§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.
§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
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Observations:
Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to implement dignified feeding practices and to maintain resident dignity for seven of 18 residents interviewed (Residents R7, R8, R9, R15, R16, R24, and R25).
Findings include:
Review of facility policy entitled "Resident Environmental Quality" dated 8/29/25, revealed "It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents."
Review of facility policy entitled "Paper Products in the Dietary Department" dated 8/29/25, revealed "To ensure safe, sanitary, and high-quality food service operations by prohibiting the use of paper products (e.g., paper plates, bowls, cups, and disposable utensils) within the dietary department. This policy supports infection control, regulatory compliance, cost management, and resident dignity. Paper products are not permitted for use in food preparation, plating, or service within the dietary department except in approved emergency situations."
Review of Resident Council meeting minutes and food committee minutes from 12/30/25, revealed resident concerns of "food is cold and sometimes hard."
Interviews on 2/18/26, between 11:30 a.m. and 5:30 p.m. with Residents R9, R16, R24 and R25 revealed that they have been receiving meals in Styrofoam containers on occasion for the last few weeks and the food is often cold as a result. The residents identified above revealed they are aware meals were being served in Styrofoam containers at dinner a few times this week due to a water issue, but unaware why meals were served in Styrofoam for the past few weeks on occasion. Resident R8 indicated that when meals are served in a disposable container, they are cold and not worthy of eating, so he/she typically orders out. Resident R8 stated, "When I see a disposable container coming, I just order out." Interviews with Resident R15 on 2/19/26, at 12:00 p.m. and Resident R7 on 2/19/26, at 2:30 p.m. revealed that meals have been served in Styrofoam containers more often, and food is cold and does not taste good.
Interviews on 2/18/26, between 2:00 p.m. and 5:30 p.m. with Licensed Practical Nurses (LPN) Employees E2 and E3, and interviews on 2/19/26, between 11:30 a.m. and 3:00 p.m. with LPN Employees E1, E5, and Certified Nursing Assistants (CNA) Employees E4 and E6 revealed evening and weekend meals have been served on Styrofoam quite a few times in the last few weeks.
Interviews on 2/18/26, between 11:00 a.m. and 4:00 p.m. with Cook Employees E6 and E10 revealed that Styrofoam has been used sometimes for the dinner meals mainly due to staffing.
Interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on 2/19/26, at 3:30 p.m. confirmed that Styrofoam containers have been used on occasion for the past few weeks for resident's meals.
28 Pa. Code 201.29 (a) Resident rights
| | Plan of Correction - To be completed: 03/27/2026
Residents R7, R8, R9, R15, R16, R24 and R25 suffered no ill effect from being served on Styrofoam dinnerware.
By 03/20/2026, all Dietary staff will be re-educated by the Administrator and/or designee, on the policies "Resident Environmental Quality" and "Paper Products in the Dietary Department" limiting the use of paper products to only emergent situations.
To ensure ongoing compliance, random audits will be conducted to ensure that all meals are served on the facility's chinaware. This audit can involve talking to individual residents and/or the review of Resident Council minutes. There will no less than 5 resident interviews per week in the audit period.
This audit will be the responsibility of the Administrator and/or designee. These random meal audits will occur 3 times per week for 4 weeks. Each audit will be on different days, on different shifts and can include weekends.
Audits will be reviewed by Quality Assurance Performance Improvement committee to determine the need for further audits.
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