Failure to Follow Planned Menus and Meet Specialized Dietary Needs
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned menus, resulting in residents not receiving food that met their nutritional needs and specialized dietary requirements. Observations revealed that residents on pureed and mechanical ground diets were served meals that did not match the planned menu items or prescribed diet textures. Specifically, residents requiring pureed diets received pureed ground beef instead of pureed pepper steak, pureed carrots, mashed potatoes, and gelatin without fruit, omitting required items such as pureed Texas toast and fruited gelatin. Similarly, residents on mechanical soft diets were served chopped fried ground beef, whole carrots, Texas toast, and plain gelatin, instead of the specified chopped pepper steak, chopped carrots, and gelatin with fruit. The preparation of these meals was not consistent with facility recipes or portion sizes, as the cook used unmeasured amounts of ingredients and substituted menu items without proper guidance. The Certified Dietary Manager (CDM) acknowledged discrepancies in portion sizes and substitutions, stating that she did not consult the Registered Dietitian (RD) due to his limited availability. The CDM also confirmed that the cook, who had only been employed for three weeks, did not follow facility recipes, and that there was insufficient beef steak and peppers available, leading to the use of ground beef as a substitute. Additionally, fruit was omitted from the gelatin dessert, contrary to the menu. A resident requiring a gluten-free diet was not provided with appropriate menu alternatives and was served standard menu items containing gluten. The CDM confirmed that there was no formal gluten-free menu and that the resident had to purchase her own gluten-free bread, with the facility only occasionally providing gluten-free pasta. The facility failed to follow planned menus and did not ensure that residents received meals in accordance with their prescribed dietary needs, as required by regulations.