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:
Residents waited an excessive amount of time for lunch service, with one meal period lasting nearly 2 hours for 59 residents. The dining room schedule listed breakfast at 7:30 AM, lunch at 11:30 AM, and dinner at 5:00 PM, but residents were still waiting after food was placed on the steam table, and two cognitively intact residents reported that meals were sometimes cold and that they had complained about the long waits. Resident Council notes also documented concerns that meals were late, and the Corporate Dietician stated that waiting over an hour for service was too long.
A facility failed to keep dinner-to-breakfast meal service within the 14-hour limit required by its policy for Rehab/West Hall, North Hall, South Hall, and Meal Assist. The Resident Council said they had not agreed to a longer span, and the Dietary Supervisor confirmed that some carts exceeded 14 hours between dinner and breakfast, noting residents who request snacks and diabetic residents receive HS snacks and that the issue could affect weight loss.
Failure to provide nourishing snacks between meals. Facility policy stated residents could request snacks and all residents were to be offered an evening snack, but the meal schedule created a 15-hour gap between dinner and breakfast. Surveyors found snack bins with only cookies or crackers and no nourishing snacks in unit or RN supervisor refrigerators. Several residents said they were not offered bedtime snacks or were told none were available, including a resident with a history of gastric sleeve surgery who reported hunger between meals and at night.
Meals were not consistently served within scheduled meal times. Residents and staff reported that breakfast, lunch, and dinner were often late, with some meals delayed 30 minutes or more. On the secured unit, lunch trays were observed being delivered late, and the RD confirmed the delay. The DM said the dietary department had been short three aides since January, which contributed to late trays. Residents who needed feeding assistance, including a resident with Devic disease and another with cerebral infarction, were also observed receiving lunch after the scheduled time.
Meal service was not provided according to the posted schedule, with breakfast, lunch, and dinner trays repeatedly going out late. Residents reported meals arriving well after scheduled times, and dietary staff confirmed delays, short staffing, and that tray line food temperatures were not taken when the kitchen was rushed.
A resident with cerebral infarction, diabetes, muscle weakness, significant memory loss, and total dependence for feeding missed a lunchtime meal when medical transport arrived for an appointment. Staff gave Ensure instead of a meal, while the RD, DD, and DON confirmed that Ensure is not a meal replacement and that a packed meal or sack lunch should have been arranged through the kitchen.
Delayed Meal Service and Long Waits for Lunch
Penalty
Summary
Meals were not served at regular times and residents experienced long waits for lunch service. The dining room bulletin board listed breakfast at 7:30 AM, lunch at 11:30 AM, and dinner at 5:00 PM, and the Administrator confirmed lunch was served at 11:30 AM daily. However, at 12:05 PM only one dietary staff member was in the kitchen while residents were already seated in the dining room waiting for lunch. At 12:10 PM, all food was placed on the steam table and the Dietary Manager took temperatures, but residents were still waiting to be served. During the lunch service, the last resident was served at 1:18 PM, making lunch service last 1 hour and 48 minutes for 59 residents. Two cognitively intact residents stated the food was sometimes cold and that they had complained about having to wait so long for food in the dining room. One resident said the issue had also been discussed at Resident Council meetings, and April Resident Council Meeting Notes documented residents’ concern that meals were late. The Corporate Dietician stated that meals should be served at a reasonable time without waiting and that waiting over an hour for service was too long for 59 residents.
Meal service times exceeded the 14-hour limit between dinner and breakfast
Penalty
Summary
The facility failed to ensure meal cart deliveries were scheduled so that no more than 14 hours elapsed between dinner and breakfast for residents on Rehab/West Hall, North Hall, South Hall, and Meal Assist. The facility’s policy for Frequency of Meals stated there should be no more than a 14-hour span between a substantial evening meal and breakfast, and the facility’s meal service times showed dinner carts beginning at 5:00 PM and breakfast carts beginning at 7:15 AM, 7:30 AM, 7:40 AM, and 8:00 AM for the respective halls and meal assist area. During the Resident Council meeting, eleven residents stated they had not agreed to a time span greater than 14 hours between dinner and breakfast. The Dietary Supervisor was interviewed and acknowledged that residents requesting snacks and diabetic residents receive an HS snack, and that 14 hours was allowed between dinner and breakfast. While reviewing the meal service times, the Dietary Supervisor stated there were 14 hours and 15 minutes between dinner and breakfast for Rehab/West Hall, North Hall, and Meal Assist, and 14 hours and 10 minutes for South Hall. When asked how the time periods extending over 14 hours could affect residents, the Dietary Supervisor said weight loss.
