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F0812
E

Delayed and Improper Meal Service to Resident Rooms

Billings, Montana Survey Completed on 08-28-2025

Penalty

Fine: $133,87547 days payment denial
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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 serve resident meal trays to rooms in a timely manner and according to posted mealtimes, resulting in multiple residents experiencing late and lukewarm meals. Observations and interviews revealed that residents who consistently ate in their rooms reported their food was often served thirty minutes late and was usually lukewarm. On several occasions, residents expressed significant hunger while waiting for their meals, with one resident rating their hunger as ten out of ten. Meals were observed being delivered after the designated end time for meal deliveries, and residents commented on the food being served late and not at the proper temperature. One resident expressed concern about the late meal affecting their ability to attend a scheduled appointment. Staff interviews confirmed that meal trays were often late getting to resident rooms, with some staff acknowledging that the facility could improve the timeliness of tray delivery. Staff attributed delays to food not coming out of the kitchen quickly enough and to the order in which halls were served. There were also reports of CNAs delaying food service due to inattentiveness. Meal delivery times were not clearly posted or communicated to residents, leading to confusion and unmet expectations regarding when meals would be served.

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