Failure to Follow Menus, Meal Tickets, and Maintain Substitution Logs
Penalty
Summary
The facility failed to ensure that menus were followed and that meal tickets matched the food served to residents, as well as to maintain an accurate and updated substitution log. For one resident with multiple diagnoses including malnutrition and moderate cognitive impairment, the meal provided did not match the meal ticket, and the resident reported that this was a recurring issue, often leaving her hungry. Observation and staff interviews confirmed that the kitchen did not typically follow the posted menu or meal tickets, and residents frequently complained about discrepancies between what was served and what was listed. Another resident, who was cognitively intact, reported not receiving menus for each meal and was unaware of what food would be served. Observation revealed that the lunch served did not match the scheduled menu, and the required substitution log did not document the change. The kitchen manager confirmed that meals did not always match the menu and that the substitution log was incomplete or missing. Diet tech audits further revealed that standard recipes were not being followed, menus and spreadsheets were not adhered to, and substitution logs were not available, with previous nutrition recommendations unaddressed.