Failure to Follow Posted Menu and Obtain RD Approval for Dessert Substitution
Penalty
Summary
The deficiency involves the facility’s failure to follow the posted lunch menu and to obtain timely RD approval for a dessert substitution affecting 29 of 32 residents. The posted Fall/Winter 2025–2026 Week 3 Wednesday lunch menu listed black bean soup, mixed green salad, turkey and Swiss sandwich, pasta salad, lettuce, tomato, pickle, apple pie, 2% milk, hot tea, and coffee. During observation of the lunch meal service, residents were instead served cheesecake for dessert. Two residents were observed eating lunch without assistance, and one resident identified the dessert as lemon cheesecake. The Certified Dietary Manager confirmed that cheesecake was served instead of the posted apple pie. The RD reported that the dietary spreadsheet/menu should be followed and that a Substitute Log must document the scheduled food item, the substituted item, and the reason for substitution. The RD stated she was not informed in advance that apple pie was unavailable and would be replaced with cheesecake. The facility’s Menu Substitution Record showed an entry dated 1/16/26 indicating apple pie was substituted with cheesecake because the pie was not delivered, but this entry lacked the RD’s signature. The facility’s Dining Service Menu Guide, dated 2019, states that any menu change, including one-time substitutions, requires Consultant Dietitian approval and that a substitution log must be maintained and reviewed and signed by the Consultant Dietitian. These observations and records show the dessert substitution was made and implemented without timely RD awareness or documented approval.
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