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F0809
D

Meal Delivery Delays in LTC Facility

Boca Raton, Florida Survey Completed on 02-06-2025

Penalty

Fine: $48,825
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to the posted schedule for meal tray deliveries during two separate observations. On the first observation, lunch trays were significantly delayed across various dining areas and halls, with actual delivery times ranging from 12:52 PM to 1:43 PM, despite scheduled times between 11:30 AM and 12:10 PM. A second observation revealed similar delays, with trays arriving between 11:50 AM and 12:25 PM, contrary to the scheduled times of 11:30 AM to 12:00 PM. These discrepancies were confirmed through interviews with residents who consistently reported late meal deliveries. Two residents, both cognitively intact with a Brief Interview of Mental Status Score of 15, expressed concerns about the late meal deliveries. One resident, diagnosed with Parkinson's and muscle weakness, reported that lunch meals often arrived between 12:30 PM and 1:00 PM, sometimes even later. Another resident, with diagnoses of muscle weakness and difficulty walking, stated that it was common for trays to arrive around 1:30 PM on their unit. The kitchen District Manager acknowledged that meal timing changes were made for breakfast and dinner but inadvertently omitted lunch, contributing to the delays.

Plan Of Correction

Boca Circle Rehabilitation Center failed to follow their posted scheduled meal time for tray delivery. **Actions Taken:** 1) Residents residing in the facility have the potential to be affected by the alleged deficient practice. The facility has reviewed and readjusted mealtimes. Updated postings have been made available to residents and visitors. A resident council meeting was held on the updated posting of mealtimes. **Others Identified:** 2) A facility audit was conducted by the Certified Dietary Manager to ensure the residents' meals were delivered timely. **Measures Taken:** 3) Dietary Staff were in-serviced by the CDM on the components of this regulation with an emphasis on ensuring the meals are delivered as per the posted mealtimes. Newly hired dietary staff will receive this education during general orientation. **Ongoing Monitoring:** 4) The Dietary Manager/Designee will conduct audits to verify that the meal delivery follows the posted meal delivery times 3x weekly for 4 weeks, and then weekly for 4 weeks, and every 2 weeks for 1 month. Audit results will be reviewed in the Center QAPI meeting until substantial compliance has been met.

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