Failure to Follow Menu and Serve Correct Portion Sizes
Summary
The facility's kitchen staff failed to follow the menu to ensure residents were served the appropriate portion sizes of food during meals. This was evidenced by the kitchen staff using incorrect serving utensils for pureed, mechanically soft, and non-mechanically altered foods. Specifically, on two separate days, the staff used a #12 scoop (1/3 cup) instead of the required 1/2 cup for carrot souffle, mashed potatoes, pureed potato salad, and steamed rice. Additionally, chopped chicken and pureed fried chicken were served in incorrect portions, and bite-sized chicken was not measured but served using tongs. These actions were observed during meal service on 05/28/2024 and 05/29/2024, and the discrepancies were confirmed by the Dietary Manager (S2DM) and the cook (S4COOK) during interviews. The cook admitted to relying on memory for determining serving utensils and was unable to state the correct portion sizes or the capacity of the utensils used. The Dietary Manager acknowledged that the staff should use a chart on the kitchen wall to determine the correct serving utensils but verified that incorrect utensils were used during the observed meals. This deficiency had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 111 residents who consumed meals from the facility's kitchen. The facility's policy on dietary serving sizes was not adhered to, as the staff did not use the dietary menus provided by the food supply company to ensure the appropriate portion sizes were served. The failure to follow the menu and use the correct serving utensils was confirmed through observations, interviews, and menu reviews conducted by the surveyors.
Penalty
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Staff failed to follow written menus and individual meal tickets for several residents, including one with stroke and heart failure on a fluid‑restricted diet who received a biscuit instead of the ordered cornbread, another with a tracheostomy and diabetes on a mechanical advanced/chopped diet who was served an unchopped pork loin and a biscuit instead of the ordered dinner roll, and a resident with dysphagia and cerebral palsy who did not receive the cornbread portion listed on the meal ticket despite expressing a desire for more food to gain weight. The Dietary Manager reported that ordered bread items were unavailable due to missed food deliveries and that substitutions were not updated in the menu/meal ticket software.
Staff failed to serve residents the correct food portions as outlined in the facility's menu and production sheets, using incorrect serving utensils for Caesar salad, lasagna, and sliced carrots. The dietary manager confirmed that the portions served did not meet the documented requirements, and leadership was notified of the deficiency.
Staff did not serve the meal listed on the posted menu and failed to inform residents of the change, as the cook swapped the planned meal with another due to unavailable ingredients without notifying the dietary manager or updating the menu. Residents were not made aware of the change and reported that this had occurred on previous occasions.
A resident with advanced cancer and intact cognition did not receive her preferred plant-based diet as agreed upon, resulting in ongoing nausea and vomiting. The facility failed to update the care plan to reflect her dietary preferences, did not provide requested foods, and restricted her ability to store outside food, leading to unmet nutritional needs.
During a lunch meal service, staff did not prepare or serve the apple crisp dessert listed on the menu and meal tickets, instead providing mixed fruit to all residents on four units. The dietary manager allowed the substitution without proper justification, citing a staff call out and time constraints as reasons for the omission.
Staff did not follow posted menus or serve meals as indicated on residents' meal tickets, resulting in multiple residents not receiving the correct foods or portion sizes, including those on specialized diets such as heart healthy and diabetic diets. Substitutions were made without documentation, and beverages were inconsistently provided. Dietary staff and management were aware of ongoing resident complaints, and facility records confirmed repeated issues with menu adherence and lack of proper dietary accommodations.
Failure to Follow Menus and Meal Tickets for Diet Orders and Portions
Penalty
Summary
Facility staff failed to serve meals according to the written menu and individual meal tickets for multiple residents. One resident with stroke, renal failure, and heart failure, who had moderately impaired cognition and required setup assistance for eating, was observed at lunch receiving roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. The resident’s menu and personal meal ticket specified that cornbread, not a biscuit, should be served, and the meal ticket also documented a regular diet with a fluid restriction of 1200 milliliters per day and one 8‑ounce beverage. The Dietary Manager later stated that cornbread was not available because the food delivery did not occur as scheduled and that the substitute item was not updated on the menu or meal tickets due to software difficulties. Another resident with tracheostomy, diabetes, peripheral vascular disease, and heart failure, who had intact cognition and required setup assistance with eating, was ordered a mechanical advanced/chopped diabetic diet. The meal ticket for this resident specified chopped roasted pork loin, diced beets, mashed potatoes, a dinner roll, margarine, apple crisp, 2% milk, and hot coffee or tea. During observation of the lunch meal, the resident was served a whole slice of roasted pork with gravy instead of chopped pork, and a biscuit instead of the dinner roll listed on the ticket. The Dietary Manager acknowledged that the pork loin not being chopped was an error and again reported that dinner rolls were unavailable due to a missed food delivery and that the substitute item was not reflected on the menu or meal tickets. A third resident with dysphagia, mechanically altered PO intake, and cerebral palsy, who had intact cognition and was able to use utensils to eat once the meal was placed before him, reported wanting more food to gain weight and stated he was not receiving extra portions despite asking. Observation of this resident’s lunch tray showed roasted pork loin, pork gravy, diced Harvard beets, creamy mashed potatoes, a biscuit, and apple crisp. The resident’s meal ticket listed the same items but included cornbread, which was not present on the tray. The resident commented that the tray “comes like that sometimes” but reiterated his desire to gain weight. The Dietary Manager later stated there was no cornbread mix available, so a biscuit was served instead.
