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F0809
F

Failure to Serve Meals at Scheduled Times Resulting in Delayed and Cold Food

Butte, Montana Survey Completed on 05-19-2025

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

The facility failed to provide meals at the regularly scheduled times for five of twenty-five sampled residents, as evidenced by multiple observations and interviews. Residents reported and were observed waiting for extended periods past posted mealtimes, with some meals being delivered up to two hours late. Several residents were found in their rooms or dining areas without food, despite the posted and documented mealtimes indicating when meals should have been served. Staff confirmed that meal delivery was consistently late, particularly for certain wings, and that food was often cold when it finally arrived. Residents expressed dissatisfaction with the timeliness and quality of meal service, with some stating they were forced to order food from outside sources due to hunger or unpalatable, cold meals. Observations showed residents seated with only drinks for prolonged periods, and some residents, such as one who was hungry but had not eaten, had untouched trays delivered late. Staff interviews revealed that dietary staffing fluctuations and process issues contributed to the delays, and that certain wings routinely received meals after others, resulting in predictable lateness for those residents. Documentation provided by the facility showed inconsistencies between posted mealtimes, the mealtime policy, and actual meal delivery times. Staff acknowledged that meal service was not consistent with the documented schedules, and that recent staffing shortages further exacerbated the delays. The deficiency had the potential to affect all residents in the facility, as the late meal service was observed across multiple units and affected both residents in dining rooms and those receiving room trays.

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