Failure to Provide Designated Dining and Activity Room During Construction
Summary
The facility failed to provide a designated room for resident dining and activities during a period of construction, resulting in the use of the dining room, activity room, day care room, and medical record room as temporary sleeping quarters for displaced residents. The dining room/activity room, which is typically used for meals and activities, was repurposed to accommodate ten resident beds, while the day care room and medical record room were used for seven additional residents. This arrangement left no dedicated space for communal dining or activities, and residents were instead served meals at their bedside tables within these makeshift sleeping areas. Staff interviews confirmed that the relocation was due to an emergency plumbing issue in one of the facility's locked units, necessitating the movement of residents to available spaces throughout the building. The rooms were cleared and cleaned to accommodate the residents, and privacy curtains and call bells were provided at each bedside. However, the lack of a designated dining or activity area persisted throughout the duration of the construction, with staff and residents reporting that meals and activities were conducted at the bedside. Some residents expressed awareness of the temporary arrangement and described eating and receiving care in these non-traditional settings. Clinical record reviews indicated that several residents involved were cognitively intact, as evidenced by their Brief Interview for Mental Status (BIMS) scores. Staff also reported that residents' personal belongings were stored in a maintenance area, which was observed to contain maintenance tools and housekeeping equipment. Facility policies reviewed by surveyors referenced the use of dining and activity rooms as safe areas during partial evacuations, but did not address the prolonged lack of a designated dining or activity space for residents during extended construction events.
Penalty
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The facility failed to provide enough dining space for residents during meals. Observations showed a crowded dining room with meal carts, coolers, and staff moving through tight spaces while residents in wheelchairs and with leg rests had limited room at tables. A resident in an electric wheelchair had to sit sideways against a wall and spilled juice while trying to eat, and residents reported the room was loud, overcrowded, and sometimes so full that meals were served on the patio where birds and droppings were present. Staff and the DON acknowledged the crowding and use of overflow dining outside, and the administrator stated there was no official dining accommodation policy.
Dining room space was inadequate for resident meals and movement. The facility’s only dining room had four tables, but residents in wheelchairs crowded the room, blocked the doorway, and left no clear path between tables. Residents said the room got too crowded, some had to eat in their rooms if they arrived late, and one resident had to wait to leave because wheelchairs blocked the exit. The ADM acknowledged the room was too small for more than about 10 residents and that the prior larger dining room had been converted to the therapy gym.
Insufficient Dining Room Seating: The Station One dining area did not have enough standard-height chairs for all residents who wanted to dine there. During meal service, residents were observed eating while standing, using wheeled walker seats as tables, sitting on the floor, or taking trays back to their rooms because no chairs were available. Residents and an LPN reported the dining area was often too full, and the Administrator stated there should be enough chairs for all residents who wanted to sit in the dining room.
Insufficient dining space left residents who required feeding assistance waiting in the adjoining TV activity area while others ate. Staff reported that the feeding table could not seat all 16 residents needing help at once, so residents were rotated in as seats became available. Observations showed a large round table and a small square table with no room for additional seating or extra tables, and residents were seen waiting there on multiple occasions.
A resident was served lunch in the 4th floor dining room but had to carry the tray around while looking for a seat because no chairs were available. The resident stood while holding the meal and ate part of the sandwich before staff provided a chair. The Maintenance Director stated the facility had enough chairs and that extra chairs would be brought to the floor if needed.
The facility did not serve meals at the posted times, with lunch, breakfast, and dinner consistently delayed. A resident reported that meals often arrived late, and a CNA confirmed that residents were upset by the unpredictability. Observations showed lunch trays were served in the dining room and delivered to resident rooms well after the scheduled time, and the Dietary Manager stated that meal plating began at the posted time, causing further delays.
Crowded Dining Area With Overflow Meals Served Outside
Penalty
Summary
The facility failed to provide sufficient dining space to accommodate residents during meals. During observation, the dining room for the LTC unit had one small area for six residents who needed assistance with eating, while the same space also contained a large dining table, three metal meal carts, two blue coolers on stands, and a coffee stand. Staff were observed picking up trays from the kitchen counter and bumping against residents' wheelchairs to get through the area, and residents were moved to make room for others entering the dining room. As more residents arrived for lunch, the dining room became increasingly crowded. Residents were seated three to four per square table, and several residents with bariatric wheelchairs, electric wheelchairs, and leg rests had limited room to sit close to their tables. One resident was observed sitting sideways in a large electric wheelchair against the wall, spilling juice on his clothing and having difficulty reaching his plate. Another resident was observed leaning to one side and being repositioned by a CNA. At one point, 37 residents were observed eating lunch in the main dining room, and half of the residents had not yet received their meals by 12:25 P.M. Interviews confirmed that the dining area was too crowded and that overflow meals were sometimes served on the patio. A CNA stated there was not enough room in the dining room, and the ADON acknowledged the patio was used because of ongoing crowding. Residents reported that they disliked eating in the dining room because of the noise and limited space, and that they were often required to eat outside where birds gathered overhead and droppings were present on tables and around the eating area. The administrator stated the facility did not have an official policy for dining accommodations and did not know the maximum dining room occupancy.
