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F0809
E

Delayed Meal Service for Room Trays

Shawano, Wisconsin Survey Completed on 05-29-2025

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 ensure that meals and snacks were served at regular times and according to resident preferences for seven sampled residents. Multiple observations over several days revealed that room trays for breakfast and lunch were consistently delivered 30 minutes to an hour after the posted meal times. Residents reported frequent delays, with some indicating that breakfast was sometimes not served until nearly two hours after the scheduled time. Residents who received room trays expressed frustration at having to wait significantly longer than those who ate in the dining room, and several noted that the issue was ongoing and had been discussed in resident council meetings. Surveyors observed that room trays were plated first but then left on carts for extended periods before being delivered to residents' rooms. The delivery process involved multiple stops across different units, further delaying meal service. Residents interviewed described feeling upset and dissatisfied with the wait times, particularly for breakfast and lunch. Some residents noted that meal delivery was more timely when a hospitality aide was scheduled, but this only occurred twice per week. The dietary manager and nursing home administrator were unaware of the extent of resident concerns, and the dietary manager stated that kitchen staff typically did not assist with tray delivery except during staffing shortages. The deficiency was further substantiated by group interviews during a resident council meeting, where multiple residents confirmed that room tray delivery was frequently late, sometimes by over an hour. Residents expressed that the delays were unacceptable and that they should not have to wait so long for meals, especially when the posted meal times were not being honored. The observations and interviews consistently demonstrated a pattern of late meal service for residents receiving room trays, with staff and management unaware or uninformed about the ongoing concerns.

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