Deficiency in Dietary Services and Portion Control
Summary
The provider failed to ensure that two residents receiving specialized diets were served the correct portion sizes and nutritional values during a meal service. Observations revealed that residents were served only a small portion of ground spaghetti without any additional food items, contrary to the menu that included a salad and bread. Despite the presence of the administrator and a notification from an aide, no further food items were offered to the residents. Interviews with the residents' family members and staff highlighted issues with the residents' dietary needs and preferences, such as one resident's preference for soft foods and another's significant weight loss. Interviews with the registered dietitian and the administrator confirmed that the meals served were not visually palatable, accurate in portion size, or nutritionally balanced. The administrator acknowledged that the dietary staff, including a newly hired cook and dietary manager, had not been adequately trained on serving sizes and specialized diets. The dietary manager admitted to having received minimal training and lacked experience in a long-term care setting, while the dietary cook also lacked formal training on portion sizes and specialized diets. The residents involved had significant medical histories, including major neurocognitive disorders and weight loss. One resident was on hospice care with a diet order for a specific texture, while the other had a regular diet with mechanical texture and specific food preferences. Both residents experienced significant weight loss over a six-month period, which was not adequately addressed by the facility's dietary practices. The facility's policy on weight assessment and intervention was not effectively implemented, as evidenced by the lack of training for dietary staff on essential topics such as food safety, nutrition, and portion control.
Penalty
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Food was not prepared in a manner that conserved flavor and appearance, as evidenced by a resident repeatedly receiving chicken noodle soup without broth, resulting in bowls of dry noodles that had to be eaten with a fork, and by broccoli consistently served in a mushy, watery state that did not hold its shape. Staff, including dietary personnel, acknowledged that the soup tin contained no broth and that the broccoli always became mushy due to the way it was cooked on the stovetop in a tin on low heat.
The facility failed to ensure meals were served at a palatable temperature, as required by its food quality policy. Resident council minutes and multiple interviews with residents and a family member described food that was frequently cold or not palatable, and residents reported that warming plates were not always used. During an observed lunch service, hot foods that began at appropriate temperatures were significantly cooler by the time the last tray cart was delivered, and a test tray taste test confirmed the hot items were not at an acceptable or palatable temperature, affecting all residents receiving meals from the kitchen except those on NPO status.
The facility failed to provide palatable meals at safe and appetizing temperatures, affecting at least two residents and potentially all receiving kitchen-prepared meals. A resident who depended on staff for all ADLs reported that food was not always hot by the time assistance was provided, while another cognitively intact resident who ate independently reported that meals were frequently cold and unappetizing. Surveyors observed that while hot foods on the steam table initially met temperature standards, trays were then placed on delivery carts without heat or refrigeration, and a test tray later showed inadequately cooled dairy items and hot foods that were not maintained at appropriate temperatures. The Dietary Director acknowledged that cold items were not held at proper temperatures and that the hot foods were not warm or seasoned to a palatable standard, contrary to the facility’s policy requiring nourishing, palatable, and attractive meals.
The facility failed to consistently serve hot foods at adequate and palatable temperatures, as evidenced by resident reports that meals were always cold or never hot and by a test tray observation with the Dietary Manager showing entrée and vegetables at 122°F and rice at 141°F, with items described as warm but not hot when eaten. The facility also identified that two residents received no food from the kitchen, and this issue had the potential to affect 105 residents receiving meals, based on a total census of 107.
Surveyors found that hot foods and cold beverages were not served at appropriate temperatures during a meal service, with eggs and sausage measured in the 90°F range and milk and juice above 48°F. The Dietary Manager confirmed these temperatures and acknowledged expectations that hot foods be at least 120°F and cold beverages at or below 40°F. Several residents reported receiving cold eggs and sausage, and facility policy identified the temperature range between 41°F and 135°F as a danger zone for potentially hazardous foods such as meats, poultry, eggs, and milk.
