Failure to Follow Posted Menu and Document Menu Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned menu and document menu substitutions during a noon meal service. Surveyors observed that at 12:30 p.m. on 12/22/25, the kitchen served chicken fried steak, mashed potatoes and gravy, cream corn, a dinner roll, and pineapple crisp, while the posted week five menu specified crumb crusted chicken, savory rice, Brussels sprouts, a dinner roll, and pineapple crisp. The administrator identified that 37 residents received nutrition from the kitchen for this meal. The facility had an undated policy titled “Menu Substitution” stating that menu substitutions would be recorded on a substitution record form and that the reason for the change would be noted. During the same observation, the dietary manager stated they were working off the week five menu and had to substitute items because the planned menu items were not available, but also acknowledged they did not document substitutions or specific reasons for them and were not aware of any substitution form. No additional resident-specific medical histories or conditions were documented in the report beyond the number of residents receiving nutrition from the kitchen.
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