Failure to Serve Lunch Meals at Scheduled Times Due to Kitchen Malfunction
Summary
The facility failed to provide lunch meals to 196 out of 216 residents at the scheduled mealtime, as required by facility policy and posted meal schedules. On the day in question, the kitchen oven thermostat and igniter malfunctioned, causing the kitchen staff to begin plating lunches an hour late. As a result, the first lunch trays did not leave the kitchen until 1257 hours, well after the scheduled lunch period of 1130 to 1230 hours. The Dietary Manager confirmed that all residents receiving kitchen-prepared meals would not receive their lunch within the scheduled timeframe, which was important for those with medications scheduled around meal times. Multiple residents reported not receiving their lunch at the expected time, expressing feelings of hunger, frustration, and aggravation. One resident, who had received six units of insulin at 1130 hours, had not received her lunch by 1320 hours and reported feeling sweaty and hungry, requiring juice and a snack from staff. Nursing documentation confirmed her blood sugar was rechecked due to the late meal. Other residents also reported not being informed about the delay and described significant hunger, with one rating their hunger as a nine out of ten. These observations and interviews confirm that the facility did not meet its obligation to serve meals at scheduled times according to residents' needs and preferences.
Penalty
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The facility failed to provide timely meal service according to its posted mealtimes and written policy on meal frequency. Resident council minutes documented that meals were often late, and an observation confirmed that lunch trays arrived on one floor 55 minutes after the posted delivery time, as verified by an LPN. The dietary manager acknowledged that the posted schedule indicated when trays should be delivered, despite stating it reflected tray line start times. Multiple residents reported late meals as an ongoing concern, and the issue affected several residents and had the potential to affect nearly all individuals receiving meals from the kitchen, excluding one resident who was NPO.
The facility failed to provide meals at scheduled times, with lunch and dinner trays arriving 30–100+ minutes late to multiple wings and the main dining room, contrary to its own meal distribution policy and tray delivery logs. Staff reported that meals were routinely late and cited ongoing problems related to new dietary management and staff. A cognitively intact resident who was independent with eating became visibly upset and complained of waiting nearly an hour for lunch, while another cognitively intact resident who required only set-up for eating reported late dinners, including one evening when trays arrived very late. The NHA confirmed that meals were not served at the scheduled mealtimes for residents throughout the facility.
Surveyors found that between-meal snacks were not consistently available or nutritionally adequate, with observations showing only a jar of peanut butter, a few peanut butter or peanut butter and jelly sandwiches on hard bread with minimal filling, and limited snack options such as small bags of Cheez-Its. Several residents reported that snacks were not always offered, especially at night, and that when provided, the sandwiches lacked substance. A staff member confirmed that dietary repeatedly sent sandwiches with only a small clump of peanut butter that was not spread. These practices did not follow facility policies requiring three meals daily plus an evening or bedtime snack and a variety of high-nutritional-value snacks stocked in each service area.
The facility failed to consistently provide between-meal and bedtime snacks in accordance with residents’ needs and preferences on all three nursing units. Although facility policy required that between-meal snacks be available, staff interviews revealed that residents were unhappy because they were not receiving bedtime snacks. Resident Council and Food Committee minutes documented repeated reports that snacks were not being offered or delivered by NAs. Residents reported that while snacks were delivered to the units, NAs sometimes ate them and did not consistently offer or provide them. The ADON confirmed that snacks were not consistently provided as desired, constituting a deficiency under 28 Pa. Code 211.12(d)(3)(5) for nursing services.
The facility failed to consistently provide substantial evening snacks to residents. Surveyors observed that the snack shelf and snack cart often contained only beverages and minimal crackers, with no other substantial snack items available, and the café refrigerator held a limited number of Jello, pudding, or fruit cups despite a resident capacity of 125. The FSD reported that snacks were delivered weekly but routinely ran out early in the week due to a reduced snack budget, and the Administrator was aware of the shortage. The dietician stated that snack availability had significantly declined since a change in ownership, that requests for additional snacks were not approved, and that snacks needed for diabetics or residents who did not eat meals for caloric supplementation were not always available.
