Failure to Provide Timely and Dignified Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents by not serving their meals in a timely manner during multiple observed meal services. One resident, who was cognitively intact and required minimal assistance, waited 36 minutes for their dinner tray after all other residents had been served, and was observed sitting without food while others ate and finished their meals. The resident reported that this was not an unusual occurrence and that their meal tray had been misplaced on a hall cart. During a subsequent lunch, the same resident again did not receive their tray until after all others had been served, with staff confirming the tray was found on a hall cart. Another resident, recently admitted with a history of stroke and acute hemolytic anemia, also experienced a significant delay in receiving their breakfast tray, waiting 33 minutes after meal service began. This resident was observed watching others eat and requested food from staff before their tray was finally delivered, after others at their table had finished and left. Staff interviews confirmed that meal trays were sometimes misplaced due to residents changing their preferred dining locations, resulting in delays and residents being left without meals while others ate.