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F0585
E

Failure to Resolve Resident Grievances Regarding Delayed Meal Service

Billings, Montana Survey Completed on 08-14-2025

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 resolve resident grievances in a timely manner regarding delayed meal service, as evidenced by multiple residents reporting consistent and significant delays in receiving their meals. Observations and interviews revealed that meals were often served two or more hours late, with residents stating that their complaints did not result in any changes. Staff interviews confirmed that the dietary department was short-staffed, leading to prolonged wait times for meals. Residents reported that the delays had been ongoing for months and that their concerns were not addressed or communicated back to them. Review of facility grievance forms documented repeated complaints about late meals and lack of consistency in meal service. The forms indicated that residents were waiting over an hour for meals and that the kitchen was short-staffed, causing delays. Despite these documented grievances, the facility did not provide evidence that residents were kept informed of progress toward resolution or that prompt efforts were made to resolve the issues, as required by facility policy. Posted mealtimes were not adhered to, further supporting the deficiency in timely grievance resolution.

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