Failure to Serve Menu-Listed Dessert During Meal Service
Penalty
Summary
Facility staff failed to prepare and serve meals in accordance with the posted menu, as observed during the lunch meal service on 6/24/25. Specifically, the dessert item, apple crisp, listed on both the menu and individual meal tickets, was not prepared or served to residents on all four units. Instead, residents received mixed fruit as dessert. The dietary manager was present during meal service and allowed the substitution without verifying or correcting the omission at the time. Upon inquiry, the dietary manager confirmed that the apple crisp was not prepared because the cook was absent due to a call out and ran out of time. Facility policy requires that menus be served as written unless changes are made in response to resident preference, unavailability of an item, or for special meals. No such justification was documented for this substitution. The deficiency was brought to the attention of the facility administrator and DON during an end-of-day meeting.