Miscommunication Leads to Missed Meal for Resident
Summary
Roosevelt Rehabilitation and Healthcare was found to be non-compliant with the requirement to provide meals at regular times, as evidenced by an incident involving Resident R3. On January 8, 2025, Resident R3 did not receive his breakfast meal due to a miscommunication among nurse aides. The facility's policy requires nursing staff to deliver food trays to each resident's room, but this was not followed for Resident R3. The resident had previously reported his assigned nurse aide, Employee E3, for refusing to change his bed linens, which he believed led to retaliation when he did not receive his breakfast. Further investigation revealed that Employee E3 was reassigned on the morning of January 8, 2025, and was not responsible for Resident R3's care at that time. However, a grievance report indicated that the meal was offered, but Resident R3 declined it, stating he was heading to lunch. The unit manager confirmed the miscommunication among staff, which resulted in the resident not receiving his breakfast tray. The facility's grievance investigation included a statement from Employee E3, noting that Resident R3 was asleep when the breakfast tray was delivered, and the tray was left because the resident did not like to be woken up.
Plan Of Correction
1. Facility cannot retroactively provide resident 3 with a missed meal. 2. Facility conducted full house audit on each meal to ensure every resident received a meal tray. Facility conducted full house audit to ensure all residents had meal tickets. 3. NHA/designee will re-educate all nursing department to ensure staff will remove food trays from the food cart and deliver the trays to each resident room when eating meals on the unit. 4. NHA/designee will conduct random audits on one cart to ensure all residents receive a meal daily x4 weeks, weekly x4 and monthly x2. Facility will conduct audits to ensure all residents have a meal ticket 3x a week for 4 weeks, weekly x4 and monthly x2. Results will be submitted to QAPI for review and recommendations as needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to consistently provide nourishing evening snacks to residents, including residents with DM. Two residents reported that snacks were not always available at night and that only limited items such as fruit, fig bars, and cheese crackers were offered, with no sandwiches available when requested. Dietary and nursing staff confirmed that snacks were kept under the nurses’ station, could be taken by some residents in excess, and that protein snacks for residents with DM were not consistently provided. Staff also stated that late-night sandwich requests could not always be met after dietary staff left for the night.
Meals were not served at the posted times, with residents and an LPN reporting repeated delays for noon and evening meals. Surveyors observed residents waiting for lunch while meal carts arrived late to the dining rooms and hall routes, including delays of 30 to 49 minutes and other carts arriving 35 to 42 minutes late.
Meal service was not provided at regular times, with tray line preparation and delivery repeatedly running late. Staff reported the goal was to have the last breakfast cart out by 9:00 AM and lunch trays delivered by 1:10 PM, but breakfast, lunch, and dinner were often delayed; residents were still eating breakfast late in the morning, lunch trays were not ready at scheduled times, and some dinner trays reportedly arrived as late as 9:00 PM. Staff attributed the delays to short staffing in dietary services.
Meals were not served at regular times, and nourishing snacks were not available for residents waiting to eat. On the 4th floor, dinner service ran for more than 2 hours, with residents at tables waiting while others ate and room trays delivered much later. Staff were observed standing around rather than helping with meal service, and a resident needed help unwrapping food before an aide intervened. A CNA reported the snack pantry was not consistently stocked, and staff described problems with the new tray line and staffing.
A facility failed to ensure snack items were available at all times for residents. During tour and kitchen observation, no snack trays or snack storage were visible on the halls, and the dry food stock room shelf was empty of resident snack items. The Dietary Manager confirmed the shelf was empty, and an LPN stated evening snack trays were not routinely available, sometimes arriving late or not at all. A resident reported there were no snacks available over the weekend and that snacks were not given regularly, despite the facility policy stating evening snacks would be offered routinely to all residents.
A facility failed to consistently provide evening and bedtime snacks as desired by residents. Four residents reported that snacks were not routinely offered, that they had raised the issue at resident council meetings, and that nursing staff did not always deliver snacks brought up by dietary. The NHA could not explain why snacks were not consistently offered, despite a policy requiring HS snacks for all residents and nourishing snacks for diabetic residents.
