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F0804
E

Failure to Ensure Palatable and Nutritive Food Service

Monterey, California Survey Completed on 05-16-2025

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 ensure that food served to residents was palatable and maintained its nutritive value. Multiple residents reported that their meals tasted bland, with one resident describing the meat as dry and overcooked. These observations were confirmed during a test tray tasting by both the dietary supervisor and the director of dietary services, who agreed that the country fried steak in all textures (puree, minced/moist, soft/bite-sized, and regular) lacked flavor. The registered dietitian also acknowledged that all foods should be palatable. The facility's policy requires that each resident is provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, considering resident preferences. Additionally, the facility did not maintain proper food preparation and holding practices. Cooked items such as minced/moist country fried steak, soft/bite-sized country fried steak, veggie patties, and mashed potatoes were stored in a heated oven at 200°F for an extended period, from the morning until the tray line preparation began several hours later. Both the dietary supervisor and director of dietary services confirmed that foods should be prepared near or within one hour of tray line preparation to preserve taste and nutritive value. The registered dietitian also verified this standard. The facility's policy and federal guidance specify that food should not be held at hot temperatures for hours prior to meal service, as this can result in a loss of vitamins and diminished food quality. The residents involved had various medical conditions, including hemiplegia, hemiparesis following cerebrovascular disease, unspecified fracture of the femur, and idiopathic peripheral autonomic neuropathy. All were alert, oriented, and able to communicate their dissatisfaction with the food. The deficiencies were identified through direct observation, resident interviews, and review of facility records and policies.

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