’s disease, CAD, CHF, ESRD, type II diabetes, and anxiety had orders for a regular diet with pureed texture, use of a divided plate and sippy cup, and to be fed for all meals. A third resident with hypertension, insomnia, nontraumatic subarachnoid hemorrhage, and a history of repeated falls had orders for a regular diet with pureed texture and a magic cup with meals for weight loss. The daily menu for the observed evening meal listed oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake. Observation of a pureed meal showed mounds of green, orange, and beige purees and a nutrition supplement ice cream, while a regular-texture meal contained fried chicken, mashed sweet potatoes, and asparagus spears. Staff interviews revealed that the morning cook prepared a broccoli blend as the vegetable for the three residents on pureed diets instead of pureed asparagus, and that no pureed chocolate banana marble cake was prepared; ice cream was used as the pureed dessert instead. Dietary staff and another interviewee confirmed that residents on pureed diets were supposed to receive the same menu items as those on regular diets, except for preferences or allergies, and that asparagus could be pureed to an appropriate texture. The facility’s policy required staff to check trays before serving to ensure the correct diet and ordered consistency, but this was not followed for the affected residents on pureed diets.
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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