Failure to Verify Meal Tray Diets by Licensed Nurse
Penalty
Summary
The facility failed to ensure that meal tray diets were properly verified by a licensed nurse prior to distribution to residents. On 5/28/25, lunch trays were delivered to the floor, and a licensed nurse was observed checking only a few trays by lifting their lids and comparing the contents to the tray cards. The nurse did not open every tray to confirm the food matched the tray card for each resident. During an interview, the nurse stated that she only checked trays for therapeutic diets that could prevent choking and did not verify the contents of regular trays or check for allergies or specific resident requests. As a result, there was a failure to confirm that each resident received the correct diet as ordered, including consideration for allergies and special dietary needs, as required by facility policy.