Delayed Breakfast Meal Service Due to Dietary Staffing Shortage
Penalty
Summary
On 5/22/2025, the facility failed to provide breakfast meals at the scheduled times for all residents who received food by mouth across all seven halls. Scheduled breakfast serving times ranged from 7:00 AM to 8:00 AM depending on the hall, but observations revealed that, except for the 500 hall, breakfast trays did not arrive on any hall by 9:00 AM. The 100 hall, for example, did not receive breakfast trays until 9:40 AM. During this delay, nursing staff offered cereal and milk to residents as an alternative, and there were no issues identified with diabetic residents receiving their meals later than usual. Interviews with staff indicated that the delay was due to two cooks calling out, which left the dietary department short-staffed. The Dietary Manager became aware of the staffing shortage at 7:00 AM and was unable to schedule replacement staff in time. A team from a sister facility arrived to assist, but meal preparation did not begin until 8:00 AM. Staff reported that they typically communicate tray delays and snack availability through a group chat. The Administrator confirmed that food trays are expected to be delivered on time and that snacks should be offered if trays are late.