F0803

E

Failure to Follow Dietitian-Approved Menus and Accurately Document Menu Substitutions

Marietta, Ohio Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide meals as written on the approved cycle menu and to accurately document all menu substitutions. Surveyors reviewed the facility’s Week #1 2025–2026 cycle menu, which listed a specific lunch for a Wednesday: cranberry orange chicken, roasted Brussels sprouts, garlic and rosemary roasted red skin potatoes, a dinner roll, and Mandarin oranges, with an alternate of cheese ravioli with marinara sauce and tossed salad. During an observation of the lunch meal service, the food being prepared and served did not match this menu. Instead, the kitchen was serving smothered chicken thigh with poultry gravy, broccoli florets, mashed potatoes, a dinner roll, and sliced pears, which corresponded to a different menu (a Tuesday meal from a 2023–2024 diet guide sheet) rather than the current 2025–2026 cycle menu.

When surveyors requested the spreadsheet for the day’s menu to verify portion sizes and menu compliance, dietary staff produced a spreadsheet from the 2023–2024 Diet Guide Sheet rather than the correct 2025–2026 Week #1 menu. Review of the facility’s Menu Substitution Log for November 2025 through January 2026 showed 27 recorded substitutions deviating from the planned dietitian-approved cycle menu. However, there was no Menu Substitution Log for February, and the Administrator later added the 02/11/26 lunch substitutions onto a previously provided log. Even then, the added entry only noted that chicken thigh was substituted with chicken breast, Brussels sprouts with broccoli, and roasted potatoes with mashed potatoes, and did not document that cranberry orange chicken had been replaced with smothered chicken or that Mandarin oranges had been replaced with pears. Both the Administrator and a Regional Nurse confirmed that the meal served did not match the current cycle menu and that the substitution log did not fully or accurately reflect the substitutions made.

Interviews with staff and a resident further described the pattern of unrecorded or inadequately recorded substitutions and deviations from the menu. The cook reported that the planned cranberry orange chicken, Brussels sprouts, and red skin potatoes were not served because residents at resident council had previously expressed dislike for those items, and that many substitutions were based on the preferences of the 15–25 residents who typically attended council meetings. She acknowledged that these preferences might not represent the entire resident population and that some menu changes based on known preferences were not communicated to residents, despite residents receiving a weekly “daily chronicle” listing upcoming meals. A resident reported frustration that the posted menus were often changed without notice, estimating that this occurred two or three times per week, and stated that residents on the same hall sometimes received different food items without explanation. The facility’s own menu policy required menus to be prepared in advance, served as written unless substitutions were made for preference, unavailability, or special meals, and required that a menu substitution log be maintained on file, but the observed practices and documentation did not align with these requirements.