Failure to Serve Meals Simultaneously to Residents at the Same Table
Penalty
Summary
The facility failed to treat residents with dignity by not ensuring that all residents seated at the same table in the main dining room were served their meals together. Multiple observations across several meals revealed that some residents were eating while others at the same table were left waiting without food or drink. For example, one resident was nearly finished with breakfast while another at the same table had not received any food or drink. Similar patterns were observed during lunch, where some residents waited for extended periods while others at their table had already been served and finished eating. In one instance, a resident waiting for their meal took food from another resident who had already been served, and another resident repeatedly attempted to leave the dining room while waiting for their meal. Staff interviews confirmed there was no process in place to ensure simultaneous meal service for all residents at the same table. The Food Service Director acknowledged that the facility was aware of ongoing issues with meal service timing in the main dining room. Residents were observed expressing hunger and frustration, with some verbally stating they were hungry or asking for their meals while waiting. These repeated delays and lack of coordinated meal service directly impacted the residents' dining experience and dignity.