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F0804
E

Deficient Food Service: Cold Meals, Inaccurate Menus, and Poor Communication

Garretson, South Dakota Survey Completed on 08-07-2025

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 ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature, as well as to provide accurate menus to residents. Multiple residents reported dissatisfaction with the quality, temperature, and organization of meal service. Several residents stated that their meals were often cold, particularly those who ate in their rooms or were served last in the dining room. Observations confirmed that meal trays were delivered on uninsulated carts and sometimes left in hallways before being distributed, contributing to food being served at suboptimal temperatures. A test tray delivered to surveyors showed food items below the recommended hot holding temperature, with potatoes at 132°F and pulled pork at 135°F, both described as cool to the touch and unappetizing. Residents also reported that menus were not consistently provided, making it difficult for them to know what meals would be served or to make alternate choices. Staff interviews confirmed that menu distribution had ceased since a new contracted food service company began operations, and residents now had to request menus from the dietary manager. Menu substitutions were frequent and often due to shortages or delivery issues, with documentation sometimes incomplete or missing. Residents expressed frustration with these changes, noting that the food served often did not match the posted or distributed menus, and that substitutions were not always communicated in advance. Resident council meeting minutes and grievance records further documented ongoing complaints about food quality, service delays, lack of condiments, and insufficient communication regarding meal options. Some residents were unaware they could request alternate meals or were not asked about their food preferences, despite care plans indicating the need to monitor intake and offer substitutes if necessary. The facility's own policies required food temperatures to be monitored and corrective action taken if standards were not met, but observations and records indicated these procedures were not consistently followed.

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