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F0550
D

Resident Meal Service Delay Compromises Dignity

Keene, Texas Survey Completed on 07-31-2025

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

A deficiency was identified when a resident with dementia and significant cognitive and physical impairments was not served her meal at the same time as other residents at her dining table. The resident, who required a pureed, gluten-free diet and total assistance with eating, was observed waiting 26 minutes after the other two residents at her table had received their meals and begun eating. Staff interviews confirmed that the delay was due to the resident's special dietary needs, which sometimes resulted in her meal being delivered later than others. Multiple staff members, including CNAs and LVNs, acknowledged that all residents at a table should be served their meals together, and that waiting more than 5 minutes was considered unreasonable. Staff also stated that such delays could cause residents to feel neglected or upset. The charge nurse and aides were responsible for monitoring meal service and ensuring that all residents at a table received their meals at the same time, with procedures in place to address missing trays promptly. The facility's own policies and resident rights documents emphasized the importance of treating residents with dignity and respect, including during meal service. Despite these policies, the resident was left waiting for an extended period while others ate, which staff and the Director of Nursing agreed was unreasonable and not in line with facility expectations for resident care and dignity.

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