F0806

D

Failure to Provide Timely and Complete Meals Due to Missing Dietary Tickets

El Dorado, Kansas Survey Completed on 04-09-2026

Penalty

No penalty information released

Summary

The facility failed to meet residents' nutritional needs in accordance with established national guidelines when a resident did not receive timely and complete meals due to errors in the dietary ticketing and delivery process. On the morning of 04/06/26, the resident was observed sitting in a wheelchair in her room at 9:00 AM with her bedside table in front of her, waiting for her breakfast tray. At 9:30 AM, a nurse aide informed her that the kitchen had not yet delivered the food cart to the hall and that her tray would be delivered once it arrived. By 10:00 AM, the resident was still waiting for breakfast. When questioned at 10:05 AM, Administrative Nurses D and E acknowledged that the resident should have received breakfast before 10:00 AM.

At 10:10 AM, the resident finally received a tray containing cream of wheat and one piece of toast, without sugar, butter, or jelly. The resident reported that she had requested eggs and orange juice but was told by staff that those items were unavailable and that what she received was all that was available. Administrative Nurse E verified that the kitchen had not printed a breakfast ticket for the resident, which resulted in her not receiving her meal on time. Dietary Staff BB later confirmed that the resident had not received her breakfast tray because the meal ticket did not print and also verified that the resident’s supper meal the previous evening had been delayed for the same reason. The facility’s Food Preparation and Service policy, dated 10/2025, states that residents are to be provided with food that is palatable, attractive, and at a safe and appetizing temperature, and that food service employees should prepare and serve food in a manner that complies with safe food handling practices.