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P4920

Failure to Post Menus in Advance

Johnstown, Pennsylvania Survey Completed on 02-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

See complete original report
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