Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for several residents. Specifically, four residents complained about the quality of the food, noting that it was often cold, unattractive, and not palatable. Additionally, discrepancies were found between the meal tickets and the actual food served to the residents, with some items missing from the trays. This issue was observed during a recertification and abbreviated survey, where residents expressed dissatisfaction with the temperature and presentation of their meals. Resident #107, who had intact cognitive ability, reported that their meals were consistently cold and unappealing. During an observation, it was noted that the resident's lunch tray did not match the meal ticket, missing several items. Temperature testing of the meal revealed that the food was not served at the appropriate temperature, with pasta noodles and beef stroganoff being below the expected temperature. Despite these issues, the resident stated that the replacement meal was satisfactory. Resident #97, who had a history of dementia and protein-calorie malnutrition, also reported that the food was cold and visually unappealing. This resident experienced significant weight loss, which was attributed to their lack of appetite due to the unappealing food. Resident #75 expressed similar concerns, noting that the food was cold and lacked flavor, and they were not provided with snacks at night. Resident #8 reported receiving food they did not like and that meals were often served cold. These deficiencies highlight the facility's failure to adhere to its policy of providing nourishing, palatable, and well-balanced meals that meet residents' preferences and dietary needs.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 1. The Registered Dietician and Food Service Director met with residents #97, 75, 8, and 107 to review meal preferences and dislikes. Revisions were updated in the menu software program. Resident #75 was provided a new lunch tray and a night snack has been scheduled per resident preference. The facility hired a new Food Service Director on 1/2/2025. 2. All residents have the potential to be affected by the deficient practice. The facility did an audit of 10 consecutive meals on the units to ensure residents' food was warm, palatable, and presentable. This audit also included checking that meal tickets were accurate and the preferences were served. 3. The Policy titled "Food Service" has been reviewed with no revisions necessary. The Registered Dietician or the staff educator will provide re-education to dietary staff on the policy titled "Food Service." The emphasis is on meal production to include tray accuracy as well as residents’ personal food preferences and meal temperatures. The Food Service Director or Supervisor will facilitate a meal production meeting daily with dietary staff and report to the registered dietician should any deviations to the menu be needed. Facility nursing staff will be re-educated on the Food Service policy with emphasis on tray accuracy, residents’ personal food preferences, and food temperatures. 4. The Registered Dietitian or Food Service Director will conduct reviews on 15 trays for accuracy, temperatures, and resident preferences weekly x 4 weeks and monthly x 3 months. The Food Service Director or Registered Dietitian will conduct a review on 15 trays per week on tray accuracy, appearance, and palatability weekly x 4 weeks, then monthly x 3 months. The Food Service Director or Registered Dietitian will review food temperature logs daily for 30 days, then weekly thereafter to ensure safe food temperatures are maintained. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. 5. Responsible party: Food Service Director