Failure to Follow Menu and Serve Required Bread and Margarine at Lunch
Penalty
Summary
During a lunch meal service, 25 residents residing in [NAME] Run Cottage were not served bread or margarine as required by the facility's posted menu for that day. Continuous observation confirmed that neither bread nor margarine was provided to these residents. Staff interviews revealed inconsistencies in the process: the Assistant Activities Director did not include bread on the menu sign and did not offer it to residents, and the kitchen did not send bread for the meal. Additionally, a staff member responsible for preparing pureed diets admitted to not pureeing bread for residents requiring such diets, stating she felt the menu already had enough items and typically followed the menu only if she deemed it necessary. Further interviews with dietary and nursing staff confirmed that bread was inconsistently sent and offered, with some staff indicating it was only provided every other day. The Certified Dietary Manager and the Administrator both acknowledged that the facility's expectation was for bread and butter to be served to all residents, including those on pureed diets, and that the menu should have been followed as written. Review of facility policy and menu documents confirmed that bread and margarine were required components of the meal, and the failure to serve them resulted in the residents not receiving meals that met their planned nutritional needs.