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F0809
F

Failure to Provide Timely Meals and Snacks per Resident Needs and Preferences

Metropolis, Illinois Survey Completed on 11-17-2025

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 ensure that meals and snacks were consistently available and served in accordance with residents’ needs, preferences, and care plans. Multiple residents, including those with diabetes and moderate cognitive deficits, reported not receiving bedtime snacks as documented in their care plans. Staff interviews confirmed that snacks were not always available, with some staff stating that the kitchen was locked after supper, preventing access to snacks for residents. Residents and their families also reported that snacks were not being distributed, and that residents who were unable to leave their rooms did not receive snacks at all. Additionally, the facility did not serve meals within the required timelines. Residents and family members reported that meals were frequently late, sometimes by over an hour, and that the timing of meal service was inconsistent. Observations confirmed that meal trays were not delivered to all areas in a timely manner, with some residents waiting significantly past scheduled meal times. Staff attributed these delays to issues such as broken kitchen equipment, lack of supplies, and staffing shortages. The facility administrator acknowledged that there was no formal snack policy and could not confirm that residents with diabetes received routine snacks as required. Staff interviews further revealed a lack of consistent process for providing snacks, with some staff unaware of procedures or not receiving education on snack distribution. The facility’s own policy outlined specific meal times, but these were not adhered to, as evidenced by both staff and resident accounts and direct observation of meal delivery times.

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