Failure to Provide Timely and Comparable Alternate Meals per Resident Preference
Summary
The facility failed to ensure that alternate meals were provided in a timely manner and comparable to regular meals in accordance with resident preferences and requests. Facility policy titled "Dining and Food Preferences" dated 1/22/26 stated that alternate meals and/or beverages would be provided in a timely manner. The facility meal schedule showed that lunch tray delivery began at 11:00 a.m. and the last delivery occurred at 1:15 p.m., indicating that tray line service continued until 1:15 p.m. Observations on 4/27/26 and 4/28/26 revealed a sign on the dining services door stating, "Alternate meals will be made at the end of tray line. Tray line does not stop!" The Dietary Manager confirmed that an alternate meal would not be prepared until tray line was completed. During an interview on 4/27/26 at approximately 12:45 p.m., Resident R55 reported requesting an alternate meal and waiting over 30 minutes to receive it, and that the alternate provided was only a peanut butter sandwich. The resident stated they were told they would have to wait until tray line was finished before receiving the sandwich. In a separate interview on 4/27/26 at approximately 1:00 p.m., Resident R123 and the resident’s representative reported requesting a grilled cheese sandwich instead of the scheduled meal and being told they would have to wait until tray line was completed. They stated it took over 30 minutes to receive the grilled cheese sandwich and that all other residents had finished eating by the time the sandwich was served. On 4/30/26 at 11:24 a.m., the Nursing Home Administrator confirmed that when a resident requests an alternate meal, it should be prepared and delivered in a timely manner. These findings were cited under 28 Pa. Code 201.14(a) Responsibility of licensee.
Penalty
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The facility failed to ensure residents were offered a substantial evening snack when more than 14 hours separated dinner and breakfast. Mealtimes were set at 8:00 a.m., 12:00 p.m., and 5:00 p.m., and staff reported that evening snacks were only provided to certain residents with orders or if a resident asked for one, rather than as a routine offering for all residents. Two residents stated they were not usually offered snacks in the evening.
Late Meal Service: Meal service was delayed beyond the posted schedule, with lunch and breakfast traylines running late and trays not fully passed until well after the expected times. Two residents reported that lunch arrived nearly 2:00 p.m. and that meals had been arriving late recently. The DS said the delay was due to extra resident requests, and the RD noted meals should come on time to maintain resident satisfaction and food palatability.
The facility failed to provide suitable, nourishing snacks consistent with resident needs and preferences, offering only limited items such as crackers, pudding, applesauce, and soda, with no meaningful alternatives. A resident with protein-calorie malnutrition and depression, for whom snacks between meals were very important, had a care plan that did not address snack interventions or preferences and reported only receiving pudding without options and not consistently receiving ordered double portions. Another resident with dysphagia, CHF, and hypertension reported that preferred snacks like sandwiches, cookies, and ice cream were no longer available, leaving only basic items. Multiple CNAs, an LPN, and dietary staff confirmed that snack choices had been reduced for cost reasons, residents complained daily, and staff sometimes bought snacks with personal funds. Resident Council and Food Committee records documented ongoing, unresolved complaints about limited snack variety and inconsistent stocking of items such as bread and peanut butter.
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.
Evening snacks were not consistently offered to residents when more than 14 hours elapsed between dinner and breakfast. Scheduled meal times created overnight gaps of 14 hours 55 minutes to 15 hours across multiple halls, and resident council and Food Committee minutes showed repeated complaints that snacks were not being passed or offered even when delivered to the units and placed in the pantry. All residents interviewed reported they did not receive a bedtime snack, and the NHA could not provide documentation that snacks were consistently offered.
A resident with CAD, Parkinson’s disease, neuropathy, and a recent below-the-knee amputation, who ate meals in their room and was on a carb-consistent diet with goals to maintain weight and consume 75% of meals, did not receive at least one scheduled dinner and had to actively seek out a missed breakfast tray. The facility’s policy required three daily meals at typical times or per resident preference, but interviews showed that CNAs, nursing aides, kitchen staff, the DM, an LPN, the DON, and the Administrator had conflicting understandings of who was responsible for taking meal orders, communicating them to dietary, tracking who ate, and ensuring all residents received trays. Staff acknowledged that the resident reported missed meals and that the resident had missed at least two meals, yet these incidents were not reported to the DON and the expected checks between dietary and nursing when a meal order was missing did not occur, resulting in failure to provide meals in accordance with the resident’s needs and the facility’s policy.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals. The facility-submitted document identified breakfast at 8:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m., creating a span of more than 14 hours between the evening meal and breakfast. The facility’s policy stated there would not be more than a 14-hour span between the substantial evening meal and breakfast unless resident council approved a longer span and a nourishing snack was provided before bed. During interviews, the manager of nutrition services confirmed the mealtimes, and the ADON stated snacks were available in the evening only if a resident asked for one, with no routine evening snack offering. NA-A said evening snacks were sent from the kitchen for specific residents between 6:30 p.m. and 7:00 p.m., labeled with resident names, and not all residents received them, though snacks were available upon request. LPN-A stated dietary brought a snack tray to some residents with orders for an evening snack, and staff were always asking residents if they wanted something to eat. Two residents stated they were not routinely offered snacks in the evening, though one believed staff would provide one if asked.
