Failure to Ensure Dignified and Timely Meal Service
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity during meal service on two of three units. On the Evergreen unit, seven residents were observed eating lunch together at one large table and a small side table. Meals were served individually, with warming dish lids and trash being placed in the middle of the table. One resident expressed hunger at 12:19 PM but was not served lunch until 12:43 PM, while another resident waiting in the common area was not served until 12:54 PM. The Dietary Manager stated that insufficient staffing prevented simultaneous meal delivery to all units, and the DON confirmed that residents seated together should be served at the same time. On another occasion, a resident was observed sitting at a table while others ate, and was told by an LNA that their tray was delayed. The LNA later explained that the resident's tray was mistakenly sent to their room due to a mix-up, resulting in the resident receiving their meal 27 minutes after the others at the table. These incidents demonstrate that the facility did not consistently provide dignified and timely meal service to all residents, as required.