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F0809
F

Failure to Routinely Offer and Provide Substantive Bedtime Snacks

Duluth, Minnesota Survey Completed on 05-02-2025

Penalty

No penalty information released
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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 consistently offer and provide a substantive, nutrient- and calorie-rich snack to residents after the dinner meal and before bedtime, resulting in a gap of up to 15 hours between the evening and morning meals. Multiple residents with intact cognition reported during interviews and a resident council meeting that staff did not deliver bedtime snacks, snacks were not substantial, and there was insufficient variety or quantity. Staff interviews revealed that snacks were available on the unit, but residents had to request them, and there was no routine snack cart service. Some staff were unaware of the existence of snack carts, and the DON stated that the expectation was for snacks to be offered before bedtime. Meal delivery times for each unit were documented, showing dinner was served in the early evening and breakfast the following morning, confirming the extended period without food. The facility's Snack Availability policy stated that residents should have access to nourishing snacks, defined as verbal offerings from basic food groups, but the practice did not align with this policy. The deficiency had the potential to affect all 107 residents in the facility.

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