F0802

F

Insufficient Dietary Staffing Leading to Delayed Meal Service

South Holland, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient dietary staff to meet resident needs and to serve meals at the scheduled times. The facility census showed 112 residents, with 6 identified as NPO, leaving 106 residents dependent on food prepared in the facility kitchen. Multiple cognitively intact residents reported that meals were generally served late and sometimes cold. One resident with diagnoses including rhabdomyolysis, lumbar spine fusion, type 2 diabetes with neuropathy, malnutrition, COPD, obesity, and major depressive disorder stated that meals were generally late and sometimes cold while being observed eating lunch in their room.

Surveyor observations on a lunch meal service day documented that at 11:37 AM there was one cook and two dietary aides in the kitchen, with the cook confirming that lunch was scheduled to begin at 12:00 PM. At 11:59 AM, the cook reported that plating had not started because the dietary aides had not finished prepping trays and estimated another 25 minutes would be needed before plating could begin. At 12:30 PM, the cook and two dietary aides were observed plating food for the first dining room, and the assistant administrator was present in the kitchen questioning the delay. The final tray in one dining room was not served until 1:47 PM, which was 1 hour and 47 minutes after the scheduled lunch start time.

Additional resident interviews and record reviews supported a pattern of late meal service. A cognitively intact resident with trigeminal neuralgia, type 2 diabetes, hypertension, and osteoarthritis reported that food was never served on time and described receiving dinner at 7:10 PM when they were supposed to eat at about 5:00 PM, attributing delays to insufficient help in the kitchen and nursing. Another cognitively intact resident with hemiplegia, cataracts, hypertension, type 2 diabetes, and depression stated that most meals were served late. The dietary manager, employed for about two months, stated that more staff were needed in the kitchen despite efforts to streamline tasks and acknowledged that meals had been late. Review of dietary schedules showed frequent shifts with only one dietary aide or one cook on duty during key meal periods, and the facility assessment did not identify a dietary staffing plan or specify the number and types of dietary staff needed, while the administrator confirmed there was no written policy for dietary staffing beyond a general reference to regulatory language.