145247
10/08/2024
Doctors Nursing & Rehab Center
1201 Hawthorn Road Salem, IL 62881
F 0803
Level of Harm - Minimal harm or potential for actual harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review, the facility failed to follow the menu and diet orders for 6 of 6 (R2, R3, R5, R6, R7 and R8) residents reviewed for menus meeting resident needs in the sample of 8.
Residents Affected - Some The Findings Include: On 10/3/2024 at 11:53 AM, R5 who was alert and oriented to person, place and time, stated he did not get any eggs or double meat with his breakfast this morning. R5 stated, today he had one biscuit and gravy. R5 stated, he does not normally get eggs or double meats for breakfast at all. On 10/08/2024 at 7:26 AM during breakfast meal observation, V14 (Cook) stated, they are serving biscuits and gravy, super cereal, and oatmeal for breakfast today. V14 stated, the kitchen had run out of meats and eggs for breakfast this morning. V14 stated, the delivery truck will be in around 11:30 AM today with those items. V14 stated, normally residents who are supposed to have eggs or double protein at breakfast will get a yogurt or one teaspoon of peanut butter added to cereal as a substitute for not getting eggs or a meat for breakfast. V14 stated, R2, R3, R5, R6, R7 and R8 did not get any substitutes today, because the kitchen is out of yogurt, and she did not put a teaspoon of peanut butter in the resident cereals when serving their meals. V14 stated, she did not discuss substitutions with V15 (Dietician) today. On 10/8/2024 at 7:46 AM, V13 (Dietary Aide) stated, the resident's menu for today does document a choice of eggs and breakfast meat. V13 stated, the kitchen had run out of eggs and breakfast meats and the delivery truck will not be here until 11:30 AM today with those items. V13 confirmed R2, R3, R5, R6, R7 and R8 did not get a substitution for eggs or double protein today at breakfast. V13 stated, the kitchen had run out of yogurt as well and no peanut butter had been added to residents' cereal this morning. On 10/8/2024 at 7:52 AM, R2 who was alert and oriented while eating breakfast in her room stated she did not get any eggs or double meat with her breakfast this morning. On 10/8/2024 at 7:54 AM, R5 who was alert and oriented while eating breakfast in his room stated he did not get any eggs or double meat with his breakfast this morning. On 10/8/2024 at 10:01 AM, V15 (Dietician) stated if the kitchen runs out of an item for a meal services, then the kitchen should replace the item with another item that is an equivocal value to the missing item. V15 stated, if the kitchen did not have eggs or a breakfast meat to serve than the kitchen should have substituted with yogurt or peanut butter. V15 stated, she had not been aware the
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145247
145247
10/08/2024
Doctors Nursing & Rehab Center
1201 Hawthorn Road Salem, IL 62881
F 0803
kitchen had run out of breakfast items today.
Level of Harm - Minimal harm or potential for actual harm
On 10/8/2024 at 10:35 AM, V1 (Administration) stated if the kitchen is out of an item, then it should be substituted with an item of the equivocal nutritional value.
Residents Affected - Some
On 10/8/2024 at 11:06 AM, V4 (Dietary Supervisor) stated, R3 did not have eggs or double protein listed on his dietary card for breakfast. V4 stated, V1 (Administrator) did add these items on after breakfast today when V1 found the orders were not listed on R5's dietary card. The menu for 10/08/24 was listed as: choice of cereal, eggs of choice, biscuits and gravy, jelly, margarine, orange, apple or cranberry juice, milk, coffee/tea. 1. R2's current physician order report lists diet order as: regular, thin liquids: double meat or eggs at all meals: offer 3 eggs at breakfast. R2's breakfast meal card, dated 10/8/2024, documented under preferences 3 eggs daily, double eggs or meat. 2. R3's current physician order report lists diet order as: regular; add double meat or eggs at breakfast. R3's breakfast meal card, dated 10/8/2024, documented under preferences double meat. 3. R5's current physician order report lists diet order as: regular; double meat or eggs at breakfast. R5's breakfast meal card, dated 10/4/2024 and 10/8/2024, did not document under preferences eggs or double meat at breakfast. 4. R6's current physician order report lists diet order as: mechanical soft; double meat or eggs at breakfast and supper. R6's breakfast meal card, dated 10/8/2024, documented under preferences double meat, boiled eggs. 5. R7's current physician order report lists diet order as: regular; thin liquids; double meat or eggs at breakfast. R7's breakfast meal card, dated 10/8/2024, documented under preferences double meat or egg. 6. R8's current physician order report lists diet order as: regular; thin liquids; double meat/eggs in am. R8's breakfast meal card, dated 10/8/2024, documented under preferences double protein or eggs. The facility policy titled Menus (December 2016) documents under Policy Menus shall be followed, which have been written, reviewed for nutritional adequacy and approved by a Registered Licensed Dietician (RDLD) in compliance with Federal and State Regulations and consistent with Standards of Practice on nutritional care. This same policy documents under Procedure step 4 Changes which occur due to shortage of stock, etc. shall be reviewed with the RDLD.
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