F0800

D

Failure to Provide Ordered Lunch Meal to Dependent, Visually Impaired Resident

Toledo, Ohio Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident received a nourishing, palatable, well‑balanced diet that met the resident’s nutritional needs. The resident had multiple diagnoses including Type II DM, hypothyroidism, hypokalemia, adult failure to thrive, and anxiety disorder, and was blind with impaired cognition (BIMS score of eight). The care plan documented ADL self‑care performance deficits related to impaired vision and arthritis, required staff assistance with meals, and specified that staff should help the resident eat, encourage self‑feeding when possible, and use the clock system to describe plate setup. The resident was also care planned as being at risk for nutrition and hydration deficits due to multiple medical conditions and diuretic use, with interventions including providing ordered supplements and monitoring intake and weight. Facility documentation identified the resident as requiring feeding assistance.

On the observed lunch meal service date, surveyors noted that the resident was in her room at 11:39 A.M. with no meal tray present. Hall trays were delivered to the hallway at 11:52 A.M., and to resident rooms by 11:58 A.M., yet from 12:02 P.M. through 12:40 P.M. the resident still did not have a lunch tray. A CNA interviewed at 12:45 P.M. stated she was unaware the resident had not received a lunch tray, explained she was unfamiliar with the residents and the facility’s lunch tray process because it was her first time in the facility, and confirmed she did not check to ensure all residents had their lunch trays. An RN interviewed at 12:49 P.M. stated the resident always refuses meals and was not offered a tray because the resident likes Cheerios, further stating the resident would not allow a plate to sit on the tray table and again confirming that lunch was not offered to the resident.