Failure to Serve Preferred Hot Beverage at Breakfast
Penalty
Summary
Surveyors determined that the facility failed to provide residents with their preferred hot beverage, specifically coffee, during breakfast as indicated on their dietary meal tickets. On the morning of the observation, the dietary food carts were delivered to the unit, but the cart containing coffee, tea, and condiments arrived later than the food trays. As a result, three residents who had coffee listed on their meal tickets did not receive coffee with their breakfast meal. The unit was staffed with only two GNAs for 32 residents, and additional staff from other departments were brought in to assist with meal delivery. The deficiency was observed during a breakfast meal service in the Arcadia unit, where seven residents required maximum assistance with feeding. Despite the presence of the unit manager, charge nurse, and medication nurse, the delay in the arrival of the beverage cart led to the omission of serving coffee to the affected residents. These findings were reviewed with the DON and the administrator later that morning.