Failure to Provide Packed Meals for Dialysis Resident
Summary
The facility failed to provide packed meals for a dialysis resident who left the facility early in the morning and did not return until lunchtime three days a week. Resident #279, who had end-stage renal disease and was dependent on renal dialysis, did not receive breakfast before leaving for dialysis. Despite the care plan indicating that a packed meal should be provided on dialysis days, the resident reported that he often had to request a bagged meal and sometimes could not find a staff member to assist him. The dietary manager and staff were unaware that bagged meals were not consistently prepared and placed in the nourishment room the night before for early morning dialysis residents. Interviews with the dietary manager, nurse, and registered dietician revealed a lack of communication and awareness regarding the preparation and provision of bagged meals for dialysis residents. The dietary manager stated that bagged meals were supposed to be prepared the night before, but this was not consistently done. The registered dietician emphasized the importance of providing three meals a day to prevent protein deficiency. The administrator expected dietary staff to provide bagged meals without residents having to ask, but was unaware of the issue until it was brought to her attention.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to provide timely meal service according to its posted mealtimes and written policy on meal frequency. Resident council minutes documented that meals were often late, and an observation confirmed that lunch trays arrived on one floor 55 minutes after the posted delivery time, as verified by an LPN. The dietary manager acknowledged that the posted schedule indicated when trays should be delivered, despite stating it reflected tray line start times. Multiple residents reported late meals as an ongoing concern, and the issue affected several residents and had the potential to affect nearly all individuals receiving meals from the kitchen, excluding one resident who was NPO.
Meal trays were consistently delivered late to the Memory Care Unit, with staff and family members confirming delays of up to an hour past scheduled times. Observations showed residents waiting for meals, and both dietary and nursing staff acknowledged the recurring issue, despite facility policies requiring prompt meal delivery to ensure freshness and quality.
The facility did not serve meals in accordance with posted mealtimes and resident preferences, resulting in delayed meal delivery to multiple residents. Staff confirmed the delays and residents reported frequent late meal service, with observations showing trays delivered well after scheduled times. The deficiency affected several residents and had the potential to impact all who received meals from the kitchen.
The facility failed to provide prescribed evening snacks to two residents, one with diabetes and another with dementia, due to an oversight by the dietary department. The snacks were not included on the delivery tray, as confirmed by the Dietary Manager.
The facility failed to provide substantial evening snacks to residents when the time between dinner and breakfast exceeded 14 hours. Observations and interviews revealed that only residents with labeled snacks received them, and several residents expressed hunger and a desire for snacks. The Food and Nutrition Services Manager confirmed the extended meal span and lack of routine snack offerings.
The facility failed to serve meals in a timely manner, affecting all residents. Observations and interviews revealed that meals were consistently late and cold, with some residents not receiving breakfast by the scheduled time. The Dietary Manager confirmed that meal carts were delivered late, and floor staff were responsible for distributing meals to residents.
Failure to Provide Timely Meal Service According to Posted Mealtimes
Penalty
Summary
The deficiency involves the facility’s failure to ensure meals were served in a timely manner in accordance with residents’ needs, preferences, and the facility’s own posted mealtimes and policy. Resident Council minutes from two separate meetings documented that meals were often late. The facility’s posted mealtime information at the second-floor nurses’ station indicated that the second-floor meal cart was to be delivered at 11:50 A.M. During an observation on 03/23/26 at 12:45 P.M., lunch trays arrived on the second floor, and an LPN confirmed that the trays were 55 minutes late compared to the posted delivery time of 11:50 A.M. The facility’s written mealtime policy titled “Frequency of meals” stated that three regular mealtimes would be scheduled comparable to normal mealtimes in the community. During interviews conducted in conjunction with the survey, the Dietary Manager stated that the posted times represented when tray line started for the food cart, but then acknowledged that the posted mealtimes indicated trays were to be delivered to the second floor at 11:50 A.M. In a resident council meeting held during the recertification survey, five residents reported that late meals were a concern. The deficiency affected five residents reviewed for frequency of meals and had the potential to affect all 47 residents who received meals from the kitchen, with one resident identified as NPO. This issue was investigated under Complaint Number 2693841.
