Failure to Follow Prescribed Menus During Meal Service
Penalty
Summary
The facility failed to follow prescribed menus for two residents during meal service. One resident was served a hot dog on a flat piece of sandwich bread without the required condiments, despite the tray card specifying an all-beef hot dog on a bun with mustard. A nursing assistant confirmed that the resident typically eats a hot dog daily and did not receive the correct bread or condiment. Another resident, who had ordered a hot dog, received it on a slice of bread with cheese instead of a bun and expressed dissatisfaction when informed by the aide that hot dog buns had run out. The Assistant Director of Nursing was present and acknowledged the lack of buns but did not provide further explanation at the time. These incidents were identified through record review, observation, and staff and resident interviews, demonstrating that the facility did not ensure menus were followed as required, potentially affecting more than a limited number of residents.