Failure to Post Menus Two Weeks in Advance
Penalty
Summary
The facility failed to comply with the regulation requiring menus to be planned and posted or distributed to residents at least two weeks in advance. During a tour of the facility, it was observed that the daily menu options were only provided on the East, West, and North units. An interview with the Dietary Manager confirmed that the facility only posted their daily menu and did not meet the requirement of posting or distributing menus two weeks in advance for all nursing units.
Plan Of Correction
2 weeks' worth of menus were hung in the dining room, each resident was given a copy of the menu. Education was provided to the Dietary staff by the NHA on tag 4920. Audits will be done weekly for 8 weeks then monthly by the NHA. All results to be reviewed through QAPI for further recommendation. 2/25/25 All employee files reviewed for completion of all orientation paperwork. Education provided to the educator on the importance of completing new hire paperwork in a timely manner. Internal audit to be performed by HR on ALL current employees to ensure all new hire paperwork is accurate and complete. HR will then perform monthly audits until substantial compliance is met. All results will be reviewed through QAPI for further recommendations.