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.
The facility failed to provide dinner within the posted meal time, with at least one cognitively intact resident reporting that dinner was not served until 8:30 p.m. on one occasion. The resident, who had multiple chronic conditions including CHF, DM, CKD, and PVD, informed a family member of the late meal, and this concern was documented in the grievance log. Multiple RNs, the DON, and the corporate dietary manager confirmed that on a date in February the evening meal was served very late, after 8:00 p.m., due to kitchen staff calling in and resulting staff shortages, and resident council minutes also reflected concerns about meals being served late, potentially affecting all residents.
Bedtime snacks were not offered to 5 of 5 residents reviewed for snacks. During a resident meeting, all 5 said they do not receive or are not offered HS snacks, and one cognitively intact resident who served as Resident Council President said she could not even get an extra cookie or dessert to take back to her room. The Dietary Manager said snacks are only provided to residents on a dietitian list and that no other residents are offered snacks, despite facility policies stating HS snacks and between-meal snacks are to be made available.
The facility did not ensure that bedtime snacks were consistently offered and documented for multiple residents, despite a policy requiring provision of bedtime snacks and/or fluids before sleep. Residents reported that staff did not routinely come around to offer snacks, with some stating they had to request snacks and that staff sometimes forgot to bring them, while others were unaware they could request snacks but wanted them offered. The Dietary Manager indicated that dietary staff only delivered a sealed snack box to the nurses’ station each evening, and the Interim DON stated CNAs were responsible for offering snacks to appropriate residents but acknowledged there was no documentation that these residents received bedtime snacks.
The facility failed to follow its policy requiring nursing staff to offer bedtime snacks daily to all residents according to their needs, preferences, and requests. Multiple residents without cognitive impairment reported they do not receive bedtime snacks unless they specifically ask, that staff do not pass snacks room to room, and that a prior practice of offering bedtime snacks stopped after concerns that staff were taking snacks for themselves. The Dietary Manager stated a snack cart is placed in a locked nutrition room on the LTC unit and that CNAs, not dietary staff, are responsible for passing snacks, while the DON stated CNAs should offer snacks during the water pass. Because the nutrition room is locked with a coded system, residents cannot independently access snacks, resulting in snacks not being routinely offered at bedtime as required.
The facility did not consistently serve meals at its posted scheduled times, despite a written policy and documented schedule indicating specific hours for breakfast, lunch, and dinner. Surveyors observed breakfast and lunch being served later than scheduled on multiple days, and the Certified Dietary Manager acknowledged that breakfast was delayed because staff had not rolled silverware in time. A resident reported that meals are served late all the time, and this pattern had the potential to affect all 95 residents.
The facility did not serve meals at scheduled times, resulting in residents waiting extended periods for food, with some not receiving trays until staff intervened. Staff interviews confirmed that meal delays were common, often due to staffing shortages, and nursing staff expressed concern for diabetic residents needing timely meals with insulin. Residents were observed eating snacks to compensate for late meals, and posted meal times were not consistently followed.
A resident was denied a requested bedtime snack, with staff and dietary personnel confirming that only diabetic residents or those with weight loss are provided snacks in the evening. The resident's care plan and physician orders did not restrict snack access, yet the facility's practice excluded non-diabetic residents from receiving snacks outside scheduled meal times.
The facility did not consistently provide meals and snacks at scheduled times or in accordance with resident preferences and care plans. Several residents, including those with diabetes, reported not receiving bedtime snacks, and staff confirmed that snacks were often unavailable due to the kitchen being locked or not leaving out snack carts. Meals were also frequently served late, with delays attributed to equipment and staffing issues, and there was no formal policy ensuring snack availability for residents who required them.
The facility did not serve meals at the posted scheduled times, resulting in consistent delays of 20 to 60 minutes for all residents receiving oral diets. Multiple residents and staff confirmed the late meal service, which was attributed to reduced food service staffing and increased meal preparation demands. Resident council meeting minutes also documented ongoing concerns about late meal delivery.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account