Failure to Follow Posted Menus and Provide Complete Ordered Meal Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its posted menus and ensure that meals met residents’ nutritional needs as required by facility policy and 28 Pa. Code 211.6(a)(b) on dietary services. The facility’s Food and Nutrition Services policy dated 10/29/25 required that each resident receive a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, considering resident preferences. The Tray Identification policy dated 10/29/25 required appropriate identification to distinguish various diets. On the lunch meal of 3/23/26, the written menu called for chicken and biscuits, carrots, cranberries, gelatin, and juice. During observation of this meal on the third floor, multiple residents did not receive all items ordered for them: one resident was missing finger foods, a magic cup, a peanut butter and jelly sandwich, and milk; three residents were missing magic cups; and three residents were missing gelatin. An LPN confirmed these missing food items at the time of the observation. On the lunch meal of 3/24/26, the written menu specified Salisbury steak, carrots, mashed chive potatoes, gravy, soup, and bread pudding. During observation of the trayline service in the main kitchen, 14 residents instead received hamburger or grilled cheese, mashed chive potatoes, and California vegetables. A dietary employee acknowledged serving a different menu, explaining that the morning cook had called off, carrots had been served two days in a row, and the correct food was not provided to the personal care area. The dietary manager confirmed that the facility failed to serve what was on the menu and to update the menu to reflect changes. Additional observations on the third floor that day showed multiple residents missing required items such as soup, vegetables, bread pudding, onions and mushrooms, and magic cups. An LPN again confirmed the missing items for these residents during interview.
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