Failure to Follow Posted Lunch Menu and Document Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to follow the posted and planned lunch menu for one of two days of observation. The written and calendar menus for the lunch meal on 1/6/26 listed fried chicken, spinach, mashed potatoes, sugar cookies, and a buttered dinner roll. During observation of the lunch meal service, some residents were served gravy with their mashed potatoes while others were not, and some residents received egg noodles even though noodles were not listed on the menu. One resident was served mashed potatoes without gravy and also received egg noodles, while another resident received mashed potatoes with gravy. The Dietary Manager later confirmed that gravy and egg noodles were not part of the planned menu for that meal. Two residents reported in interviews that they did not always receive all items as reflected on the menu and stated they had previously complained about this issue without seeing improvement. They expressed that they did not like when they did not receive what was listed on the menu but felt they could not do anything about it. The Dietary Manager stated that the cook should have followed the menu and that any substitutions should have been discussed with her and documented on the substitution log for Dietician review. Facility policy titled “Menu Changes and Substitutions” dated 10/2010 stated that any variations from the planned menu must be properly documented by the Dietary Services Manager and reviewed and signed by the Dietician, and that menu changes and substitutions, when necessary, must be made with foods of equivalent nutritive value.
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