Failure to Provide Residents with Selected Menu Items
Penalty
Summary
The facility failed to ensure that residents received the menu items they selected at mealtime, as evidenced by observations, interviews, and review of records. Two residents with intact cognition and specific medical diagnoses, including hemiplegia, type II diabetes mellitus, hypertensive heart disease, and heart failure, did not receive the food items they had chosen on their meal tickets. One resident did not receive vegetable soup as selected, and another did not receive crackers, despite both items being available and provided only after staff intervention during the meal service. Staff interviews confirmed that residents frequently complained about not receiving their requested menu items. Further review revealed that CNAs were responsible for distributing and collecting menu tickets, but there were ongoing issues with ensuring residents' selections were honored. Resident Council Food Committee notes documented concerns about menus not being filled out and residents not getting what they requested. These findings demonstrate a pattern of the facility not providing food according to residents' documented preferences and selections.