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F0550
D

Delayed Meal Service Compromises Resident Dignity

Montrose, California Survey Completed on 04-10-2025

Penalty

No penalty information released
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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

A deficiency occurred when a resident was not provided with respect and dignity during a meal service. The resident, who was moderately cognitively impaired and required supervision or assistance with eating, was observed waiting for her lunch tray for at least 20 minutes after other residents at her table had already received their meals and begun eating. The resident expressed dissatisfaction and stated that this was not the first time her tray was served late. Staff present in the dining room were unable to explain why the resident's tray was delayed, and the dietary supervisor acknowledged that the list of residents eating in the dining room was not always updated, which contributed to the delay. The resident's medical history included heart failure, schizophrenia, and hypertension. Facility policy required that residents at each table be served together and that all residents be treated with kindness, respect, and dignity. However, the failure to deliver the meal tray in a timely manner resulted in the resident eating alone, after the others had finished, and did not honor her right to dignified and equal care.

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