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F0550
E

Failure to Serve Meals Promptly Undermines Resident Dignity

Madison, South Dakota Survey Completed on 07-17-2025

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 maintain residents' dignity and respect by not serving meals promptly during one of two observed meal services. Multiple residents, including the resident council president, reported frequent and lengthy wait times for meals, with some residents waiting up to an hour. These concerns were not documented in the resident council minutes, and it was unclear if they had been communicated to facility management. Observations during the evening meal service confirmed that several residents waited between 23 and 66 minutes to receive their meals after being seated in the dining room. Some residents who required full assistance with eating were left with their meals untouched for several minutes before receiving help. Staff interviews revealed there was no established order for serving residents, and dietary aides prioritized residents with diabetes but otherwise served individuals as they arrived. The dietary manager and registered dietitian both acknowledged the issue, attributing delays to a bottleneck at the service window, where only one person was responsible for plating meals. The registered dietitian stated that ideally, residents should be served as soon as they arrive, and waiting over an hour was considered highly unusual. The facility's dining policy emphasized person-centered care, dignity, and serving all individuals at the same table simultaneously to the best of staff availability, but these procedures were not consistently followed during the observed meal service. Several residents expressed frustration and dissatisfaction with the long wait times, both in interviews and through their actions, such as attempting to leave the dining room before being served. Staff attempted to encourage residents to remain seated and order food, but delays persisted. The lack of timely meal service and assistance for residents who required help with eating directly impacted their dining experience and failed to uphold their right to dignity and respect as outlined in facility policy.

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