F0809

D

Late Meal Service and Resident Frustration Due to Delayed Lunch Trays

Hamilton, Montana Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide meals at the scheduled times established by its own meal schedule, resulting in resident frustration. The facility’s posted meal schedule indicated that lunch trays for Birch Hall residents were to be delivered at 12:20 p.m. However, observations on two separate days showed that lunch trays were passed significantly later than scheduled: at 12:56 p.m. on one day (36 minutes late) and at 1:07 p.m. on another day (47 minutes late). On one of these days, the last lunch tray to Birch Hall was still being delivered at 1:14 p.m. Staff interviews confirmed that meals were sometimes late, that residents often sat waiting in the dining room for extended periods, and that meals had been served late more frequently recently.

One resident, identified as resident #31, was directly affected by these delays. On one day, the resident’s lunch tray was delivered to his room at 12:56 p.m., and a family member (NF1) reported that lunch meals were often served late and that “you get used to it over time.” On another day, NF1 approached staff to ask where the lunch meal was, stating that the resident wanted to lie down but had been told he could not do so until after lunch, and that he was not happy lunch was so late. When the tray was finally delivered at 1:07 p.m., the resident expressed dissatisfaction with the meal, and NF1 returned the tray and ordered an alternative. Staff interviews attributed the late meals to factors such as training a new cook, being short two kitchen staff members, and the time it took staff to dish up and pass the meals, despite a facility policy stating that residents would receive at least three meals daily without extensive time lapses between meals.