The Haven Of Tuscola

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests.

Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a bedtime snack and breakfast for two (R1, R3) of three residents reviewed for food services on a sample list of six.

Findings include:The facility's undated Passing Meal Trays policy provided by the facility documents that nursing will be responsible for delivering all trays to residents whether the resident is eating in the dining room or in the resident room.

Nursing will advise Food Service of residents not eating in their usual location.

The facility's Meal Schedule undated policy provided by the facility documents that three meals will be served daily at similar times as served in the community.

This policy documents that there will be no more than fourteen (14) hours between a substantial evening meal and breakfast the following day.

And an evening snack will be served.

R1 was admitted to the facility on [DATE] for rehabilitation following left total hip replacement. R1 was discharged from the facility on 8/12/25. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of fifteen indicating that R1 has normal cognitive function.R3's MDS dated [DATE] documents a BIMS score of fifteen indicating that R1 has normal cognitive function.R3's Care Plan dated 8/05/25 documents The resident has potential for pressure ulcer development related to alteration in circulation.

This Care Plan lists an intervention for staff to monitor nutritional status and serve diet as ordered, monitor intake and record.On 8/25/25 at 11:14 AM, R1 stated the facility failed to bring her breakfast or lunch on the day after her admission to the facility on 8/05/25. R1 stated she lost ten pounds while residing in the facility. On 8/25/25 at 11:49 AM, R3 stated the facility failed to bring her breakfast on several days within the past two weeks and that she had to call to have it delivered.R1's Electronic Medical Record (EMR) documents an admission weight of 181 pounds. On 8/26/25 at 8:12 AM, R3 was sitting up in her bed with the head of the bed elevated and R3 was wearing a clothing protector. R3 stated that breakfast hadn't arrived yet and that R3's last meal was delivered around 5:30 PM the previous evening. On 8/26/25 at 8:30 AM, R3's breakfast was observed being delivered to R3's room. On 8/26/25 at 9:30 AM, V17 PA stated that he saw R1 for a surgical follow-up visit on 8/12/25. V17 stated that he had known R1 as a patient for 14 years and had never seen her so distraught. V17 said that R1 was very upset and crying.

V17 stated R1 told him that the facility was not feeding her. V17 stated that R1 did appear to be thinner and that if she would have continued to remain at the facility, he feared for R1's health and her recovery. On 8/26/25 at 11:36 AM, V2 Director of Nursing stated that obviously if R1 missed meals it caused her to lose weight.On 8/26/25 at 1:06 PM, V14 Dietary Manager stated that they use an electronic system to enter resident information regarding their dietary needs and then it creates daily meal tickets. V14 stated that she could not provide me with any documentation showing that R1 had been entered into the facility's electronic system upon admission and that meals were being delivered to R1. On 8/25/25 at 3:15 PM, V16 Registered Nurse (RN) working with V17 Physician Assistant (PA) confirmed that R1 was seen by V17 for a surgical follow-up on 8/12/25. V16 stated that R1's weight at this visit was 78 kilograms (171.9 pounds). V16 stated that R1 was wearing baggy pants and R1 told V16 that the facility was not feeding her.

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