Failure to Provide Palatable, Appealing, and Accurate Meal Service
Penalty
Summary
The facility failed to provide residents with food and beverages that were palatable, appealing, and matched their documented preferences as indicated on tray tickets. Multiple residents received meals that did not correspond to their selections, such as being served the wrong type of bread, juice, or milk, and missing items like bananas, yogurt, or house shakes. Several residents reported receiving food that was cold, tasteless, or of poor quality, including bread with mold, mushy vegetables, and melted ice cream. In some cases, residents received food items they specifically disliked or could not consume, such as oatmeal or milk, despite their tray tickets indicating otherwise. Observations and interviews revealed that the discrepancies were due to a combination of staff errors on the tray line, miscommunication between dietary staff and GNAs, and supply shortages or substitutions without resident input. Staff admitted to running out of certain items, such as house shakes and bananas, due to delivery schedules and back orders. Additionally, some staff members were identified as making repeated mistakes and were subsequently removed from the tray line. The dietary manager acknowledged substituting items based on general preferences rather than individual resident requests, such as providing vanilla instead of chocolate frozen nutritional treats. The Nursing Home Administrator confirmed during direct observation that meals served to residents did not match tray tickets and were not visually appealing. Residents expressed dissatisfaction with the quality, temperature, and presentation of their meals, and some reported not receiving alternative items when they voiced concerns. The surveyor documented that these issues persisted even after staff were made aware of the problems, indicating ongoing failures in meal service and communication.