Non-Compliance with Menu Planning and Nutritional Adequacy
Penalty
Summary
Embassy of Wyoming Valley was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B and the 28 PA Code regarding menu planning and nutritional adequacy. The facility failed to follow written planned menus for four of seven residents sampled, as evidenced by frequent menu changes and substitutions without proper notification or consent from the residents. Residents reported that the facility often ran out of food items and blamed supply issues, leading to unapproved meal substitutions and a lack of access to preferred menu options. Interviews with residents revealed dissatisfaction with the meal service, as they frequently received incorrect orders or substitutions without prior notice. Residents expressed concerns about the inconsistency of the "always available" menu, which was often not available, and the lack of weekly menus in their rooms. The Resident Council Meeting Minutes also documented ongoing issues with food supply shortages, including basic items like sugar, butter, milk, and coffee, but there was no evidence that these concerns were addressed by the facility. The facility's substitution records for November 2024 through January 2025 showed numerous instances where planned menu items required substitutions due to unavailable ingredients. The dietary manager confirmed that substitutions were frequently made due to incomplete deliveries from the food service supplier. The Nursing Home Administrator acknowledged the supply shortages and confirmed that the facility was unable to consistently follow the planned menus, resulting in unapproved meal substitutions and inconsistent meal service.
Plan Of Correction
The facility follows the written planned menus. Residents 14, 55, 27, and 56 were not harmed from the deficient practice, nor were the remaining residents. On 1/30/2025, a substitution was made as the food items on the menu did not arrive with the weekly order nor the makeup order the following day. All substitutions are approved by the dietician; all will be audited for appropriateness. The dietary department may "run out of an item," or an item may not have come in. The dietary department is in weekly contact with the vendor regarding missed items and will purchase locally any items that we do not have available for the next meal. Audits will be conducted weekly for 6 weeks of items needed to be purchased locally. Menu changes will be posted next to all menus as soon as a change needed is known. The Food Service Director has in-serviced staff on food substitutions, accurate ordering, and inventory. Surveys will be conducted with residents weekly for 8 weeks to assure they are getting the food items as per menus. Audits will be conducted weekly for 6 weeks by the dietician/FSS on any changes on the menu as well as shopping needs. Eight residents attended the recent food committee on 2/10/2025, with little concerns. Results of audits will be reviewed monthly at the Facility's QAPI meeting for 3 months.