The facility failed to provide consistently palatable meals at appropriate temperatures for all residents receiving meals from the kitchen. Several residents reported that their food was sometimes cold, often only warm instead of hot, and in some cases overcooked and difficult to eat. Observations showed a delay between tray plating and delivery on one wing, with CNAs starting room tray service shortly after plating but the last tray not being served until more than 20 minutes later. A test tray followed to the wing and sampled after service revealed green beans that were not warm, with the Dietary Manager confirming a temperature of 120°F, which was not appropriate for palatable consumption.
Improper Food Preparation Affecting Soup Consistency and Vegetable Texture
Penalty
Summary
Failure to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature was identified through observations, test trays, and interviews. During a lunch meal, one resident on the Lifebridge Unit, which was the last hall to be served, received two bowls of what appeared to be pasta salad on his tray at approximately 1:25 P.M. The resident clarified that both bowls were supposed to be chicken noodle soup, but there was no broth in either bowl, and he was eating the contents with a fork. He stated that he requested two bowls of chicken noodle soup daily for lunch and that sometimes there was broth, but usually he had to eat the soup with a fork. A CNA confirmed that the resident had received two bowls of chicken noodle soup without broth. On a subsequent lunch observation, the same resident again received two bowls that were supposed to be chicken noodle soup; one bowl had no visible broth and the other had only a small amount of liquid at the bottom. The Dietary Manager, present during this observation, acknowledged that the noodles appeared to be soaking up the broth and verified that the soup tin in the kitchen contained no broth, only noodles and carrots, and appeared dry at the bottom. Additional observations during the dinner tray line showed that broccoli being served did not maintain its shape and appeared mushy and watery. When a test bowl of broccoli was served later in the meal service, it still did not hold its shape and had a mushy, watery texture. An interview with a dietary staff member revealed that the broccoli was cooked on the stovetop in a tin on low heat, and he confirmed that the broccoli always became mushy. These findings demonstrated that food was not being prepared by methods that conserved nutritive value, flavor, and appearance, affecting items such as chicken noodle soup and broccoli and having the potential to impact all 86 residents in the facility.
Failure to Maintain Palatable Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were served at a palatable, appetizing temperature in accordance with its policy titled “Food: Quality and Palatability.” Resident council minutes documented that residents had complained of cold food. Multiple resident and family interviews corroborated these concerns: one resident stated the food was not palatable, another resident’s family member reported the food was not always hot, another resident stated the food “sucks,” and another resident reported the food was not always warm. During a resident council meeting, several residents reported that food was frequently cold and that the kitchen was not always using warming plates to keep food hot. The facility identified eight residents on NPO status who did not receive food from the kitchen, and thus the issue had the potential to affect all other residents receiving meals. Surveyors directly observed a lunch meal service and documented food temperatures at the start of service and at the end of tray delivery. At the start of service, hot dogs measured 190°F, baked beans 175°F, and coleslaw 32°F. By the time the last hallway cart was completed and delivered, a test tray on that cart showed significantly reduced temperatures: 105°F for the hot dog, 109°F for the baked beans, and 36°F for the coleslaw. A taste test of the hot dog and baked beans determined the food was not at a palatable temperature. The district manager who took the temperatures and participated in the taste test confirmed that the hot dog and baked beans were not at an acceptable or palatable temperature. This failure to maintain palatable temperatures occurred despite the facility’s written policy requiring food to be palatable, attractive, and served at a safe and appetizing temperature.
