Failure to Serve Menu-Required Bread Items During Meals
Penalty
Summary
The facility failed to follow its posted menus, spreadsheets, and standardized recipes, resulting in residents not receiving all required food items during meal service. Observations on multiple occasions showed that residents on various diets, including regular, mechanical soft, and pureed, did not receive bread, Garlic Texas Toast, or appropriate bread substitutes as listed on the menu and required by the facility's dietary policies. Residents expressed dissatisfaction, noting that they would have liked to receive the missing bread items and that meal portions felt insufficient. Interviews with dietary staff revealed that the cook did not serve bread or bread substitutes at lunch, despite these items being listed on the menu and spreadsheets. The dietary manager confirmed that bread was not being served at lunch for about a year, based on instructions from a previous administrator, and that no menu substitute was provided. The Registered Dietitian was unaware that bread was being omitted and stated that all menu items should be served as planned to ensure nutritional adequacy. The facility's own policies and menu documents required bread or bread equivalents to be served at specific meals, and recipes for these items were available in the kitchen. Record review confirmed that all residents had dietary orders specifying their required diets, and the menu spreadsheets detailed the bread or bread substitute to be served for each diet type. The failure to provide these items was not discussed with the Resident Council, and the Registered Dietitian was not informed of the change. The deficiency affected all 93 residents receiving food from the facility's kitchen, including those on specialized diets such as pureed or thickened liquids.