Failure to Follow Menus, Recipes, and Resident Preferences in Meal Service
Penalty
Summary
The facility failed to ensure that menus and recipes were followed as written, resulting in residents not receiving meals that met their documented nutritional needs and preferences. During breakfast meal observations, staff did not serve the breakfast sandwiches listed on the menu, instead providing items such as eggs, bacon, and oatmeal. Residents reported through interviews and resident council meetings that the meals served often did not match the posted menus, and this concern had been ongoing without resolution. The Dietary Manager confirmed that breakfast sandwiches should have been served, but staff chose not to prepare them, citing resident limitations and preferences without documented justification or menu changes. Further deficiencies were observed in the preparation of special diets, specifically puree diets. Staff did not follow the facility's puree egg recipe, instead blending scrambled and hardboiled eggs with unmeasured amounts of hot water, resulting in a product that was thick, chunky, bland, and gritty. The recipe book was not consulted during preparation, and the staff member was unsure of the quantities used. Similarly, oatmeal was prepared with unmeasured ingredients and insufficient cooking time, resulting in a thin, watery, and undercooked product. The oatmeal was not pureed for residents on puree diets as required by the recipe, and the staff member admitted to being pressed for time. Additionally, the facility failed to accommodate resident meal preferences as documented on meal tickets. One resident, who was supposed to receive fresh fruit with each meal, consistently did not receive it despite it being listed on the meal ticket and fresh fruit being available in the kitchen. The resident reported receiving the same breakfast daily without the requested fruit, and staff acknowledged that preferences should be followed when possible. These failures had the potential to affect all residents in the facility.