Failure to Follow Pre-Approved Menus
Penalty
Summary
The facility failed to adhere to pre-approved menus, as evidenced by resident interviews, facility documentation review, observations, and staff interviews. During a Resident Council interview, four residents reported that meal items were frequently substituted without prior notice. A review of the facility menus showed that on December 8, 2024, the lunch meal was supposed to include roasted potatoes, a dinner roll, and fruit pie, but residents received mashed potatoes, fruit ambrosia salad, and no dinner roll. On December 9, 2024, the menu indicated that fruit ambrosia salad should be served, but residents received applesauce instead. The Dietary Manager confirmed that the planned menu items were not served as intended.
Plan Of Correction
1&2 The pre-approved menus will be followed. If not, residents will be notified of substitutions via announcement & the daily posted menu. 3. The Director of Dining Services and dietary staff will be educated on following pre-approved menus. If substitutions are made, the residents will be notified via announcement & the daily posted menu. 4. The NHA and/or designee will complete weekly random audits x 90 days of posted menus and the substitution logs to ensure residents were notified. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.