Failure to Consistently Serve Meals According to Posted Menus
Penalty
Summary
The facility failed to consistently serve meals according to the posted menus, as required by regulations. Multiple residents reported that the meals served often did not match what was listed on the menu, with frequent substitutions and changes occurring without prior notice. Residents expressed frustration over the lack of variety, repeated substitutions, and the perception that cost-saving measures were prioritized over their dietary needs. Specific examples included changes such as substituting grilled cheese with deli meat sandwiches, replacing breakfast meats with eggs, and altering side dishes and desserts without explanation. Review of facility records confirmed numerous instances where the planned menu items were substituted with different foods across several weeks. These substitutions included changes to main entrees, side dishes, and desserts for multiple meals, often resulting in residents receiving meals that did not align with the posted or planned menus. The Dietary Manager's job summary indicated responsibility for planning menus with the dietitian, ensuring menus meet nutritional needs, and maintaining sufficient inventory, but the observed practices did not align with these responsibilities. Interviews with residents and facility staff further corroborated the inconsistency in meal service. Residents consistently reported dissatisfaction with the quality, quantity, and predictability of meals since a new company took over food service operations. The facility administrator acknowledged that dietary staff sometimes could not obtain the necessary food items and had to make substitutions, but did not perceive this as a frequent issue. The facility census indicated that all 76 residents were potentially affected by these deficiencies.