Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor residents’ rights to a dignified existence, self-determination, and timely communication by not providing sufficient food to follow the posted menu and not answering call lights in a timely manner. Facility policies required that resident rights be promoted, that call lights be answered promptly by all staff, and that dietary staff prepare and serve meals according to planned menus and standardized recipes. Despite these policies, surveyors observed that on a day when the lunch menu listed beef and bean chili, cornbread, and Snickerdoodle Blonde Bars, residents were served chocolate pudding instead of the listed dessert because the facility was out of eggs. Multiple CNAs and a prior dietary manager reported that running out of food, including main menu items and desserts, had been an ongoing issue, with residents sometimes receiving only toast when eggs or sausage were unavailable, or peanut butter and jelly sandwiches when portions were small. Staff also reported that residents who ate in their rooms, particularly those in certain room ranges, often did not receive the menu items because there was not enough food for all residents. Several residents with intact or mildly impaired cognition described not receiving the food listed on the menu and having to supplement with personal food supplies. One resident with a BIMS score indicating intact cognition stated that the kitchen runs out of food and that she does not get served what other residents are having, regardless of what the menu says. Another cognitively intact resident reported that the facility does not serve enough food during meals and kept a basket of various food items at the bedside to avoid going hungry. A different resident with intact cognition stated that she never receives a menu and that even when menus were posted, they were not followed; she kept a three-shelf storage unit in her room stocked with items such as beef stew, tamales, and soda. CNAs corroborated that several residents purchased their own cereal and other food because the facility frequently ran out of items like juice, eggs, and sausage, and that residents in specific rooms often did not receive the planned menu items. The deficiency also includes repeated failures to answer call lights in a timely manner, affecting multiple residents. One cognitively intact resident reported turning on the bathroom call light after removing a wet disposable brief and waiting 35 minutes without response, ultimately putting the wet brief back on and returning to bed, where she waited with the room call light on until staff eventually arrived and took her to the shower; she stated she is supposed to have help with toileting but often goes alone because there is not enough staff. Another resident with intact cognition stated that call light response times ranged from two minutes to two hours, especially on evening shifts. A resident with mild cognitive impairment had a roommate report that a call light activated at 6:14 a.m. for incontinence care was not answered until 6:56 a.m., during which time the resident remained soiled in urine. Additional residents with intact cognition reported long call light wait times and reliance on family members to assist with showers, changing disposable briefs, and ostomy care because staff said they were short-staffed. Family members and staff further described the impact of delayed call light responses. A family member of a severely cognitively impaired resident stated that staff were often short, that he routinely toileted the resident himself because staff did not answer call lights quickly, and that staff would delay responding because they knew he helped. CNAs reported that staffing was always short, that daily staffing sheets were inaccurate, and that they did not have time to complete all resident care because they were also required to assist dietary by delivering trays and serving meals and drinks. Resident council minutes and concern/compliment forms documented repeated complaints over several months about call lights not being answered timely and concerns about the dietary menu, including late trays, missing milk for cereal, and dissatisfaction with peanut butter and jelly or grilled cheese as meal alternatives. The ombudsman reported numerous complaints from residents that call lights were not answered or that staff would turn off the light and state they would return but did not. The administrator acknowledged that residents should not have to wait more than 10–15 minutes for call lights to be answered and that the kitchen should have the ingredients needed to follow the menu and provide the same meal to all residents, while the registered dietitian and regional dietary manager indicated they had not been fully informed of the extent of menu noncompliance and food shortages.