Unapproved Menu Substitution and Failure to Inform Residents of Meal Changes
Penalty
Summary
The facility failed to ensure that the published lunch menu was followed, that residents were informed of menu changes in advance, and that the Registered Dietitian (RD) was notified of these changes. The posted and facility menu for lunch on 3/18/2026 listed BBQ chicken, macaroni and cheese, collards, corn bread, and sweet potato pie. However, during a kitchen observation, the test lunch tray contained green beans instead of the planned collard greens. In an interview, the Dietary Manager stated that collard greens were not available, so she substituted green beans without obtaining prior approval from the RD, did not update the posted menu outside the dining room, and did not maintain a log of substitution changes or RD approvals. These actions and omissions resulted in the potential for all residents consuming food from the kitchen to be dissatisfied with their meal service and for meals to not be nutritionally adequate, as the menu was not served as planned, residents were not informed of the change, and the RD was not consulted regarding the substitution.
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