Failure to Provide Nourishing Snacks Between Meals
Penalty
Summary
The facility failed to ensure meals and snacks were served at times in accordance with resident needs, preferences, and requests, and failed to provide or offer a nourishing snack outside of scheduled meal times. Facility policy stated that nourishing snacks are available, residents may request snacks as desired, snacks may be scheduled between meals to match typical eating patterns, and all residents are offered a nourishing evening snack. However, the meal cart delivery schedule showed dinner was served as early as 4:15 PM and breakfast as late as 9:20 AM, creating a 15-hour span between the evening meal and breakfast the next day. Survey observations found that snack bins in multiple unit nourishment pantries contained only items such as graham crackers and cookies, and no peanut butter crackers or nourishing snacks were observed in refrigerators. Additional observations in medication storage room refrigerators and the RN Supervisor office refrigerator found no nourishing snacks or sandwiches. Staff interviews indicated that snacks were delivered to units daily or every other day, and that sandwiches were stored in the RN Supervisor refrigerator for new admissions or resident requests, but the observed refrigerators did not contain those items at the times surveyed. During a resident group meeting, several residents stated they were not offered bedtime snacks and were told none were available when they asked. One resident with a history of gastric sleeve surgery reported eating small meals, feeling hungry between meals and at night, and being told staff did not have any snacks. Another resident stated he did not like the taste of the food, did not get enough to eat, and was usually told there were no snacks when he asked. The record for the resident with gastric sleeve surgery showed a regular diet and intake ranging from 25% to 75%, and a physician note documented prior complaints of nausea and poor oral intake related to a history of gastric bypass surgery.
Meals Served Late and Outside Scheduled Times
Penalty
Summary
Meals and snacks were not served at times in accordance with resident needs, preferences, and requests. Review of the Monthly Resident Council Meeting Minutes showed that residents had already voiced concern that meals were being served late. During a resident group interview, six residents who were identified by the facility as reliable historians and alert and oriented stated that meals were frequently served 30 minutes or more late and that this could happen with any meal. One resident reported that meals were sometimes late because nursing assistants did not deliver them in a timely manner and sometimes because the kitchen did not have enough staff, especially on weekends. Observations on the secured unit showed lunch trays being served late to residents in their rooms, including one resident who was the last resident on the unit to receive lunch at 2:26 PM. The Registered Dietitian confirmed that lunch meals on the secured unit were served late and stated she did not know why they were later than scheduled. The Dietary Manager stated the dietary department had been short three dietary aides since January, that staff tried to stick to the schedule, and that if breakfast was late then lunch was late because the department was short-staffed. The deficiency also affected residents who required assistance with eating. One resident with Devic disease, bilateral upper and lower extremity impairments, and dependence on staff for all ADLs was observed beginning the noon meal at 2:35 PM and finishing at 2:55 PM, and later stated that lunch and dinner were served after their scheduled times. Another resident with cerebral infarction and dependence on staff for eating was observed receiving lunch assistance at 2:19 PM. A cognitively intact resident with spinal stenosis stated that lunch was served after 2:00 PM on one day and at about 12:30 PM on other days. The facility’s documented meal start times listed breakfast from 7:00 AM to 8:45 AM, lunch from 12:00 PM to 1:45 PM, and dinner from 5:00 PM to 6:45 PM.
Late Meal Service and Missed Scheduled Tray Delivery
Penalty
Summary
The facility failed to ensure meals were served in accordance with its posted meal service schedule for breakfast on 05/30/2026 and for breakfast, lunch, and dinner on 06/13/2026. The facility policy titled, "Mealtimes," listed breakfast as 7:45-8:45, lunch as 12:45-1:45, and dinner as 5:45-6:45. However, an observation of the posted meal times on the bulletin boards showed staggered meal delivery times across different halls and dining areas, and staff and resident interviews described repeated delays in tray delivery. A concern was reported on 06/01/2026 that several residents said breakfast on 05/30/2026 was two hours late. Staff interviews confirmed that breakfast trays were very late that morning, with one staff member stating no one showed up in the kitchen and management had to start breakfast until a cook arrived. For 06/13/2026, staff reported that the first lunch carts did not go out until 1:45 PM and the last lunch cart did not go out until 2:30 PM, while dinner carts began around 7:30 PM and the last cart went out after 8:00 PM. One dietary staff member also stated that, because of short staffing and being rushed, tray line food temperatures were not taken. Residents consistently reported late meal service on 06/13/2026. One resident said meals were late except when a particular dietary staff member worked. Other residents stated lunch arrived around 2:00 PM to 3:00 PM and dinner arrived around 7:00 PM to 8:30 PM, with one resident noting dinner was too late and could affect digestion before bedtime. Another resident expressed concern that late meals could affect diabetic residents and medication administration times. Staff also acknowledged ongoing complaints about meal timing, short staffing, and difficulty getting trays out on time.
Missed Meal During Appointment
Penalty
Summary
The facility failed to ensure that Resident 12 received a suitable meal when the resident had a scheduled appointment during lunchtime. Resident 12 was admitted with diagnoses including cerebral infarction, diabetes, and muscle weakness, and the record showed significant memory loss, wheelchair use, impairment in both arms and legs, and dependence on caregivers for all daily activities, including feeding assistance. The care plan directed that the resident receive the ordered diet, and the SBAR noted a 16-pound weight loss over six months. During observation, medical transport arrived while Resident 12 was in the room, and the resident's meal tray arrived shortly afterward. LVN 2 stated that because of the appointment, Resident 12 could not be fed a meal and was given Ensure instead. LVN 2 later stated the appointment should have been communicated to the kitchen so a snack pack could be prepared before the appointment. The RD stated Ensure should not replace a meal, and the DD confirmed the kitchen was not aware of the appointment and no sack lunch was prepared. The DON stated the Meals Packed to Go policy was not followed and that Ensure is not an appropriate replacement for a meal.
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