Failure to Follow Prescribed Menus and Provide Menu Variety
Penalty
Summary
The facility failed to follow prescribed menus and provide adequate menu variety for several residents, as evidenced by observations, interviews, and record reviews. One resident with severe cognitive impairment, Alzheimer's disease, diabetes, and dysphagia was repeatedly served meals that did not match the pureed diet ordered by the physician and outlined in the care plan. Meals provided to this resident included regular textured foods and ground meats instead of pureed options, and the textures of pureed foods were inconsistent, sometimes being too firm. Additionally, the resident was served a frozen supplement that could not be consumed as intended. Multiple residents reported dissatisfaction with the lack of menu variety, particularly with vegetables and side dishes. Residents expressed that they were served the same types of mixed vegetables and potatoes multiple times within a week, leading to complaints about repetitive meals. The facility's menu records confirmed that similar vegetable blends and potatoes were served frequently over a short period. Interviews with dietary staff and the Registered Dietitian revealed a lack of oversight and communication regarding menu adherence and resident preferences. The facility did not have a written menu policy, and the new Dietary Manager was unfamiliar with the reasons for menu inconsistencies. Although the facility had a Performance Improvement Plan related to food palatability, it did not address resident complaints about repetitive menus or lack of variety.