Failure to Provide Timely Meal Service to Residents
Penalty
Summary
The facility failed to provide residents with meals at regular, scheduled times in accordance with their needs, preferences, and requests, as well as the facility's own designated meal service schedules. Multiple residents reported and staff confirmed that meals, including breakfast, lunch, and dinner, were often served late, sometimes by several hours. For example, lunch was served as late as 2:00 PM when it was scheduled for 11:30 AM-12:30 PM, and dinner was once served at 8:00 PM. These delays occurred on multiple occasions over the course of at least two months. Residents affected by these late meals included individuals with significant medical histories, such as chronic kidney disease, hypertension, and neuropathy, all of whom were cognitively intact and able to report their experiences. Residents described feeling hungry, unpleased, and forgotten due to the late meal service. Staff interviews corroborated these accounts, with explanations including disorganization in the kitchen and a specific incident where the head cook left unexpectedly, resulting in a significant delay in meal preparation and service. Staff, including the dietary manager, LVN, DON, and administrator, acknowledged that late meals had occurred multiple times and recognized the potential negative impact on residents, such as hunger and possible interference with medication administration. The facility's own documentation indicated that meals were to be served at regular hours, but this standard was not consistently met, as evidenced by both resident and staff testimony and direct observation.