Failure to Follow Planned Menu and Provide Complete Meal Trays
Penalty
Summary
The facility failed to follow their planned menu, as evidenced by observations and interviews with residents and staff. A facility policy dated November 25, 2024, required service staff to inspect food trays to ensure the correct meal was provided to each resident. However, on January 13, 2025, a resident's lunch tray was missing margarine for her roll, which she stated made her unwilling to eat it. The resident also reported that her meal trays routinely lacked sugar packets, condiments, napkins, or flatware. An interview with a nurse aide confirmed that no margarine was available on any trays in A wing, and the kitchen was contacted but had none available. Further interviews with a group of residents on January 14, 2025, revealed that they often did not receive the correct menu items or were missing items on their trays. The facility's written and printed menu for January 13, 2025, specified that residents were to receive beef meatloaf with glaze, green beans, scalloped potatoes, a buttered dinner roll, margarine, pound cake, and a choice of beverage. However, the dietary manager confirmed that while the kitchen had margarine available, it was not placed on the trays. The facility did not have individual packets but could provide small lidded cups of margarine, which were not utilized by the kitchen staff.
Plan Of Correction
1. The Dietary Manager immediately educated line staff on the importance of adding the condiments that are listed on the menu. 2. The dietary department will add an extra bowl of condiments to each tray cart sent to the units to ensure there is extra available. 3. The Dietary Manager or designee will review the Food Preparation and Service Policy and Menus. The Dietary Manager or designee will educate the Dietary staff on the importance of following the menus as listed to include condiments. 4. The Dietary Manager or designee will randomly audit daily for 4 weeks, then weekly for 3 months to ensure that the food delivered to residents matches the menu posted. The Dietary Manager or designee will report the results of this audit monthly to the Quality Assurance Performance Improvement (QAPI). 5. The completion date will be 03/5/202.