Failure to Maintain Palatable and Safe Meal Temperatures During Tray Service
Penalty
Summary
The facility failed to ensure that meals provided from the kitchen were palatable and maintained at safe and appetizing temperatures for residents, affecting at least two residents and potentially all residents receiving kitchen-prepared meals. One resident, admitted with a fracture of the lower end of the right radius, anxiety disorder, morbid obesity, and requiring assistance with all ADLs including eating, had a regular diet with thin liquids and intact cognition per a BIMS score of 13. This resident reported that food was not always hot by the time staff were able to assist with meals. Another cognitively intact resident, admitted with bilateral patella fractures, osteoporosis with current fracture, CHF, and CKD, and who was independent with eating, also had a regular diet with thin liquids and reported that meals were frequently cold and did not taste good. Surveyor observations of the meal service showed that hot foods on the steam table initially met appropriate temperatures, but meal trays were then loaded onto 11 delivery carts that had no heat or refrigeration sources. Disposable Styrofoam plates and cups with dome lids and paper bowls for soup were used due to dish machine repairs. When a test tray was evaluated after the last resident tray was served, several items were found at inadequate temperatures: yogurt at 73°F, milk at 61.3°F, mashed potatoes at 132.4°F, mechanical chicken at 101.3°F, and pureed bread at 119.3°F. The Dietary Director confirmed that cold items were not held at appropriate temperatures and stated that, from a personal perspective, the hot foods were not warm enough and some items were bland and needed more seasoning. The facility’s Community Dining and Meal Service Policy required that individuals be provided with nourishing, palatable, attractive meals that support nutritional and special dietary needs, which was not met under these observed conditions.
Failure to Serve Hot Foods at Adequate and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that all hot foods were served at adequate and palatable temperatures for residents receiving meals. Resident interviews documented that one resident stated the food was cold all the time and another resident reported the food was never hot. During observation of a test meal tray with the Dietary Manager, the tray contained a chicken breast filet, rice, peas and carrots, and a grape drink. Food temperatures taken at that time showed the chicken breast at 122°F, peas and carrots at 122°F, and rice at 141°F, with the chicken and vegetables described as warm but not hot when consumed. The Dietary Manager verified these findings. The facility identified that two residents received no food from the kitchen, and the issue had the potential to affect 105 residents who received meals, with a total facility census of 107. This deficiency was investigated under Complaint Number 2671148 and was based on observations, resident interviews, and staff interviews indicating that hot foods were not consistently served at appropriate temperatures.
Improper Food and Beverage Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food and beverages were served at appropriate, palatable temperatures, affecting the majority of residents who received meals from the kitchen. During observation of a test tray after breakfast trays had been passed, the eggs and sausage were found to be lukewarm and not palatable, with temperatures of 93°F and 93.4°F respectively. The milk, poured from a carton that had been placed on top of the tray cart, measured 48.8°F, and the orange juice measured 51°F. The Dietary Manager confirmed these temperatures and stated his expectation that hot foods should be at least 120°F and that milk and juice should be 40°F or less when served. Interviews with several residents confirmed that their eggs and sausage were cold when they received their trays. The facility’s “Food Preparation and Service” policy, dated April 2019, defined the temperature “danger zone” for food as between 41°F and 135°F, noting that this range promotes rapid growth of pathogenic microorganisms that cause foodborne illness. The policy identified potentially hazardous foods as including meats, poultry, eggs, and milk, and stated that these foods must be maintained below 41°F or above 135°F. The deficiency was identified through observation, staff and resident interviews, and policy review, and was associated with multiple complaint investigations.
Failure to Provide Palatable Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for residents receiving meals from the kitchen. One resident reported that food was sometimes cold and attributed this to living at the end of a hall and being served last, another resident stated that food was often cold or only warm but not hot, and a third resident described some food as lousy, specifically noting a hamburger that was very overcooked and tough to bite and eat. Observation showed that the last tray for a room on the east wing was plated and placed on the cart at 12:20 P.M., and a test tray with pizza casserole, green beans, and pumpkin mousse was prepared and followed to the east wing. CNAs began passing trays and drinks to residents in their rooms at 12:23 P.M., and the last tray for the identified room was not served until 12:46 P.M., at which time the test tray was sampled for taste, texture, and temperature. The green beans on the test tray were found not to be warm, and the Dietary Manager measured their temperature at 120 degrees Fahrenheit, confirming they were not at an appropriate temperature for palatability as intended. This deficiency was investigated under Master Complaint Number 2733050.
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