Meals and snacks were not consistently served at posted times, with residents and CNAs reporting repeated delays for breakfast and lunch. A resident council president said late trays shortened dining time in the main dining room, another resident said he sometimes waited up to an hour, and a resident on the 3rd floor was still waiting for breakfast when the surveyor observed the tray had not arrived by the posted time. The DON, Dietary Mgr, and RD acknowledged meals should follow the schedule, and resident council minutes and a grievance form documented ongoing complaints about food not being on time.
Meals were not consistently served at scheduled times, with residents reporting late breakfast and supper service and some trays arriving well after posted meal times. Observations showed supper trays being delivered late, including to residents who said they were hungry but felt it was too late to eat, and breakfast trays not fully delivered until after 9:00 AM. Staff attributed the delays to kitchen staffing shortages, unfinished cleanup, and meal card issues, and the ADM acknowledged the problem was ongoing.
Residents waited an excessive amount of time for lunch service, with one meal period lasting nearly 2 hours for 59 residents. The dining room schedule listed breakfast at 7:30 AM, lunch at 11:30 AM, and dinner at 5:00 PM, but residents were still waiting after food was placed on the steam table, and two cognitively intact residents reported that meals were sometimes cold and that they had complained about the long waits. Resident Council notes also documented concerns that meals were late, and the Corporate Dietician stated that waiting over an hour for service was too long.
Meals were not served at the posted times, with residents and an LPN reporting repeated delays for noon and evening meals. Surveyors observed residents waiting for lunch while meal carts arrived late to the dining rooms and hall routes, including delays of 30 to 49 minutes and other carts arriving 35 to 42 minutes late.
Bedtime snacks were not routinely offered or provided to all residents. Five residents reported that snacks were only given to some people, were placed on dinner trays, and were no longer brought to the dining room for everyone; they said residents who wanted snacks had to buy them from the activity table and were hungry between dinner and breakfast. RN, dietary, and DON interviews confirmed that snacks were not routinely offered, were mainly provided for residents with orders or DM, and the five residents reviewed had no bedtime snack orders despite a facility policy stating bedtime nourishments would be provided after the evening meal.
Failure to offer bedtime snacks to three diabetic residents was identified during record review and resident interviews. The snack policy said snacks are available during and after kitchen hours, but records did not show snacks were offered or consumed, and each resident stated nighttime snacks were not being provided. The residents included one cognitively intact resident with Type 2 DM, CHF, and insulin dependence; one resident with moderate cognitive impairment and multiple serious diagnoses including Type 2 DM and leukemia; and one cognitively intact resident with Type 2 DM, insulin dependence, and a nutrition plan calling for peanut butter and crackers at 7:00 PM. The DON stated snacks were kept in the clean utility closet and residents could request them anytime.
A facility failed to consistently provide bedtime snacks to residents who wanted them. Residents reported that snacks were often unavailable at night, that staff sometimes said there were none to give, and that some residents went without unless family brought food. Resident council members said there were not enough snacks for everyone, diabetic residents did not always receive snacks, and CNAs sometimes ate the snacks. EHR task records also showed multiple dates with no documentation that residents received or declined a snack, despite the facility policy requiring bedtime snacks daily.
A facility failed to routinely offer bedtime snacks to all residents, despite a snack policy calling for nourishing food between the evening meal and breakfast. EHRs for several residents lacked documentation of snack offers or receipt, and those residents stated they were never offered snacks at bedtime. The DON said snacks were not routinely passed and residents had to use the call light to request them, which the ED confirmed.
Failure to Offer Bedtime Snacks: Residents reported they were not offered HS snacks and wanted them offered. A CNA stated staff do not go around offering bedtime snacks to all eligible residents, and the DON said snacks are kept at nurse stations for residents to request. The Dietary Manager stated snacks are actively distributed only on one hallway, while on another hallway they are available only upon request. Facility policy calls for bedtime snacks and/or fluids as appropriate.
The facility failed to provide timely meals in accordance with posted meal times, resulting in several residents receiving breakfast and lunch trays significantly later than scheduled and interfering with at least one resident’s ability to attend an activity. Staff were observed delivering a large number of unserved room trays well past the designated meal periods, and residents reported that their trays had just been delivered while they were eating much later than the scheduled times. Facility documentation noted concerns about meal trays not being picked up from rooms and the need for CNAs to return trays promptly, while staff acknowledged that the kitchen was far behind and that there were too many room trays being delivered late.
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