Failure to Follow Menus and Provide Required Meal Components
Penalty
Summary
The facility failed to follow its posted menus and standard recipes for two consecutive lunch meals, resulting in residents not receiving the food items as planned or appropriate substitutions. On one occasion, residents were served baked potatoes without the required sour cream, despite the menu and recipe specifying its inclusion. Multiple residents expressed dissatisfaction during a group meeting and directly to the surveyor, noting the absence of sour cream and the lack of adherence to the menu. Observations confirmed that the lunch meal did not include the specified condiment, and residents' requests for sour cream went unmet. On another occasion, the facility served baked ziti with plain tomato sauce instead of the required meat sauce, as the meat was not thawed in time and no substitute protein was provided. Residents interviewed during this meal reported the pasta lacked flavor and meat, indicating a deviation from the planned menu and recipe. The Food Service Director acknowledged the failure to provide the correct meal components and did not notify administration or the dietitian in time to arrange for an alternative. The dietitian confirmed the importance of the missing protein and was unaware of the change prior to meal service.