Failure to Provide Sufficient and Competent Dietary Staff for Meal Service
Penalty
Summary
The facility failed to provide sufficient and competent dietary staff to safely and effectively carry out the functions of the food and nutrition service, as evidenced by repeated delays in meal service, inadequate meal preparation, and missing dietary accommodations. Observations showed that meal trays were not delivered in a timely manner, with breakfast and lunch service running significantly behind scheduled times. Food items were often served cold, missing condiments, and in some cases, were not prepared according to residents' dietary needs, such as pureed diets or supplements. The facility's own policy required meals to be served no more than 30 minutes after scheduled times, but this standard was not met on multiple occasions. Interviews with residents, family members, and staff confirmed ongoing issues with meal timeliness and quality. Residents reported receiving cold food, missing items, and frequent delays, sometimes waiting over an hour past scheduled meal times. Some residents received only peanut butter and jelly sandwiches and oatmeal for meals, and dietary tickets were not always followed, resulting in incorrect or incomplete trays. Family members and staff corroborated these accounts, noting that meal service was especially problematic after the dietary staff walked out, and that non-dietary staff had to step in to prepare and deliver meals, often without adequate training or resources. The administrator and other staff confirmed that all previous dietary staff left the facility, leading to a period where nurses and CNAs prepared meals. During this time, residents did not consistently receive required supplements or special dietary items, and meal service was late and incomplete. Staff also reported ongoing struggles with insufficient supplies and staffing, which continued to impact the quality and timeliness of meal service for all 74 residents in the facility.