The facility failed to consistently provide and offer evening and HS snacks as required by its own policy. A bedbound, oriented resident reported never being offered facility snacks and relying on family-provided food, while another oriented resident in a wheelchair stated they often missed evening snacks because they had to be at the nurses’ station at the right time and some days received no snack despite wanting one daily. A nonverbal resident’s family member reported the resident appeared hungry at night, requested double portions that were often not received, and had not been offered a grievance form. The Dietary Manager stated that various snacks were prepared and sent to the unit but acknowledged that snacks disappeared quickly, possibly due to residents hoarding them or staff taking them, and snacks were also kept in the dietary office. These observations and interviews showed that snacks were not reliably offered or made accessible to all residents in line with facility policy.
Failure to Provide Timely Meal Service According to Posted Mealtimes
Penalty
Summary
The deficiency involves the facility’s failure to ensure meals were served in a timely manner in accordance with residents’ needs, preferences, and the facility’s own posted mealtimes and policy. Resident Council minutes from two separate meetings documented that meals were often late. The facility’s posted mealtime information at the second-floor nurses’ station indicated that the second-floor meal cart was to be delivered at 11:50 A.M. During an observation on 03/23/26 at 12:45 P.M., lunch trays arrived on the second floor, and an LPN confirmed that the trays were 55 minutes late compared to the posted delivery time of 11:50 A.M. The facility’s written mealtime policy titled “Frequency of meals” stated that three regular mealtimes would be scheduled comparable to normal mealtimes in the community. During interviews conducted in conjunction with the survey, the Dietary Manager stated that the posted times represented when tray line started for the food cart, but then acknowledged that the posted mealtimes indicated trays were to be delivered to the second floor at 11:50 A.M. In a resident council meeting held during the recertification survey, five residents reported that late meals were a concern. The deficiency affected five residents reviewed for frequency of meals and had the potential to affect all 47 residents who received meals from the kitchen, with one resident identified as NPO. This issue was investigated under Complaint Number 2693841.
Failure to Provide Timely Meal Service According to Scheduled Mealtimes
Penalty
Summary
The deficiency involves the facility’s failure to serve meals at the scheduled times established in its own meal distribution policy and tray delivery logs. The policy dated June 26, 2025, required timely delivery of meals to dining locations, but observations and records on March 18, 2026, showed significant delays for both lunch and dinner across all wings (A, B, C, D) and the main dining room. Lunch trays scheduled for delivery between 11:55 a.m. and 12:40 p.m. arrived between 12:45 p.m. and 2:22 p.m., with delays ranging from 50 minutes to 1 hour and 42 minutes. Dinner trays scheduled between 5:30 p.m. and 6:10 p.m. arrived between 6:04 p.m. and 7:17 p.m., with delays of 34 minutes to 1 hour and 7 minutes. Staff interviews indicated that meals were routinely late by 10–20 minutes and that breakfast and supper on the same day and the previous evening had also been significantly delayed. Residents were directly affected by these delays. A quarterly MDS for one cognitively intact resident who was independent with eating showed that this resident became visibly upset in the dining room, stating it had almost been an hour and expressing hunger while slapping the table. An admission MDS for another cognitively intact resident who required only set-up for eating showed that this resident reported dinner trays being late on the survey day and recalled a recent Sunday when dinner did not arrive until 8:45 p.m. Activity and nursing staff attributed the ongoing delays to new dietary management and staff. The Nursing Home Administrator confirmed that lunch and dinner meals were served late and not at the scheduled mealtimes for all residents in the affected wings and the main dining room, in violation of 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Inadequate Availability and Quality of Nutritional Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a variety of snacks with nutritional value were consistently available and properly prepared for residents, as required by facility policy. Surveyors observed the snack pantry containing only one jar of peanut butter, no bread, and a tray with a small number of peanut butter and peanut butter and jelly sandwiches in baggies, with hard bread crusts and no other snacks available except those purchased by residents themselves. The snack cart was observed to have only small bags of Cheez-Its as snacks. On another observation of snack sandwiches sent from dietary, surveyors found several peanut butter and peanut butter and jelly sandwiches with hard crusts and such minimal fillings that the peanut butter and jelly had saturated into the bread, leaving no substance to the sandwiches. Multiple residents reported that snacks were not always available or offered, particularly at night, because staff did not have anything to provide. One resident stated that the peanut butter and jelly sandwiches had barely any filling, with only thinly spread peanut butter and jelly that soaked into the bread, which was hard. Another resident reported that the only snacks available were peanut butter sandwiches on hard bread with very little peanut butter. A staff member confirmed that dietary had repeatedly sent peanut butter sandwiches with only a small clump of peanut butter, about the size of a quarter, placed in the middle of the bread and not spread. Another resident indicated that nursing staff had to go out and buy peanut butter and bread so residents could have snacks because the dietary department rarely sent snacks. These findings were inconsistent with the facility’s written policies stating that each resident shall receive three meals daily plus an evening or bedtime snack, and that a variety of snacks of high nutritional value will be stocked in each service area by dining services.
