Failure to Follow Menus and Dietary Orders for Residents
Penalty
Summary
The facility failed to ensure that menus and dietary orders were consistently followed to meet residents' nutritional needs. Multiple residents reported receiving meals that did not match their prescribed dietary orders or the posted menu. For example, one resident with a physician order for double portions due to weight loss did not consistently receive the correct portions, and on one occasion, was missing both milk and a beverage from his tray. Other residents reported receiving smaller portions than expected, missing menu items such as eggs or bread, and being served alternative items not aligned with their dietary needs or preferences, such as a grilled cheese sandwich instead of a ham sandwich for a lactose-intolerant resident. Observations and interviews revealed that these discrepancies were not isolated incidents but occurred across several meals and residents. The dietary manager and regional director of operations acknowledged that menu adherence was expected but cited issues such as supply shortages and delivery delays, which led to substitutions and incomplete meals. Resident council minutes also documented ongoing concerns about missing food items and portion sizes, indicating a pattern of unmet dietary needs within the facility.