Failure to Serve All Meal Ticket Items During Lunch Service
Penalty
Summary
Surveyors identified that the facility failed to serve all items listed on meal tickets for three out of five residents observed during a lunch meal service. One resident reported frequently not receiving all items indicated on her tray ticket, a concern that was also documented in the resident council meeting summary for the previous month. Direct observation confirmed that this resident did not receive bread or margarine as specified on her meal ticket. Additionally, two other residents did not receive cottage cheese and a grilled cheese sandwich, respectively, as listed on their meal tickets. During the meal service, a nurse aide delivered trays and assisted residents but did not notice the missing items until informed by the surveyor. The aide then contacted the kitchen to request the missing food items. These findings were discussed with the Nursing Home Administrator, and the deficiency was cited under state regulations regarding the responsibility of the licensee and facility management.