Late Meal Service
Penalty
Summary
The facility failed to provide meals at regular scheduled times in accordance with resident needs, preferences, and requests when lunch was served late on 4/22/2026. The deficiency affected 124 to 125 residents receiving meals from the kitchen, including two residents who were interviewed during resident council and reported that lunch had arrived nearly 2:00 p.m. and that breakfast and lunch had been arriving late recently. One resident had diagnoses including HTN, type 2 diabetes, and dysphagia, and the other had diagnoses including HTN, hyperlipidemia, and CHF; both were assessed as understanding others and making themselves understood and needed supervision or touching assistance when eating. Meal service observations showed the posted schedule listed breakfast at 7:30 a.m., lunch at 12:30 p.m., and dinner at 5:30 p.m. On 4/20/2026, dietary staff did not begin lunch trayline until 12:48 p.m., the first cart did not reach the dining room until 12:58 p.m., trayline finished at 2:08 p.m., and the last tray cart reached the station at 2:11 p.m.; nursing staff were still passing trays at 2:14 p.m. through 2:18 p.m. On 4/22/2026, breakfast trayline began at 7:33 a.m., the first cart left the kitchen at 7:56 a.m., the last breakfast tray was prepared at 9:04 a.m., and nursing staff finished passing the last tray at 9:13 a.m. During interview, the Dietary Supervisor stated the breakfast trayline runs from 7:30 a.m. to 8:30 a.m. and that the trayline was delayed because of food production for special resident requests, including extra omelets. The Dietary Supervisor stated the delay was not reasonable and that meals should be served on time because residents expect them at a certain time. The Registered Dietitian stated it was important for meals to come on time to prevent resident dissatisfaction and to keep food temperatures palatable. The facility policy stated residents' meals would be served at regular hours, with an unavoidable variance of 15 minutes considered acceptable, and listed lunch service as 12:30 p.m. to 1:30 p.m.
Failure to Provide Suitable, Nourishing Snacks Consistent With Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure suitable, nourishing snacks were available and provided in accordance with resident needs, preferences, and care plans. Surveyors found that snacks being distributed consisted primarily of pudding, graham crackers, saltine crackers, applesauce, and soda, with no meaningful alternatives when those items were not desired or appropriate. Observation of the nourishment room showed only limited beverages, crackers, and an almost empty freezer, confirming the restricted snack inventory. Staff interviews revealed that previously available items such as cookies, fig newtons, cheese crackers, and ice cream had been discontinued, and that residents complained daily about the lack of variety and availability. One resident with protein-calorie malnutrition, anxiety disorder, and major depressive disorder was cognitively intact and had an assessment indicating it was very important to have snacks between meals. The resident’s care plan addressed potential nutritional deficit with double portions at meals but did not include any interventions related to snacks or snack preferences. Dietary documentation showed a one-time update of food preferences without ongoing assessment or follow-up regarding snacks. This resident reported only receiving pudding for snacks without additional options, stated that no one had discussed snack preferences, and produced a meal ticket showing an order for two sandwiches when only one was received. Another cognitively intact resident with dysphagia, congestive heart failure, and hypertension reported that snacks were not regularly offered and that preferred items such as sandwiches, cookies, and ice cream were no longer available, leaving only crackers and applesauce as options. Multiple CNAs, an LPN, and the dietary clerk confirmed that snack choices were limited to crackers, pudding, applesauce, and similar items, and some staff stated they purchased snacks with personal funds due to the facility’s limited offerings. The administrator acknowledged that snack availability and resident preferences had been an ongoing concern, that snack options were reduced due to cost without exploring alternatives, and that prior efforts to obtain and follow up on resident preferences were ineffective. Resident Council and Food Committee documentation over several months showed repeated resident complaints about snack availability and variety, with inconsistent stocking of items such as bread and peanut butter and no documented effective resolution.
