Failure to Provide Correct and Timely Meals to Resident
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including metabolic encephalopathy, vascular dementia, dysphagia, and muscle weakness, did not receive a meal as required. The resident, who had moderate cognitive impairment, was observed on one occasion expressing hunger and stating that she had been forgotten for a meal the previous night. Additionally, there was a documented lack of food intake for dinner on a specific date. During another observation, the resident was found with a lunch tray intended for another resident, and staff only realized the error after it was pointed out by a surveyor. The correct lunch tray was then delivered, but the incident resulted in another resident not receiving their meal in a timely manner. Facility records and resident council forms further documented ongoing concerns about meal service, including dietary tickets not being read properly, residents receiving incorrect or disliked food items, and inconsistent portion sizes, particularly at dinner. These issues were noted as recurring and unresolved, contributing to the failure to provide nourishing, palatable, and well-balanced meals that meet residents' dietary needs.