Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature for multiple residents. Two residents with cognitive intactness, one with anemia, diabetes, depression, and anxiety, and another with a history of sepsis, reported that hot foods were often served cold, with one specifically mentioning a cold pork chop at dinner. Both residents had previously communicated their concerns to staff, including the registered dietitian, but continued to experience the same issues. Additionally, a group interview with nine residents revealed unanimous dissatisfaction, with all participants stating that food was always cold, vegetables were overcooked and mushy, and items were frequently missing from trays. The group also reported that their food preferences and requests were not honored, and that a food committee had not led to any improvements. Observations during meal service confirmed the deficiency. While hot food items on the steam table were initially at appropriate temperatures (over 175°F), the process of delivering trays to different halls resulted in significant temperature drops. A test tray placed on the last cart delivered to a hall was found to have mashed potatoes at 119°F, Salisbury steak at 109°F, and carrots at 118°F, well below the recommended serving temperatures. No additional food temperatures were recorded during the meal service, indicating a lack of ongoing monitoring to ensure food remained at a safe and appetizing temperature until served.