Dining Room Too Small for Resident Use
Penalty
Summary
The facility failed to ensure the resident dining room had enough space for residents to dine and to enter and exit without moving other residents. During an observation, the facility’s only designated dining room contained one refrigerator, one section of upper and lower cabinets, and four tables. Seven residents in wheelchairs were eating breakfast in the room, including one resident seated at a table in the back left corner facing a wall. One resident wheelchair blocked the doorway, and there was no space to walk between the two center tables without moving residents, although there was visible table space for 10 residents. The facility census posted that day was 53 residents. During later observation and interview, residents stated the dining room became crowded, especially with wheelchairs, and that when there were about 10 residents in the room, they would run out of room and some residents had to eat in their rooms if they arrived later. One resident who self-propelled into the room stated they were not crazy about facing the wall and said they had to wait to leave because other residents’ wheelchairs blocked the way, and they wanted a pathway that stayed open. The Maintenance Director measured the dining room at 24 feet by 14 feet and stated that if all 50 or so residents wanted to eat there, that would be an issue. The Administrator stated the prior larger dining room had been converted to the therapy gym and acknowledged the current dining room was too small for more than about 10 residents.
Insufficient Dining Room Seating
Penalty
Summary
The facility failed to provide sufficient seating in the Station One dining area to accommodate all residents for dining. Fifty-eight residents from the 100, 200, and 300 halls shared the dining area, but observation showed only 12 standard-height dining chairs, 10 tall chairs along the back wall with no tables in front of them, and 3 tall chairs placed between shorter tables where the chairs were higher than the tables. During lunch service, residents were observed eating in ways that reflected the lack of available seating, including one resident using a wheeled walker seat as a tray table, another eating while standing at the counter, and another standing at a table before taking the tray back to the room. One resident entered looking for a chair, found none, and left saying there was no place to sit. Additional observations showed the same pattern on later dates, including residents using walker seats as tables, multiple residents taking trays to their rooms to eat, one resident sitting on the floor while eating, and another eating while standing. At one meal, all standard dining chairs were occupied and a resident and visitor stood because no open chairs were available. Residents interviewed said there were not enough chairs to sit at the dining room tables and that they often ate in their rooms or had to leave the dining room because seating was unavailable. An LPN said the dining room got full at meal service time, and the Administrator stated there should be enough chairs for all residents who wanted to sit in the dining room.
Insufficient Dining Space for Residents Requiring Feeding Assistance
Penalty
Summary
The facility failed to ensure there was sufficient space in the dining room to accommodate residents who required assistance with feeding. During observations on 03/09/2026, Resident #3 and Resident #35 were seen sitting in the adjoining TV activity section of the dining room while other residents were eating lunch. A CNA told S10TN that these residents were waiting to eat at the feeding table because space was not available. Later that morning, Resident #3 and Resident #35 were moved to the feeding table when space became available. On 03/10/2026, Resident #35 was again observed waiting in the adjoining TV activity section of the dining room to eat because there were no available seats at the feeding table. S10TN stated the facility did not have enough space to seat all residents who required feeding at once, so staff rotated residents out of the table as others finished eating. An observation of the feeding area showed a large round table and a small square table with no space for additional residents, staff, or extra tables. On 03/11/2026, Resident #121 was also observed waiting in the TV activity section to eat. S1DON stated there were 16 residents who had to be fed and it was not feasible for all of them to sit at the table at one time, so CNAs brought all of the residents needing feeding to the dining room and seated them in the TV activity section while waiting for space at the feeding table.
Insufficient Seating in Dining Room
Penalty
Summary
The facility failed to ensure adequate seating was available for a resident in the 4th floor dining room. On 1/5/26 at approximately 1:25 PM, the resident was served lunch on a tray at the steam table and carried the tray through the dining room looking for a seat, but no chairs were available. The resident stood in the dining room while holding the meal and ate half of a grilled cheese sandwich before staff provided a chair. On 1/7/26, the Maintenance Director stated that the facility had enough chairs in each dining room and said extra chairs would be brought to the floor if needed. The facility policy on the order of meals served states that dining rooms with open dining will serve the resident in a timely manner after being seated.
Failure to Serve Meals at Posted Times Disrupts Resident Dining Experience
Penalty
Summary
The facility failed to serve meals to residents at the posted serving times for breakfast, lunch, and dinner. Observations and interviews revealed that lunch, which was scheduled for 12:30 pm, was consistently served late, with the first tray being served in the dining room at 12:51 pm and the last at 1:11 pm on one day, and similar delays observed on the following day. Trays delivered to resident rooms in the north and south halls were also delayed, with the first trays not arriving until well after the posted lunch time. The Dietary Manager confirmed that the kitchen begins plating food at the posted time rather than having meals ready to serve, resulting in further delays. Residents and staff reported ongoing issues with meal timeliness. One resident stated that all meals, including breakfast and dinner, are always late, sometimes with breakfast arriving as late as 9:00 am and lunch and dinner being served significantly after the scheduled times. A CNA confirmed that residents become upset due to the unpredictability of meal delivery. These consistent delays in meal service disrupted the residents' dining experience as meals were not provided at the times posted by the facility.
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