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F0809
E

Delayed Meal Service and Untimely Tray Delivery

Oshkosh, Wisconsin Survey Completed on 11-25-2025

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 were served in a timely manner according to posted meal times and residents' needs and preferences. On the observed date, lunch service for multiple halls began later than scheduled, with Hall 4 starting at 11:45 AM instead of the posted 11:10 AM, and the meal cart not being sent to the unit until 12:00 PM. Similarly, Hall 2's meal service began at 12:07 PM, well after the scheduled 11:40 AM, and the meal cart was not sent to the unit until 12:30 PM. Certified Nursing Assistants did not begin delivering trays on Hall 2 until 12:43 PM, with the last tray delivered at 1:16 PM, significantly past the intended meal time. Resident and staff interviews confirmed that meal trays were frequently served late. One resident with intact cognition stated that trays should have been served earlier and that late service was a consistent issue. A CNA also confirmed the frequent lateness of meal service. The Dietary Manager acknowledged awareness of the ongoing problem and noted that they had recently started working full-time at the facility to address kitchen issues, having previously split time between two facilities.

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