Food Temperature and Palatability Issues in LTC Facility
Penalty
Summary
The facility failed to provide food that was palatable and at acceptable temperatures for nine residents, which had the potential to affect 111 out of 112 residents on PO diets. Observations, interviews, and record reviews revealed that several residents consistently received meals that were not hot or palatable. For instance, Resident #23 noted that while the food was good on one occasion, it was usually not hot, and the green beans were often undercooked. Resident #75 complained about meals being served cold and voiced his concerns to staff, while Resident #83 reported that her food was not served hot, even after reheating. Resident #251 expressed dissatisfaction with the taste of the food, describing it as bland and tasteless, and compared it to eating grass. A test tray conducted by surveyors confirmed that the food was warm but lacked seasoning, making it unsatisfactory. Other residents, such as Resident #10, reported that food trays sat out in the hall for too long, resulting in cold meals. Resident #29 also noted that the food was not hot and suspected that the presence of the survey team led to a temporary improvement in food service. The Registered Dietician (RD) acknowledged awareness of the complaints and suggested that the issue might be due to trays sitting in the hallway for extended periods, possibly related to staffing issues. Despite conducting numerous temperature checks in the kitchen, no concerns were identified there, indicating that the problem likely occurred during the delivery process to residents' rooms.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident # 75, 83, 23, 251, 10, 29, 50, 27, and 85 were assessed by licensed nurse, no concerns identified. On 4.4.25 resident # 75, 83, 23, 251, 10, 29, 50, 27, and 85 were provided nutritive, palatable meals, at appropriate temperature per their preference; no concerns identified. Resident #251 discharged on 4.9.25 and is no longer residing in the facility. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. On 4.14.25 facility with external consulting company for dietary services to include management oversight, line staff and cooks. On 4.8.25 the facility ordered 6 insulated food delivery carts which were shipped on 4.16.25, and have delivery date of 4.22.25. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.9.25 a quality review was completed by Registered Dietician on current residents to ensure provided with nutritive/palatable meal at appropriate temperature per their preference. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.17.25 Ad Hoc Resident Council meeting held to review survey results and plans being implemented for correction of alleged deficiencies identified. On 4.22.25 Dietary manager completed education with current dietary staff on the components of F804 nutritive value/appear/palatable/temperature with emphasis on ensuring residents are provided nutritive/palatable meals at appropriate temperatures per their preference by the Director of Nursing/designee. Newly hired dietary staff will be educated on the components of F804 nutritive value/appear/palatable/temperature with emphasis on ensuring residents are provided nutritive/palatable meals at appropriate temperatures per their preference Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Registered Dietician/Designee to conduct audits of 5 residents meals twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F804 nutritive value/appear/palatable/temperature with emphasis on ensuring residents are provided nutritive/palatable meals at appropriate temperatures per their preference. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.