Failure to Serve Meals Timely and Consistently to Residents
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner, as required to meet residents' needs, preferences, and requests. Multiple residents reported and were observed experiencing significant delays in meal service, with some meals being served well past the scheduled times. On several occasions, residents were seen waiting in the dining room for extended periods before receiving their meals, and some resorted to eating snacks such as chips due to hunger. Staff interviews confirmed that meal delays were a recurring issue, often attributed to staffing shortages and operational challenges in the kitchen. The facility's posted meal times were not consistently adhered to, with documented instances of lunch and supper being served over an hour late. Additionally, there were instances where residents did not receive their trays at all until staff intervention occurred. One resident was observed preparing to leave the dining room without supper, believing she would not receive a tray, until a staff member intervened to provide her meal. Another resident was also reported to have not received a tray until prompted by staff. Nursing staff expressed concerns about the impact of these delays, particularly for diabetic residents who require timely meals in relation to insulin administration. The deficiency was substantiated through direct observation, resident and staff interviews, and review of facility records.