Failure to Employ a Dietary Manager Resulting in Ongoing Food and Menu Problems
Penalty
Summary
The deficiency involves the facility’s failure to employ a certified Food Service Manager/Dietary Manager as identified as necessary in its own Facility Assessment Tool and Dietary Manager job description. The assessment specifies that a Food Service Manager/Dietary Manager is needed to care for the resident population, and the job description outlines responsibilities such as planning, organizing, developing, and directing the Food and Nutrition Services Department, maintaining menus, participating in survey inspections, and possessing Food Service Sanitation Manager Certification. Despite these documented requirements, the facility census showed 63 residents on 12/24/25, and on multiple survey dates (12/27/25, 12/28/25, and 12/29/25) the facility could not identify or provide evidence of an employed Food Service Manager/Dietary Manager, nor a contact person for that role. The employee contact list also documented “Dietary Manager none.” Resident Council minutes from two separate meetings documented that the facility was looking for a new Dietary Manager, that the DON was handling dietary questions, and that there was no Food Committee meeting due to the absence of a manager. Multiple staff interviews confirmed that the former Dietary Manager had left about two months earlier and that no replacement had been hired. The DON stated that the facility did not currently have a Dietary Manager and that she helped out in the department when she could, while dietary staff reported that they “all just pitch in,” with certain cooks handling “a lot of the kitchen stuff” and one cook stating that they “pretty much do everything” in the kitchen because there had been no manager since the former manager left. The contracted registered dietician and the ombudsman both corroborated that the facility was still looking for a Dietary Manager and had not hired one. Multiple alert and oriented residents reported ongoing problems with food quality and service during the period without a Dietary Manager. The Resident Council President stated that there had not been a kitchen manager for a long time and described the kitchen as run “terrible,” with menus not matching what was served and food being cold and undercooked. Other residents reported that they did not receive what was on the posted menu, that food was “not edible,” undercooked, cold, and sometimes consisted only of carbohydrates without fruit or vegetables. Several residents stated that the facility frequently ran out of coffee and milk, that salads were brown, mushy, and slimy, and that they could not obtain requested items such as turkey sandwiches. One resident on a special diet reported not receiving what they were supposed to get and inadequate assistance when requesting alternatives, and another diabetic resident reported insufficient evening snacks. Staff, including the MDS RN/manager on duty, acknowledged hearing resident complaints that the food was terrible and that the posted menu was not followed.
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