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F0809
E

Failure to Provide Adequate Evening Snacks to All Residents

West Frankfort, Illinois Survey Completed on 09-16-2025

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 provide sufficient evening snacks to ensure that every resident had access to a snack, as required by their needs and preferences. Multiple residents, including those with diagnoses such as protein-calorie malnutrition and those at risk for malnutrition, reported that evening snacks were inadequate, often limited to only two saltine crackers or other minimal options. Residents also noted that snacks were sometimes only available to certain groups, such as smokers, and that there was a lack of variety and quantity, with some residents suggesting that additions like peanut butter would make the snacks more suitable, especially for those with diabetes. Staff interviews consistently confirmed that the facility frequently ran out of snacks in the evening, with CNAs and LPNs stating that there were not enough snacks to serve all residents. Staff described situations where ambulatory residents would take preferred snacks, leaving little or nothing for others, and noted that mechanically altered diets were not always accommodated. Dietary staff reported assembling snack baskets with a limited number of items, estimating that the total number of snacks was often insufficient for the resident population, and that they did not count or track the distribution to ensure all residents received a snack. Documentation and resident council minutes further supported these findings, with written complaints about the lack of snacks and long intervals between dinner and breakfast without adequate nourishment. The facility's own policy required snacks to be provided as requested and at bedtime, but observations and interviews indicated that this was not consistently implemented. The deficiency was substantiated by direct resident statements, staff admissions, and review of facility records and snack basket contents.

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