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F0565
E

Failure to Address Resident Council Grievances Regarding Meal Utensils

Rural Retreat, Virginia Survey Completed on 04-08-2025

Penalty

Fine: $135,372
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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

Facility staff failed to consider and act upon the grievances and recommendations of the Resident Council regarding the consistent lack of appropriate utensils, specifically knives, with resident meals. Over several months, Resident Council meeting minutes repeatedly documented concerns about not receiving knives or only receiving plastic knives, which were inadequate for cutting meat and spreading condiments. Residents reported having to use their fingers or forks to eat items like pork chops due to the absence of proper knives. The issue persisted despite multiple documented complaints, with residents also noting the frequent use of plastic plates and utensils, especially on weekends. During interviews, residents confirmed the ongoing problem, and staff acknowledged a shortage of knives in the kitchen, with an order for additional knives placed months prior. Surveyor observations during meal service corroborated the absence of knives on meal trays. Documentation provided by the administrator regarding staff education and room rounds did not address the specific concern about knives. No further information or evidence of resolution was provided to the survey team before the exit meeting.

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