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F0557
E

Failure to Provide Appropriate Utensils Compromises Resident Dignity

Salisbury, Missouri Survey Completed on 11-24-2025

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 maintain resident dignity on the secured unit by providing only plastic forks and spoons for meal service, with no knives available for residents to use. Observations showed that residents were served meals such as meatballs and pork chops, which could not be easily cut with the provided utensils, resulting in residents having to use their hands to eat meat. Multiple residents expressed dissatisfaction with the use of plastic utensils, stating it was difficult to eat certain foods and that they did not like using plastic silverware. Staff interviews confirmed that plastic utensils were routinely used for safety reasons and to avoid delays in residents' smoke breaks, which occurred if metal silverware was unaccounted for after meals. Although butter knives were reportedly available upon request, staff did not routinely provide them, and residents were not always aware they could request them. The facility's policy on promoting and maintaining dignity emphasized treating residents with respect and considering their preferences and former lifestyles. However, the practice of serving meals without appropriate utensils, particularly knives, did not align with this policy. Staff and residents indicated that the use of plastic utensils was primarily to prevent issues with accounting for metal silverware and to avoid delaying smoke breaks, rather than based on individual resident needs or preferences. The deficiency affected all 57 residents on the secured unit, as observed and confirmed through interviews and record review.

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