Failure to Follow Dietician-Approved Menus for Multiple Meal Services
Penalty
Summary
The facility failed to follow the dietician-approved menus for three observed meal services, despite having policies requiring adherence to written menus and standardized recipes. Surveyors observed that the posted Week 3 menus, approved for 2025–2026, specified sliced ham, crispy cubed sweet potatoes, seasoned greens, cornbread, and chocolate cream pie for a Monday lunch; glazed meatloaf, red roasted potatoes, southern green beans, a honey kissed roll, and gelatin parfait for a Tuesday lunch; and a tuna melt sandwich, steak fries, mixed green salad, and apple crisp for a Tuesday dinner. Instead, the kitchen served meatballs, mashed potatoes with gravy, boiled mixed vegetables, and yellow cake with cream cheese frosting for the Monday lunch; kielbasa sausage, mashed potatoes, creamed corn, and Jello for the Tuesday lunch; and beef pot pie, boiled squash, cornbread, and peach cake for the Tuesday dinner. The administrator identified 112 residents receiving meals from the kitchen, with one additional resident receiving nutrition and hydration solely via feeding tube. Staff interviews confirmed that menu changes were made without following the established process or involving the dietician. Cook #1 reported that the food service director instructed preparation of meatballs instead of the scheduled menu item and stated that the food service supervisor sometimes changed the menu at the last minute, possibly due to insufficient quantities of the planned food items. The food service director acknowledged deciding on alternative meals because not all items for the written menus were available and also acknowledged that the written menus had not been followed. During a resident council meeting, residents reported that posted menus were often not the meals actually served. The administrator stated they were unaware that written menus were not being followed and believed kitchen staff should have all required food items to follow the dietician-approved menus daily. The dietician stated the written menus should have been followed per regulations and reported not being informed by the food service director about the menu changes that week.
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