Delayed Meal Service and Tray Management Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide meals and snacks at appropriate times in accordance with residents’ needs and the posted meal schedule. The facility’s dietary menu for the week indicated set meal times of 8:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for dinner. Despite this, surveyors observed multiple residents receiving and consuming meal trays significantly later than these scheduled times. One resident reported still finishing breakfast at 11:09 a.m. and stated they missed a 10:00 a.m. activity because their breakfast tray was delivered late. Another resident was just beginning to eat a lunch tray at 2:11 p.m. and stated they had just received their lunch. Additional residents were observed eating lunch trays around 2:07–2:08 p.m. and reported that their trays had just been delivered. The facility’s own documentation reflected concerns with tray management and timeliness. A concern/compliment form noted that trays were not being picked up from rooms at night and that staff did not always pick up a specific resident’s meal tray. An in-service sign-in sheet documented training for CNAs emphasizing that breakfast, lunch, and dinner trays needed to be collected and returned to the kitchen and not left in residents’ rooms. During the survey, staff were observed pushing a dietary meal tray cart containing 13 unserved room trays, and the activity staff stated the kitchen was “really far behind” that day. The Administrator in Training acknowledged there were too many room trays and that residents should not be receiving trays so late, confirming the pattern of delayed meal service and tray pickup for multiple residents.
Evening snacks were not consistently offered when overnight meal intervals exceeded 14 hours
Penalty
Summary
The facility failed to ensure residents were consistently offered a nutritious evening snack when more than 14 hours elapsed between the substantial evening meal and breakfast the following day, affecting 5 of 5 residents reviewed who expressed a desire for a bedtime snack (Residents 10, 53, 9, 65, and 105). Scheduled mealtimes showed dinner was served between 4:40 PM and 5:15 PM and breakfast between 7:35 AM and 8:15 AM, creating overnight intervals of 14 hours 55 minutes to 15 hours across Pine, Oak, Willow, and Spruce Halls. Food Committee meeting minutes documented ongoing resident concerns that snacks were not always being passed, then still were not consistently passed, and later that snacks were being delivered to the units and placed in the pantry but were not being offered to residents. During a resident council meeting, all 5 residents interviewed reported they were not offered a snack in the evening and did not receive a snack before bedtime. The Nursing Home Administrator was unable to provide documentation showing that evening snacks were consistently offered to residents.
Failure to Ensure Timely Meal Service and Delivery of Trays to a Resident Eating in Room
Penalty
Summary
The deficiency involves the facility’s failure to provide meals in a timely manner in accordance with a resident’s needs and preferences, resulting in missed meals for one cognitively intact resident. The facility’s policy, titled “Frequency of Meals,” required that each resident receive at least three meals daily at times comparable to typical community mealtimes or in accordance with resident needs, preferences, requests, and the plan of care, and that no more than 14 hours elapse between the evening meal and breakfast. Resident #2, admitted for rehabilitation after a below-the-knee amputation and with diagnoses including CAD, Parkinson’s disease, and neuropathy, had a care plan that included a carb-consistent diet, goals to maintain stable weight, avoid nutritional deficits, and consume 75% of the ordered diet daily. The resident ate meals in his/her room due to hand tremors associated with Parkinson’s disease. The resident reported that on one evening, staff came to the room at approximately 7:30 p.m. to pick up a dinner tray, but the resident had never received a dinner tray that night. The resident further reported that the following morning, he/she did not receive a breakfast tray and had to “chase down” the breakfast tray around 9:30 a.m., and also reported to the Social Services staff that an aide came to get a tray on the evening in question even though no dinner had been served. Therapy staff and the Director of Rehab confirmed that the resident told them he/she had not received a dinner tray on that date. Another nursing aide stated the resident had missed two meals, one lunch and one dinner, though the aide could not recall the specific days. Interviews with multiple staff revealed inconsistent and unclear practices and responsibilities for ordering, preparing, and delivering meal trays to residents who eat in their rooms. CNAs, nursing aides, kitchen staff, the DM, an LPN, the DON, and the Administrator each described differing understandings of who was responsible for taking meal orders, communicating them to the kitchen, tracking who ate, and ensuring all residents received their meals. The DM and kitchen staff indicated that when no menu or order is received, kitchen staff are supposed to check with nursing staff or the charge nurse, and the cook stated that unmarked names on the roster should be checked with the charge nurse. However, staff also reported that the resident’s missed meals were not reported to the DON, and there was no indication that the required checks and communication occurred to ensure the resident received all scheduled meals in accordance with facility policy and the resident’s care plan.
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