Failure to Provide Coffee as Required by Menu
Penalty
Summary
The facility failed to serve coffee as required by the planned and approved menu, which specified that coffee should be provided at every breakfast meal daily. Observations and interviews revealed that coffee was frequently unavailable to residents during meal times. Staff reported that the coffee cart was initially placed in the second-floor dining room, but by the time residents in the dining room were served and received seconds, there was no coffee left for residents served in the hallway. Staff also indicated that when coffee ran out, they could call food service for more, but shortages persisted, especially toward the end of the week when staff sometimes had to purchase coffee from a store. Multiple residents reported not receiving coffee during meals, with some stating that the facility often ran out of coffee or that it was difficult to obtain. One resident noted that sometimes coffee was served, but other times it was not, and another stated she often did not receive coffee or other beverages during meals. During breakfast service, a resident was observed receiving her meal without coffee and stated that coffee was frequently missing. Dietary staff and the administrator confirmed that the facility had run out of coffee for residents at times, despite the administrator having the ability to purchase food items as needed.