Inconsistent Access to Evening Snacks
Penalty
Summary
The facility failed to consistently provide a nourishing evening snack to residents, including 11 residents with diabetes mellitus. During the resident council meeting, two residents stated that they did not always have snacks available at night and reported that the snacks previously kept at the nurse’s station were not reliably available because some residents took too many while others did not receive any. They also stated that there were no sandwiches available if they wanted one, only items such as apples, bananas, fig bars, and cheese crackers. Dietary staff and nursing staff confirmed that evening snacks were not consistently available in a way that ensured access for all residents. The Dietary CC stated he was working on a better selection of evening snacks, that the current options included Jell-O, pudding, and Cheetos, and that he had not consistently provided protein snacks for residents with DM. He also stated that residents could request sandwiches only when dietary staff were in the building, and that evening snacks were handed off to staff before dietary staff left. An LN stated the snacks were kept in a container under the nurses’ station and given to residents if they asked. An Administrative Nurse stated some residents took multiple snacks, leaving too few for others, and that some residents had requested grilled cheese sandwiches late at night after dietary staff had already left. The facility’s Food and Nutrition Services policy stated nourishing snacks were available 24 hours a day and could be requested as desired or scheduled between meals.
Meals Served Late
Penalty
Summary
Meals were not served at the scheduled times posted by the facility. The report states that the facility failed to ensure meals were served in accordance with residents’ needs, preferences, and requests, and that suitable and nourishing alternative meals and snacks were provided for residents who wanted to eat at non-traditional times or outside scheduled meal times. The deficiency was identified through observation, interview, and record review and was noted as affecting all 62 residents in the facility. Residents and staff described repeated delays in meal service. R5 and R7, both documented as cognitively intact on their MDS assessments, stated that meals delivered to their rooms were always late, with noontime and evening meals sometimes delayed by 30 minutes to an hour and a half. R2, whose MDS showed moderate cognitive impairment, said she ate in the large dining room and that noontime and evening meals were often served late. An LPN and a CNA also reported that meals were often late, with one meal served an hour and a half late a couple of weeks earlier and the noontime meal over 30 minutes late during the survey. The facility’s posted dining schedule listed specific serving times for each dining room and cart route, but surveyors observed residents waiting for the noon meal and saw the meal carts arrive late on multiple occasions, including the small dining room cart arriving 49 minutes late on one day and 30 minutes late on another, with other carts arriving 35 to 42 minutes late.
Late Meal Delivery and Irregular Meal Times
Penalty
Summary
The facility failed to ensure residents received meals and snacks at times in accordance with their needs, preferences, and requests, and failed to provide three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. During the kitchen tour on 5/17/2026, dietary staff were still on the tray line at 9:05 AM while prepping cart #7 of 9, and at 9:25 AM they were still preparing the last cart. The dietary aide stated the goal was to have the last cart out by 9:00 AM, but that it did not always happen. The last tray cart left the kitchen at 9:50 AM for the 400 hall. The cook later stated the lunch tray line should start at 11:30 AM, but at that time the tray line was not ready and the District Manager said they needed 15 more minutes; at 12:05 PM it was still not ready, and the tray line did not become ready until 12:40 PM. The last cart was finished and loaded at 2:00 PM. On 5/17/2026 at 11:25 AM, three residents on the [NAME] unit were still eating breakfast and several others still had breakfast trays in their rooms. Two of those residents stated it was fairly normal for breakfast to be that late and that when breakfast was late, each consecutive meal would be late as well, with supper likely not until 8:00 PM or later. On 5/18/2026 at 2:38 PM, residents on the 400 hall still did not have lunch trays, and the Administrator stated the trays were on a cart outside the kitchen door and no one had pushed them up. The last tray on that cart was passed at 2:48 PM, leaving many residents on the unit still eating lunch after 3:00 PM. The District Manager stated the department had been short staffed since taking over the building in March and that the goal of four aides and one cook on each shift was rarely happening. On 5/19/2026, lunch trays arrived on the 400 hall at 1:36 PM. A CNA also stated that dinner trays had once not been served until 9:00 PM, and another CNA stated meals were often really late and that dinner trays had sometimes arrived around 7:00 to 7:30 PM.
