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F0802
F

Inadequate Dietary Staffing Led to Delayed Meal Service

Carbondale, Illinois Survey Completed on 07-23-2025

Penalty

40 days payment denial
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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 provide an adequate number of dietary staff to serve dinner in a timely manner, affecting all 51 residents. On the evening in question, two scheduled dietary aides did not report to work, and only one dietary aide was called in late, arriving at 4:00 PM for a dinner service scheduled to begin at 5:15 PM. Certified Nurse Aides (CNAs) were observed assisting in the kitchen with meal preparation, and some residents also helped by clearing trays and dishes. Multiple residents reported receiving their dinner significantly late, with some meals not served until approximately 7:30 PM. Observations confirmed that only one dietary staff member was present in the kitchen during key meal preparation times, and the first tray was not served until 6:27 PM, with hall trays starting at 6:58 PM. The facility's staffing plan, as documented in the Facility Assessment Tool, did not specify dietary staffing levels, and the policy required prompt meal service and appropriate feeding assistance. Despite the expectation that more than one staff member would be present, only one was observed in the kitchen during the dinner service. Residents interviewed were alert and oriented, and they consistently reported delays in meal service and the involvement of non-dietary staff in food preparation.

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