Failure to Follow Menus and Provide Planned Meals
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received meals as planned, resulting in multiple deficiencies related to meal preparation and service. Observations revealed that dietary staff did not consistently use the correct portion sizes when serving food, such as not fully filling four-ounce scoops for broccoli and using three-ounce scoops instead of the required four-ounce scoops for pork. Staff interviews confirmed these inconsistencies, and the Dietary Director acknowledged that the wrong scoop sizes were used and that it was the cook's responsibility to ensure proper portions. Additionally, the facility did not provide items listed on the always available menu to residents who requested them. On one occasion, a resident requested a grilled cheese sandwich, which was listed as always available, but was not provided because the kitchen had run out of cheese. The Dietary Director confirmed that the item should have been available but was not due to a lack of ingredients. Another resident's meal ticket specifically requested a grilled cheese, but the item was not provided, and the resident reported that this mismatch between the meal ticket and what was served happened frequently. Further review of meal tickets and resident records showed that residents with specific dietary needs and orders did not receive the correct menu items. For example, one resident on a carb-controlled, pureed diet was served mashed potatoes instead of pureed sweet potatoes as ordered, and another resident on a no added salt, mechanical soft diet did not receive green beans as indicated on the meal ticket. Staff interviews and documentation confirmed that these discrepancies occurred, and residents reported dissatisfaction with the food and frequent mismatches between the menu and what was served.