F0803

E

Failure to Follow Menus and Meal Tickets for Diet Orders and Portions

Norfolk, Virginia Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

Facility staff failed to serve meals according to the written menu and individual meal tickets for multiple residents. One resident with stroke, renal failure, and heart failure, who had moderately impaired cognition and required setup assistance for eating, was observed at lunch receiving roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. The resident’s menu and personal meal ticket specified that cornbread, not a biscuit, should be served, and the meal ticket also documented a regular diet with a fluid restriction of 1200 milliliters per day and one 8‑ounce beverage. The Dietary Manager later stated that cornbread was not available because the food delivery did not occur as scheduled and that the substitute item was not updated on the menu or meal tickets due to software difficulties.

Another resident with tracheostomy, diabetes, peripheral vascular disease, and heart failure, who had intact cognition and required setup assistance with eating, was ordered a mechanical advanced/chopped diabetic diet. The meal ticket for this resident specified chopped roasted pork loin, diced beets, mashed potatoes, a dinner roll, margarine, apple crisp, 2% milk, and hot coffee or tea. During observation of the lunch meal, the resident was served a whole slice of roasted pork with gravy instead of chopped pork, and a biscuit instead of the dinner roll listed on the ticket. The Dietary Manager acknowledged that the pork loin not being chopped was an error and again reported that dinner rolls were unavailable due to a missed food delivery and that the substitute item was not reflected on the menu or meal tickets.

A third resident with dysphagia, mechanically altered PO intake, and cerebral palsy, who had intact cognition and was able to use utensils to eat once the meal was placed before him, reported wanting more food to gain weight and stated he was not receiving extra portions despite asking. Observation of this resident’s lunch tray showed roasted pork loin, pork gravy, diced Harvard beets, creamy mashed potatoes, a biscuit, and apple crisp. The resident’s meal ticket listed the same items but included cornbread, which was not present on the tray. The resident commented that the tray “comes like that sometimes” but reiterated his desire to gain weight. The Dietary Manager later stated there was no cornbread mix available, so a biscuit was served instead.