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
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Meals and snacks were not consistently served at posted times, with residents and CNAs reporting repeated delays for breakfast and lunch. A resident council president said late trays shortened dining time in the main dining room, another resident said he sometimes waited up to an hour, and a resident on the 3rd floor was still waiting for breakfast when the surveyor observed the tray had not arrived by the posted time. The DON, Dietary Mgr, and RD acknowledged meals should follow the schedule, and resident council minutes and a grievance form documented ongoing complaints about food not being on time.
Meals were not consistently served at scheduled times, with residents reporting late breakfast and supper service and some trays arriving well after posted meal times. Observations showed supper trays being delivered late, including to residents who said they were hungry but felt it was too late to eat, and breakfast trays not fully delivered until after 9:00 AM. Staff attributed the delays to kitchen staffing shortages, unfinished cleanup, and meal card issues, and the ADM acknowledged the problem was ongoing.
Failure to provide substantial evening snacks for residents on the memory care unit when the interval between dinner and breakfast was 15.5 hours. Three residents with severe cognitive impairment and nutritional diagnoses had no documentation of a substantial after-dinner snack. Staff confirmed there was no scheduled snack pass, evening refreshments were not provided after the activity assistant left, and the RD verified no substantial snack tracking was done for these residents.
Late Meal Tray Delivery: Meal trays were not delivered at scheduled times for breakfast and lunch, with carts for Halls 100 and 200 arriving late and out of sequence. Dietary staff reported call-outs and limited coverage, while nursing staff said they were not notified when trays were delayed; residents waited for meals and were offered snacks and juice until trays arrived.
Meals and room trays were not served on time for multiple residents. Residents with intact cognition and diagnoses including dementia, depression, anxiety, HF, HTN, and CAD reported late lunch service, and staff observations showed the last dining room meal was served before room trays were even started. Staff could not explain the delay, and one tray was delivered uncovered while drinks were still pending.
A resident with a hx of protein-calorie malnutrition and intact cognition did not receive a physician-ordered 2 PM snack, despite a documented preference for yogurt. Surveyor review found the resident was not on the kitchen snack list, and a CNA delivered labeled snacks to the unit without a snack for the resident’s hallway; the DM stated the resident should have been on the list and had been missed.
Late Meal Delivery and Missed Posted Dining Times
Penalty
Summary
The facility failed to ensure meals were served at scheduled times in accordance with residents’ needs, preferences, and requests. The meal schedule provided to the surveyor listed breakfast and lunch seating times for the main dining room and unit-specific times for the 2nd and 3rd floors, but multiple residents and staff reported that trays were routinely delivered late. On 07/30/26, the surveyor observed that breakfast trays had not arrived on the 3rd floor by 8:00 AM, and they did not arrive until 8:28 AM even though the posted mealtime for that unit was 7:50 AM. Residents described repeated delays and the effect on their routines. R6 stated meals were served late and that he sometimes waited up to one hour for his meal. R1 stated breakfast was received at 7:50 AM instead of 7:15 AM and said delays could be up to one hour without explanation. R15, the Resident Council President, stated late meal delivery disrupted the schedule in the main dining room and left less time to eat because the next seating group was already gathering in the hallway. R16 stated he had been waiting a long time for breakfast and was hungry while sitting in the 3rd-floor hallway. Staff also confirmed the problem. CNAs on the 2nd and 3rd floors stated breakfast was usually served later than the posted times and that residents frequently complained about waiting for trays. An Activity Director reported that meal lateness had been raised in Resident Council meetings in June and July, and a grievance/complaint form documented residents’ concerns that food was not on time. The Dietary Manager and Registered Dietitian stated meals should follow the posted schedule, with the RD noting residents should have at least 30 minutes to eat and that delays beyond a 10-15 minute grace period were not acceptable. The affected residents included individuals with intact cognition and one resident with moderately impaired cognition, and diagnoses listed included COPD, HTN, CKD, DM2, PVD, depression, bipolar disorder, anemia, and nicotine dependence.
Late Meal Service and Delayed Trays
Penalty
Summary
Meals and snacks were not served at regularly scheduled times in accordance with resident needs, preferences, and requests. Residents reported that breakfast and supper were often late, with one resident stating supper had been served as late as 8:00 PM and another stating meals were late when eaten on the halls. During observation, the supper meal was posted as 5:30 PM, but the first tray was not served until 5:45 PM, and some residents did not receive supper until about 7:00 PM or later. When asked about the delay, one resident said she would eat the meal because it was already too late to eat supper and she was hungry, while another refused the tray because she was not hungry at that time and asked staff to remove it. Breakfast was also observed to be delayed, with residents receiving trays after 8:55 AM and the last breakfast tray not served until 9:10 AM. Residents stated this was normal and that meals were often late, especially supper. Staff members reported that late meals were a pattern and attributed the delays to kitchen staffing problems, unfinished cleanup and dishes from the prior shift, and meal cards not being ready on time. The Administrator acknowledged that supper being late was an ongoing issue and stated it was not acceptable. The facility census report documented 64 residents residing in the facility.