Failure to Consistently Provide Resident Snacks as Required
Penalty
Summary
The facility failed to consistently provide snacks in accordance with residents’ needs, preferences, and requests on all three nursing units (North, South, and [NAME]). The facility’s Greenery Snack Policy dated 1/5/26 stated that between-meal snacks shall be available for residents. However, two nurse aides reported that residents were unhappy because they were not receiving bedtime snacks and that the facility was aware of this issue. Resident Council meeting minutes from 1/6/26, 2/4/26, and 3/3/26 documented residents’ statements that snacks were not being offered or delivered by nurse aides. Food Committee meeting minutes from 1/5/26, 2/3/26, and 3/2/26 also recorded that snacks were not being delivered to residents. During resident interviews, residents stated that snacks were delivered to the units but that NAs ate them and/or did not offer them consistently or provide them to residents. The Assistant DON confirmed that the facility failed to consistently provide snacks as desired for all three nursing units, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services. No specific resident medical histories or clinical conditions related to the deficiency were described in the report.
Failure to Provide Substantial and Consistent Evening Snacks to Residents
Penalty
Summary
The facility failed to provide residents with a substantial evening snack on a daily basis, as required by regulation and facility policy. Surveyor observations of the dietary department’s dry storage room on multiple dates showed that the designated snack shelf contained only a small quantity of items, such as one box of crackers and several 1-liter bottles of cola, with no chips, cookies, crackers, or other substantial snacks available. On another observation, there were no snacks available to residents at all. Review of the snack cart revealed it typically contained only a coffee carafe, a bottle of ginger ale, and at most a single or partial package of crackers, with no other food items present for residents. Further observations of the café refrigerator showed fewer than 20 containers of Jello, pudding, or fruit cups available for a facility with a capacity of 125 residents. In interviews, the Food Service Director (FSD) reported that snacks were delivered weekly on Thursdays but routinely ran out by Mondays due to a reduced snack budget of $315 per week. The Administrator acknowledged awareness of the lack of snacks and that the FSD had raised concerns. The dietician reported that snack availability had significantly declined since a change in ownership, that requests to purchase more snacks were not approved, and that snacks needed for residents who are diabetic or who did not eat meals were not always available, despite their importance for caloric supplementation.
Failure to Consistently Provide and Offer Required Evening Snacks
Penalty
Summary
The facility failed to ensure the consistent provision and availability of evening and bedtime snacks in accordance with residents’ needs and preferences. One resident, who was alert and oriented and restricted to bed, reported that they had never been provided or offered a snack by the facility and relied on family to bring snacks, expressing a desire to at least be offered something to see if there was an item they liked. Another alert and oriented resident in a wheelchair stated they were missing snacks at times, especially in the evenings, and explained that if they were not at the nurses’ station when snacks were passed out, they did not receive one. This resident described that snacks such as peanut butter and jelly sandwiches, pudding, and chips were available but that residents had to “run to that desk” to get them, and there were days they did not receive a snack despite wanting one daily. A family member of a nonverbal resident reported they were not aware of the resident receiving snacks and stated the resident seemed hungry during visits, leading the family member to request double food portions, which were often not received. During the interview, the nonverbal resident, who used a manual wheelchair, indicated through nonverbal cues (pointing to the surveyor’s and their own stomach and grimacing) that they were hungry at night, which the family member said occurred often. The family member had not been offered a grievance or concern form regarding snacks until prompted during the survey. The Dietary Manager reported that snacks such as chips, cookies, Jello, pudding, sandwiches, and rice crispy treats were prepared and sent to the unit on a tray, but acknowledged awareness of residents stealing and hoarding snacks and stated it was possible staff were taking snacks as they disappeared quickly. Although dry snacks were observed in the Dietary Manager’s office, residents’ reports and staff statements demonstrated that snacks were not reliably offered or made accessible to all residents as required by the facility’s policy, which states that all residents on regular diets are to be offered a bedtime snack each evening and that such snacks must be documented as offered.
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