Failure to Follow Planned Menus and Provide Nutritionally Appropriate Meals
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned, dietician-reviewed menus and ensure that meals met residents’ nutritional needs as required by policy and facility assessment. The facility’s assessment tool identified the need for a Food Service/Dietary Manager to ensure appropriate food services and menus. Facility policies and the Dietary Manager job description required that menus be planned in advance, maintained, followed, and that residents be offered items from the planned menu. Resident Council minutes over several months documented ongoing dietary concerns, including removal of available off‑menu options, lack of a Dietary Manager, and complaints that substitutes were becoming regular meals instead of true alternatives. Surveyor observations on specific dates showed that posted menu items were not served as planned. The week-at-a-glance menu listed western egg bake with ham for breakfast and baked potato with sour cream and margarine for lunch on a specific date, but the western omelet served that morning contained no ham, and residents at lunch received sweet potatoes instead of baked potatoes. Multiple alert and oriented residents reported that the menu was frequently not followed, that food was cold, undercooked, or not edible, that there was often no choice, and that they did not receive what was listed on the menu or what their special diets required. Residents also reported frequent lack of milk and coffee, inability to obtain requested items such as turkey sandwiches, brown and slimy salads, meals composed only of carbohydrates without fruit or vegetables, and inadequate evening snacks for a resident with diabetes. Staff interviews confirmed that the facility had been without a Dietary Manager for about two months, with the DON informally overseeing the department and dietary staff “pitching in” without clear management. Dietary staff and the contracted dietary supplier reported ongoing problems obtaining and managing ingredients needed to follow the menus, frequent running out of key items such as milk and ham, and corporate-driven budget constraints that led to cutting orders and improvising menu items. The contracted supplier noted that ham supplies were depleted after a Christmas potluck, leaving no ham for the planned western omelet, and that sweet potatoes were substituted for baked potatoes due to lack of regular potatoes. Staff also described poor portion control and failure to properly use or prepare produce such as lettuce, contributing to food waste and further deviation from the planned menus. These actions and inactions resulted in the facility not following its posted menus and not consistently providing the planned, nutritionally appropriate meals to its 63 residents.
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