Delayed Dinner Service and Empty Snack Pantry
Penalty
Summary
Meals were not served at regular times comparable to normal mealtimes in the community, and suitable, nourishing alternative snacks were not available for residents waiting for meals. On the 4th floor, dinner service on 05/11/2026 took more than two hours to complete. Residents were seated in the dining area between 4:20 PM and 5:03 PM, but dinner was not fully served to those residents until between 4:50 PM and 5:30 PM, and residents eating in their rooms were not served until much later, with hallway cart service continuing until after 7:00 PM. The facility’s written meal schedules identified dinner as occurring between 5:30 PM and 7:00 PM, but the observed service extended beyond that timeframe. During the dinner observation, residents at tables were left waiting while others at the same table began eating, and staff were observed standing in the dining area without assisting with meal service or expediting tray delivery. At least ten staff were present in the dining area at 4:25 PM, but no staff were observed helping with meal service. One resident was seen trying to unwrap a sandwich at 5:05 PM, and dining staff did not notice the resident needed help until an activities aide intervened and assisted at 5:06 PM. A resident later stated they were unable to go to the patio because dinner had not yet arrived and said breakfast and dinner were always served late. The snack pantry was also found to lack nourishing options, and a CNA stated it should always be stocked but had not been. Staff interviews indicated the snack restocking process was inconsistent, with one staff member responsible for checking inventory daily and restocking between meals, while another stated the new tray line system and staffing shortages were making meal service difficult. The Food Service Director and other staff described a new food system implemented on 05/05/2026, including separate preparation for residents eating in rooms and those eating in floor dining rooms, and acknowledged that dinner service on the prior day had been a major struggle for the tray line serving residents in their rooms.
Snack Items Not Routinely Available
Penalty
Summary
The facility failed to ensure snack items were available at all times for residents. During the initial facility tour on 05/11/26, no snack trays or snack storage were visible on any of the three residential hallways. During the kitchen tour later that morning, the dry food stock room shelf was empty of resident snack items. The Dietary Manager confirmed the shelf was empty and stated food ordering was done on Mondays, with delivery on Thursdays, and that snack items had been available as of the prior Friday, though the reason the shelf was empty was not known. Resident interview revealed there were no snacks available the previous Saturday or Sunday. The resident stated snacks were usually offered after supper and before bedtime and could sometimes be obtained from the nurse's area, but also stated she had to buy her own snacks at times because they were not given regularly. An LPN stated evening snacks were not routinely available, explaining that kitchen staff were supposed to deliver snack trays around 7:00 P.M., but they sometimes arrived late or did not arrive at all. When delivered, the trays were kept at the nurse's desk and passed out by night shift staff. The facility policy titled Frequency of Meals stated evening snacks would be offered routinely to all residents.
Failure to Consistently Provide Requested Snacks
Penalty
Summary
The facility failed to consistently provide snacks as desired by residents, including bedtime snacks required by facility policy. A review of the Snacks policy showed that HS snacks are to be provided for all residents, and diabetic residents are to receive a nourishing snack consisting of two food groups. During a resident group interview, four residents stated that snacks were not routinely offered in the evenings and that they wanted an evening or bedtime snack. Those residents reported that they had raised the concern at multiple resident council meetings and that it remained ongoing. Two residents stated that dietary staff brought snacks to the unit, but nursing staff did not deliver them to residents, and not all residents knew snacks were available at the nurses station. Review of grievances for the prior six months found no documented grievances about snacks, and the NHA was unable to explain why residents were not consistently offered snacks as desired.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.