Failure to Provide Substantial Evening Snacks
Penalty
Summary
The facility failed to provide substantial evening snacks for residents on the memory care unit when the time between dinner and breakfast was greater than 14 hours. The posted meal schedule showed breakfast delivered to the memory care cart by 7:30 A.M. and dinner delivered by 4:00 P.M., creating a 15.5-hour interval. The facility policy stated meals must be served on a planned schedule allowing no more than 14 hours between dinner and breakfast unless an evening snack consisting of at least two food groups is offered, which could extend the interval to 16 hours. Record review showed that three residents with severe cognitive impairment and significant care needs had no documentation of a substantial after-dinner snack. Resident #49 had diagnoses including dementia, major depressive disorder, and mild protein-calorie malnutrition and required moderate assistance with eating. Resident #96 had vascular dementia, major depressive disorder, and unspecified protein-calorie malnutrition and required supervision with eating. Resident #99 had Alzheimer’s disease, major depressive disorder, and mild protein-calorie malnutrition and was dependent in activities of daily living. Interviews with staff confirmed there was no scheduled snack pass, evening refreshments were not provided by the activity assistant after 4:30 P.M., and the regional registered dietitian verified there was no substantial after-dinner snack tracking for these residents.
Late Meal Tray Delivery
Penalty
Summary
The facility failed to serve meals and snacks at times in accordance with residents’ needs, preferences, and requests. Surveyors observed that the lunch meal on 7/19/26 and the breakfast and lunch meals on 7/21/26 were not delivered at the scheduled mealtimes. The deficiency affected residents receiving food by mouth on Halls 100 and 200 in a facility with a census of 115. For the lunch meal on 7/19/26, the facility’s schedule showed staggered tray delivery times to the dining room and both halls, but observation found that no resident was eating lunch in the dining room at the scheduled time and the trays for the 200 hallway had not arrived when expected. The only trays delivered to any hallway were for the 100 hallway, and the first tray cart to the 200 hallway did not arrive until 12:45 PM. A nurse aide stated the kitchen alternated which hallway received trays first and that trays were sometimes delivered late. For breakfast on 7/21/26, the scheduled tray times were not met after two dietary aides called out and only three dietary staff were present in the kitchen. The first breakfast cart did not leave the kitchen by 8:10 AM and was delivered to the 100 hallway at about 8:20 AM; residents in the 200 hallway did not receive breakfast until 9:20 AM, and nursing staff offered snacks and juice while residents waited. For lunch on 7/21/26, the first cart for the 100 hallway was not delivered until 12:45 PM, and carts for the 200 hallway arrived at about 1:30 PM. Staff interviews showed that dietary staff did not notify nursing when trays were running late, and the Administrator stated she was not aware that meal cart delivery between hallways alternated.
Delayed Meal and Room Tray Service
Penalty
Summary
Meals were not served in a timely manner for 7 of 7 residents reviewed for meal service. The facility’s meal schedule listed lunch at 11:30 AM in the Assisted Dining Room and 12:00 PM in the Main Dining Room, but it did not indicate when residents in their rooms were to receive lunch. On 7/13/26, Resident #3, who had diagnoses including heart failure, non-Alzheimer’s dementia, and anxiety disorder and a BIMS score of 15, received lunch in her room at 1:24 PM. Resident #55, who had diagnoses including non-Alzheimer’s dementia, anxiety disorder, and depression and a BIMS score of 15, stated at 12:35 PM that meals arrived late. Resident #58, who had diagnoses including depression, high blood pressure, and coronary artery disease and a BIMS score of 15, stated at 2:40 PM that lunch was received around 1:30 PM, as usual. Additional observations showed delayed room tray delivery throughout the meal period. Resident #64 stated residents should receive food by 12:30 PM and that 12:30 PM was the latest she wanted to eat; she also stated meals usually arrived late and that she had reported this without seeing changes. Resident #68 stated meals arrived late sometimes and expressed frustration about available options. At 1:00 PM, the last meal in the main dining room was served, and room trays were not brought out until 1:11 PM. Resident #38 stated at 1:20 PM that she wished staff would bring food because she was hungry and wanted tea. Staff C stated one staff member usually passed out room trays while another cleaned the dining room, but did not know why meal delivery took so long that day. Staff H later carried an uncovered tray to Resident #28’s room at 1:35 PM and said drinks still needed to be obtained, but did not return with them.
Missed Ordered Afternoon Snack
Penalty
Summary
The facility did not ensure that a resident with a physician-ordered 2:00 PM snack received that snack in accordance with the resident’s plan of care and preferences. The resident was admitted with a diagnosis of unspecified protein-calorie malnutrition and had a BIMS score of 15 out of 15, indicating cognitive intactness. The resident stated that she was supposed to receive a 2:00 PM snack and preferred yogurt, but did not remember the last time she received one. The physician order directed staff to offer a 2:00 PM snack, with yogurt noted as the resident’s preference, and to record afternoon supplement intake. Surveyor observations and record review showed the resident was not on the kitchen’s snack list, and the dietary manager confirmed the resident should have been on the list if an order existed. On observation, a CNA delivered labeled snacks to the wing, but the resident did not have a labeled snack on the tray for her hallway. When asked about the missing snack order, the dietary manager stated this was the first time she had heard the resident was not receiving the snack and indicated the resident may have been missed when she took over the position.
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