Failure to Provide Timely Meals and Consistent Snacks
Penalty
Summary
The facility failed to consistently provide meals and snacks in a timely manner and in accordance with residents’ needs, preferences, and requests. Multiple residents reported and were observed experiencing significant delays in meal service, with lunch and breakfast often served well after the posted mealtimes. For example, one resident expressed frustration at having to wait until 1:45 p.m. for lunch and ultimately refused to eat due to the delay. Another resident stated that breakfast was often served so late that it was nearly time for lunch by the time it arrived. Observations confirmed that food carts and tray delivery to various halls and units were frequently delayed, with some residents waiting up to 30 minutes after the posted mealtime for their food. Residents on the secured dementia unit were also affected, with one resident requiring total assistance for eating left with a tray for over 20 minutes before receiving help. Resident council meetings and interviews further revealed widespread dissatisfaction with the timeliness and quality of meals and snacks. Several residents reported that evening snacks were not consistently offered, and some had to request snacks but did not always receive them. Review of snack distribution records showed that certain residents were not offered evening snacks on multiple occasions within a 30-day period. Resident council minutes repeatedly documented poor ratings for snack quality, tray passing, and meal timing, with residents expressing that meals were often late and snacks and water passes were needed more frequently at night. The facility’s dietary manager was unaware of regulatory requirements regarding meal service hours, specifically the rule that no more than 14 hours should elapse between the evening meal and breakfast unless a nourishing snack is provided and agreed upon by residents. There was no evidence that residents had been consulted about extending the meal span to 16 hours. Facility policies stated that meal schedules should be posted and that residents needing assistance should be served last, but observations showed that assistance was not provided promptly. The failure to adhere to posted meal times, provide timely assistance, and consistently offer snacks resulted in residents experiencing long gaps between meals, dissatisfaction, and missed meals.