Failure to Employ Qualified Dietary Staff and Maintain Menu Standards
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, as required by regulation. Specifically, the Dietary Manager (DM) position was vacant after the previous DM left, and the Operations Manager (OM), who lacked the required certification and training, was serving as the interim DM. The OM also worked as a cook without having received any training for the DM or cook roles and had not consulted with the Registered Dietician regarding menu changes. Additionally, the facility did not employ a full-time dietician, and dietary staff had not received adequate training or demonstrated competency to serve as cooks. Record review and staff interviews revealed that the OM was responsible for ordering food and, due to insufficient ordering, the facility was unable to follow the preapproved/planned menus. Instead, available food from the freezers and storeroom was used as substitutes. The dietary schedule showed the OM frequently filled in as a cook due to staffing shortages, and the Interdisciplinary Team (IDT) assisted with dietary aide duties, receiving only limited training related to dishwasher safety and temperature logs. These deficiencies had the potential to affect all residents who consumed food prepared in the facility.