Meals Served Did Not Match Posted Menus or Tray Tickets
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals served matched residents’ tray tickets and the posted menus, as required by facility policy. For one resident, admitted with diagnoses including COPD, history of TIA and cerebral infarction without residual deficits, left bundle-branch block, mood disorder, acute kidney failure, toxic encephalopathy, and cocaine abuse, surveyors observed a breakfast tray containing milk, grape juice, hot oatmeal, breakfast ham, and scrambled eggs. The tray ticket for this meal specified cold or hot cereal, juice of choice, waffles, breakfast ham, milk, and coffee or hot tea. The resident reported that tray tickets and menus often did not match the meals served, and confirmed that the breakfast provided did not match the ticket or menu that day. A CNA verified the discrepancy between the tray ticket and the items actually on the tray. The Dietary Manager confirmed that the written breakfast menu for that date included cold or hot cereal, juice of choice, waffles, breakfast ham slice, milk of choice, and coffee or hot tea, and stated that the cook forgot to make and serve the waffles listed on the menu. At lunch on the same date, the written menu indicated residents were to receive lemon zest broccoli, chocolate cake with icing, a chicken patty on a bun, and rice. During observation of lunch service with the Dietary Manager, residents’ trays were seen to include lettuce and tomatoes on their chicken patties, items not listed on the menu. Later in the meal service, the kitchen ran out of lettuce, and the Dietary Manager confirmed that 17 residents did not receive lettuce and tomatoes on their chicken sandwiches because the facility did not have enough of these items. Further observation showed that all residents received chocolate pudding instead of the chocolate cake with icing specified on the menu. The Dietary Manager verified that chocolate cake was available but a cook followed an incorrect menu and served chocolate pudding instead. Review of the facility’s “Menus” policy stated that menus are to be developed and prepared in advance to meet residents’ needs, but the observed meal service did not consistently follow the planned menus or tray tickets for all 84 residents receiving food from the kitchen.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.