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F0585
E

Failure to Address Resident Grievances on Cold Food

Everett, Pennsylvania Survey Completed on 01-15-2025

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

The facility failed to address ongoing resident grievances regarding the serving of cold food, as evidenced by a review of facility policy, Food Committee meeting minutes, and interviews with residents and staff. The facility's policy, dated March 18, 2024, stated that food should be palatable, attractive, and served at a safe and appetizing temperature. However, Food Committee meeting minutes from January through August 2024 and October through December 2024 documented resident complaints about receiving cold food. During a meeting with residents on January 13, 2025, they confirmed that they had been served cold and unpalatable food for at least one year and had requested food at the correct temperature. The Director of Dietary acknowledged awareness of these complaints but did not address the issue, citing that food temperatures were correct when checked in the kitchen.

Plan Of Correction

1. Action to immediately correct the appearance and palatability of food was not possible retroactively. The Dietary Manager/designee will monitor the temperature and palatability of food served. 2. Grievances in the last 30 days will be reviewed by the Executive Director (ED) to ensure ongoing efforts to resolve grievances. 3. The Executive Director reeducated the Social Services Director and Department Managers on the facility's grievance guidelines and time frames for resolution. 4. The ED/designee to conduct Quality Improvement (QI) monitoring of regulation deficiency of 585 to ensure ongoing efforts to resolve grievances including dietary complaints. Monitor conducted via weekly grievance reviews times 4 weeks. The Dietary Manager/designee to conduct weekly meetings with the residents who choose to attend, to monitor the overall satisfaction of the food served weekly X 4 weeks, biweekly X 1 month, then monthly as needed. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. Quality monitoring schedule modified based on findings.

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