F0803

E

Failure to Follow Planned Menus and Communicate Undocumented Food Substitutions

Meadville, Pennsylvania Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that meals were prepared and served according to the planned menus, that menu changes were documented and updated, and that residents were notified of substitutions. The facility’s own menu change policy, dated 8/29/25, required that any change to the posted or planned menu be intentional, documented, and communicated to residents and staff, with substitutions of equal nutritional value that meet resident preferences and dietary restrictions, and that all changes be recorded on a monthly menu substitution log and communicated via pre-meal huddles, nursing staff, and menu boards or general communication. Despite this policy, multiple residents reported recently receiving foods that were not on the posted menu without prior notification of the changes.

Interviews with residents and staff, along with confidential interviews, revealed that food substitutions were occurring due to ordered items not being delivered or running out of specific foods, and that these substitutions were not documented or communicated. Examples included cabbage being served to approximately 12–15 residents instead of brussels sprouts, mashed potatoes being served in place of biscuit mix for pot pie, and pears being served instead of apples for dessert, as well as a planned cream of broccoli soup that was not delivered as ordered. An LPN reported noticing food substitutions on resident trays without notification from the kitchen to nursing staff or residents. Follow-up interviews confirmed that the facility failed to follow the planned menus, complete the monthly menu substitution log, update posted menus, or alert residents to menu changes, in violation of the cited state regulatory requirements for management and dietary services.