Failure to Serve Correct Food Portions According to Menu Requirements
Penalty
Summary
Facility staff failed to provide residents with the correct portion sizes of food as specified by the facility's menu and production sheets. Observations in the kitchen revealed that staff used incorrect serving utensils to plate Caesar salad, lasagna, and sliced carrots, resulting in residents receiving less than the required amounts. Specifically, a beige/off-white handle scoop holding three ounces was used for Caesar salad instead of the required one-cup portion, a grey handle scoop holding four ounces was used for lasagna instead of the required eight ounces, and a red handle scoop holding two ounces was used for sliced carrots instead of the required half-cup portion. The facility's menu and production count clearly documented the required serving sizes, and a disher size reference sheet was available in the kitchen. During interviews, the district manager for dietary confirmed that the serving utensils used did not match the required portion sizes and acknowledged that residents did not receive the correct amount of food for dinner. The executive director, vice president of operations, and regional director of clinical services were informed of these findings. No further information was provided prior to the survey exit.
Failure to Follow Posted Menu and Inform Residents of Meal Changes
Penalty
Summary
Facility staff failed to follow the posted menu for residents on both units, as observed during a lunchtime meal service. The posted menu listed Salisbury steak, steamed rice, squash, brown gravy, dinner roll, strawberry shortcake, condiments, and beverage of choice, but the meal served did not match this menu. The dietary manager reported that the cook changed the menu without informing him, swapping the planned meal with the next day's menu due to the ground beef not being thawed. The dietary manager was not made aware of the change until after the meal was prepared and served, and the posted menu was not updated to reflect the change. Residents interviewed stated they were not informed of the menu change and had expected the meal listed on the posted menu. Residents also reported that this was not the first time the posted menu was not followed and that they were not always informed of such changes.
Failure to Honor Resident's Plant-Based Dietary Preferences
Penalty
Summary
Facility staff failed to make reasonable efforts to honor and meet the meal choices and preferences of a resident who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, use of a nephrostomy tube, and bilateral lymphedema. The resident was cognitively intact and dependent on staff for most self-care activities, requiring setup assistance with eating. Despite a care plan identifying her risk for malnutrition and the need to identify food and beverage preferences, the resident reported ongoing nausea and vomiting over several days due to not receiving her preferred plant-based diet, which consisted mainly of beans, fresh vegetables, and fruit. The facility did not provide these preferred foods as previously agreed upon, and the resident's attempts to supplement her diet with outside food were hindered when staff discarded her purchased bean burritos due to storage policies. Additionally, the resident was informed she could not have a personal refrigerator in her room, further limiting her ability to store preferred foods. Interviews with facility leadership confirmed that the resident's person-centered care plan did not reflect her plant-based food preferences, and the dietary department had not consistently accommodated her nutritional needs as outlined in her care plan. The failure to update and follow the care plan and dietary preferences contributed to the resident's ongoing nutritional issues.
Failure to Serve Menu-Listed Dessert During Meal Service
Penalty
Summary
Facility staff failed to prepare and serve meals in accordance with the posted menu, as observed during the lunch meal service on 6/24/25. Specifically, the dessert item, apple crisp, listed on both the menu and individual meal tickets, was not prepared or served to residents on all four units. Instead, residents received mixed fruit as dessert. The dietary manager was present during meal service and allowed the substitution without verifying or correcting the omission at the time. Upon inquiry, the dietary manager confirmed that the apple crisp was not prepared because the cook was absent due to a call out and ran out of time. Facility policy requires that menus be served as written unless changes are made in response to resident preference, unavailability of an item, or for special meals. No such justification was documented for this substitution. The deficiency was brought to the attention of the facility administrator and DON during an end-of-day meeting.
Failure to Follow Posted Menus and Serve Prescribed Diets
Penalty
Summary
Facility staff failed to follow posted menus and serve meals as indicated, resulting in residents not receiving the foods listed on their meal tickets. Observations revealed that for both breakfast and lunch, the items served did not match the posted menus or the residents' meal tickets. For example, cranberry muffins listed for breakfast were not prepared or served, and instead, toast was substituted without documentation or use of a substitution log. Beverages, including milk, were not consistently provided with meals, and substitutions were made at the discretion of the cook without guidance or oversight. The cook admitted to making substitutions based on availability and did not maintain or reference a substitution log, as required by facility policy. During lunch service, further discrepancies were observed. The posted menu called for baked ham, carrots, scalloped potatoes, dinner rolls, and chocolate cake with chocolate frosting, but residents were served mixed vegetables, diced red potatoes instead of scalloped potatoes, yellow cake without chocolate frosting, and in some cases, no roll or milk. Residents on specialized diets, such as heart healthy or diabetic diets, did not receive the appropriate menu items or portion-controlled servings. For example, residents requiring a heart healthy diet were supposed to receive baked pork chops but were served ham instead. Diabetic residents received full portions of dessert rather than the required half portions, and when cake ran out, sherbet was substituted without documentation. Chopped meats were not prepared to consistent sizes, and dietary aides did not question discrepancies between meal tickets and what was served. Interviews with dietary staff, the registered dietician, and the activities director confirmed ongoing issues with menu adherence, lack of proper substitutions, and resident complaints about meals not matching posted menus or dietary needs. Resident council minutes and the grievance log documented repeated concerns from residents about these issues over several months. The registered dietician and activities director both acknowledged the lack of a functioning substitution log and ongoing communication problems with the contracted dietary company. Multiple residents were directly affected, including those with specific dietary orders, who did not receive meals as prescribed.
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