Failure to Follow Menu and Provide Required Bread Item During Meal Service
Penalty
Summary
The facility failed to follow its posted menu for a lunch meal, resulting in the omission of garlic toast, a required menu item, for all residents, including two residents on therapeutic diets. Observations revealed that during meal preparation and service, dietary staff did not prepare or serve garlic toast as listed on the menu, nor did they provide a bread substitute. Staff interviews confirmed that garlic toast was not served due to supply issues, and no alternative was consistently provided. The Dietary Manager acknowledged the omission and indicated that supply shortages sometimes led to menu substitutions, but these were not always implemented. Two residents were specifically affected: one with severe cognitive impairment and a risk for weight loss, and another with moderate cognitive impairment and diabetes requiring a therapeutic diet. Both residents received their meals without the bread component as specified in the menu, and neither was offered a substitute. The facility's policy requires that residents receive a nourishing, well-balanced diet that meets their nutritional and special dietary needs, which was not met in this instance.