Failure to Post and Update Menus Following Meal Substitutions
Penalty
Summary
The facility failed to ensure that posted menus accurately reflected the meals served to residents and that menu changes were properly documented and communicated. On one occasion, the posted lunch menu listed braised beef tips, parsley noodles, seasoned carrots, wheat rolls, and Boston cream pie, but residents were instead served hamburgers with buns, lettuce, tomato, onion, pickles, and ice cream. The Dietary Manager explained that a new employee had used the meat intended for a different meal, leading to a last-minute substitution. Although residents were consulted about the substitute menu, there was no evidence that the menu changes were formally posted or that meetings regarding these changes were documented. Further review of the substitution log revealed additional instances where planned menu items were replaced with alternatives, such as potato salad being substituted with potato chips and salmon croquettes being replaced with pizza and salad. These substitutions were not promptly documented, and staff were unaware that posted menus should be updated to reflect changes. Additionally, for special occasions like Easter, planned menu changes were not communicated to residents or posted in advance. No additional evidence was provided by facility leadership to explain the lack of updated or posted menus in accordance with the changes made.