Failure to Follow Approved Menu and Serve Correct Portion Sizes
Penalty
Summary
The facility failed to follow the approved menu by not providing the specified protein options and not serving the correct portion sizes to residents. On multiple occasions, residents were served scrambled eggs, hot cereal, and toast for breakfast instead of the menu-approved options, which included a choice of cereal, biscuits and gravy, and breakfast meat. Several residents reported not receiving meat with their breakfast for an extended period, despite menu requirements and personal dietary needs, such as a resident who required double protein and milk but did not consistently receive them. Staff interviews confirmed that breakfast meats were unavailable for about a week, and substitutions were made without consulting the dietitian. During lunch and dinner services, similar deviations from the approved menu were observed. For example, when chicken was unavailable for lunch, Salisbury steak was served instead, and for dinner, residents received only four small pieces of sausage instead of the required whole sausage portion. The dietary manager acknowledged that the correct portion sizes were not served and attributed the shortages to ordering issues related to the holiday schedule. Cooks and dietary staff confirmed that menu substitutions were made based on available ingredients, and the dietitian was not consulted regarding these changes. Resident council meeting minutes and referral forms documented ongoing concerns about menus not being updated or followed, with specific complaints referred to the dietary manager. Facility policies require that menus be followed as written and reviewed by a registered dietitian, and that any changes be approved and revised as necessary. Despite these policies, the facility did not ensure that residents received meals consistent with the approved menu, affecting all 73 residents in the facility.