Failure to Follow Posted Menus and Provide Appropriate Pureed Diet Desserts
Penalty
Summary
The facility failed to ensure that menus were followed as written, affecting nearly all residents who received meals from the kitchen. On a specified lunch date, the posted menu called for braised beef tips, rice pilaf, buttered carrots, a dinner roll, and strawberry pretzel dessert. Instead, during observation of the lunch tray line, dietary staff served beef stew with rice mixed into it, carrots, pears, a dinner roll, and ice cream. The dietary manager reported substituting beef tips with beef stew and adding rice to the stew based on resident preferences, and also substituting the strawberry pretzel dessert due to its high cost. A resident interviewed that afternoon stated the food was “so/so,” was often cold, and that the menu was often not followed. For dinner on the same date, the menu specified a bratwurst patty on a bun, but observation of the dinner tray line showed that a turkey burger was served instead. The dietary manager stated that facility policy did not allow hot dog–shaped bratwurst because of choking hazard concerns and that she was unable to obtain a non–hot dog–shaped bratwurst. On another dinner date, the menu and spreadsheet indicated that residents on a pureed diet were to receive a pureed confetti cake bar for dessert. Observation of the dinner tray line revealed that the confetti cake had not been pureed, and the dietary manager acknowledged she had not pureed the cake, was unsure if there was enough, and had planned to give residents on pureed diets a different dessert. The dietician and regional director of food services confirmed that residents on pureed diets should receive the same food as those on regular diets, in pureed form. These findings were inconsistent with the facility’s policy stating that individuals will be provided with nourishing, palatable, attractive meals that support each individual’s daily nutritional and special dietary needs.
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