Failure to Provide Menus in Advance
Summary
The facility failed to comply with dietary services regulations by not posting or distributing menus to residents at least two weeks in advance. During an initial tour of the facility, it was observed that only the menu for the current week was available on all three skilled nursing units. Interviews with four residents revealed that they did not receive copies of the menus two weeks in advance. Additionally, the Nursing Home Administrator acknowledged the expectation for dietary services to post or distribute menus in advance, which was not being met.
Plan Of Correction
Two weeks of menus were immediately posted for residents. 2. Dietary Director or Designee will provide education regarding the requirement for two weeks of menus to be posted. 3. Compliance will be monitored by the Dietary Director or Designee through audits on two weeks in advance menu posting, daily for 30 days, and then 3x per week for 3 months. 4. Findings will be reported to the QAA Committee to determine the need for further audits.
Penalty
The facility did not comply with the regulation to post or distribute menus to residents at least two weeks in advance. Residents reported not knowing meal details until delivery, and observations confirmed only the current day's menu was posted. The Director of Dietary acknowledged the lack of advance menu distribution.
The facility did not comply with the regulation to post or distribute menus to residents at least two weeks in advance. Observations revealed that only daily menu options were provided on the East, West, and North units. The Dietary Manager confirmed the facility's failure to meet the advance posting requirement.
The facility did not comply with the regulation to post menus two weeks in advance. Observations revealed that only meals for two days were posted, and the Registered Dietician confirmed that menus were not distributed to residents or posted in advance. The Nursing Home Administrator acknowledged this deficiency.
Failure to Post Menus 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 an interview with a group of residents, it was revealed that they were unaware of what meals would be served until they were delivered, as they did not receive menus in advance. Observations during meal delivery confirmed that only the current day's menu was posted in the hallway, with no advance menus available for residents. The Director of Dietary confirmed that the facility was not posting or distributing menus in advance as required.
Plan Of Correction
Unable to retroactively correct the posting of the menus. Residents receiving meals from Dining Services have the potential to be affected. Menus will be posted in the dining room two weeks in advance. The menu will be posted on channel 2 two weeks in advance, which is available in resident rooms for viewing. Monitoring will be captured through auditing. The dining room will be checked to ensure the menus are posted. Channel 2 will be viewed to ensure menus are available. Audits will be done weekly for 4 weeks, then monthly for 2 months. The audits will be conducted by the Director of Dietary or designee. The results of the audits will be provided to the Administrator by Dietary Director and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
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.
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 at least two weeks in advance. During a tour of the facility, it was observed that the menus posted on the nursing units only included lunch and dinner meals for January 3 and 4, 2025, rather than the required two-week advance posting. In an interview, the Registered Dietician admitted that menus were neither given to residents nor posted two weeks in advance. The Nursing Home Administrator confirmed this deficiency, acknowledging that the facility did not meet the regulatory requirement for menu posting and distribution.
Plan Of Correction
Dietary Director was posting menus in a common area daily; the NHA re-educated the director on posting menus two weeks in advance. Dietary Director will distribute two weeks' worth of menus at least weekly to residents and have them posted as well. NHA/Designee will conduct audits to ensure two weeks' worth of menus are posted and available for residents. Audit will be conducted weekly at 4 weeks, then monthly x 2. All results will be reported to the QAPI Committee.
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