Delayed Meal Service on Memory Care Unit
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner on the Memory Care Unit, affecting all 33 residents residing there. Multiple interviews with residents' families, CNAs, dietary staff, and supervisors confirmed that meal trays were consistently late, with reports indicating delays of up to an hour. Direct observation showed residents seated and waiting for their lunch meals well past the scheduled delivery time, with the first meal cart arriving at 12:37 P.M. instead of the scheduled 12:00 P.M. for the first cart and 12:15 P.M. for the second cart. Staff interviews corroborated that late meal service was a recurring issue. Review of facility policies revealed that meal trays were expected to be delivered promptly to ensure freshness and quality, with specific delivery times outlined for the Memory Care Unit. Despite these policies, both dietary and nursing staff acknowledged that meals were not being served on time, and no specific reasons for the delays were consistently identified other than general untimeliness. The deficiency was substantiated through direct observation, staff and family interviews, and policy review, confirming non-compliance with established meal service protocols.
Failure to Serve Meals Timely According to Resident Needs and Posted Mealtimes
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner according to posted mealtimes and resident preferences. Observations revealed that lunch trays were delivered late to certain halls, with one food cart leaving the kitchen 24 minutes after the scheduled time and meal trays being delivered to residents well past the posted mealtime. Staff interviews confirmed the delay, with one staff member stating they were unsure of the reason for the late meal service and had been asked to assist with passing trays. Residents also voiced concerns during a Resident Council meeting that meals were often served late. The deficiency affected at least three residents and had the potential to impact all residents receiving food from the kitchen. The facility census was 86, with four residents identified as NPO (nothing by mouth). Review of posted mealtimes indicated that the Middle Hall and Back Hall received their meal trays later than scheduled. The findings were based on observation, interview, and record review, and were investigated under two complaint numbers.
Failure to Provide Prescribed Evening Snacks
Penalty
Summary
The facility failed to ensure that residents received their prescribed evening snacks, affecting two residents out of thirteen who were ordered an evening/bedtime snack. Resident #3, who was readmitted with diagnoses including diabetes mellitus, mild intellectual disabilities, and cerebral infarction, was supposed to receive vanilla ice cream at bedtime. Resident #28, admitted with non-Alzheimer's dementia and anxiety disorder, was to receive nectar thickened cranberry juice. However, during an observation between 6:50 P.M. and 7:07 P.M., it was noted that their snacks were not included on the snack tray delivered to the residents. The Dietary Manager #500 confirmed that the snacks for Resident #3 and Resident #28 were not on the snack tray due to an oversight, as they were not placed on the tray for distribution. This oversight was verified through a review of the Snack Summary list, which showed that the snacks were not prepared for delivery. The deficiency was identified during an investigation under Master Complaint Number OH00163355 and Complaint Number OH00162745.
Failure to Provide Evening Snacks
Penalty
Summary
The facility failed to ensure that residents were offered a substantial evening snack when the time between dinner and breakfast exceeded 14 hours. This deficiency was identified through observations, record reviews, and interviews. The facility's Fall and Winter menu for 2024 to 2025 did not list an evening snack, and the time span between the last dinner tray and the first breakfast tray was approximately 15 hours. Interviews with several residents revealed that they were not offered snacks in the evening, and some residents expressed that they were hungry and would have liked to receive snacks. A Certified Nursing Assistant confirmed that only residents with labeled snacks received them, and there was no routine offering of snacks to other residents. The Food and Nutrition Services Manager (FNSM) confirmed that the time between dinner and breakfast was greater than 14 hours and that only labeled snacks were provided to select residents. The resident council meeting minutes did not document any agreement from residents to have a meal span greater than 14 hours. Observations of snack deliveries showed that only labeled snacks were provided, with no extra snacks available for other residents. The facility's document on meal times indicated a scheduled time span of 14 hours and 45 minutes between dinner and breakfast, which was not adhered to.
Delayed Meal Service for Residents
Penalty
Summary
The facility failed to ensure meals were served in a timely manner, affecting all 100 residents. Observations and interviews revealed that residents frequently received their meals late and cold. For instance, Resident #52 and Resident #54 reported that their meals were consistently served late and cold, with Resident #54 not having received breakfast by 9:07 A.M. on the day of the interview. Observations confirmed that the breakfast cart arrived late to the 200-Hall unit, and Resident #77 and Resident #115 were without breakfast trays well past the scheduled meal service time. The facility's meal service schedule indicated breakfast should be served between 7:00 A.M. and 8:45 A.M. However, observations showed that the first unit did not receive its last tray until 8:46 A.M., and other units had not been served by that time. The Dietary Manager confirmed that the kitchen staff delivered meal carts to the units, but the floor staff were responsible for distributing them to residents. This delay in meal service was identified during an investigation of multiple complaints, highlighting a systemic issue in the facility's meal delivery process.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
