Failure to Follow Menus and Ensure Consistent Meal Service
Penalty
Summary
The facility failed to ensure that menus met residents' nutritional needs, were prepared in advance, and were followed as required. Staff interviews and observations revealed that food service staff did not use proper serving sizes or utensils, with cooks admitting to guessing portion sizes and serving inconsistent amounts of food. Production sheets and serving size documentation were not available when requested by surveyors, and serving scoops were not filled completely. During meal service, some residents received less than the intended portion of chicken, and the kitchen ran out of key menu items such as chicken and broccoli, leading to unapproved substitutions without Registered Dietician consultation. Additionally, the current menu was not posted, and residents were not informed of menu changes, with posted menus often not matching what was served. Resident Council meeting minutes over several months documented ongoing concerns about food quality, portion sizes, menu substitutions, and lack of communication regarding menu changes. Residents reported not receiving meals as listed on the menu, dissatisfaction with food temperature and toughness, and unfulfilled scheduled events such as cookouts. The facility's own policies required that all substitutions be noted and menus be updated, but these procedures were not followed, as evidenced by both staff and resident reports and direct surveyor observation.