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F0809
E

Failure to Serve Meals Timely According to Resident Needs and Preferences

Davis, California Survey Completed on 04-18-2025

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 serve meals and snacks at times consistent with resident needs, preferences, and requests, as well as with community norms, for five sampled residents. Multiple residents reported that meals were consistently late, with some waiting up to 1 to 2 hours for their food. Observations confirmed that meal trays were not served at the scheduled times, and staff interviews acknowledged the delays. The posted dining schedule did not indicate specific meal times, and on several occasions, meal trays had not arrived or been served at the expected times. Residents expressed dissatisfaction, noting that meals were sometimes cold and that the lack of a consistent schedule made it difficult to plan their day. The affected residents had various medical conditions, including type 2 diabetes with hypoglycemia, hypomagnesia, hypokalemia, acute kidney failure, myopathy, paraplegia, anemia, and hyperlipidemia. Some residents had impaired cognition, while others were cognitively intact. Staff, including a registered dietician, CNA, dietary consultant, and the DON, confirmed awareness of the late meal service and acknowledged that it could impact medication administration and resident satisfaction. Review of facility policy indicated that meals should be served according to routine schedules and resident preferences, but these procedures were not followed.

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