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F0804
D

Failure to Serve Palatable and Hot Meals to Residents

Millbury, Massachusetts Survey Completed on 04-25-2025

Penalty

Fine: $72,173
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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 and beverages were served at a palatable and appetizing temperature on one unit, as evidenced by multiple resident complaints and direct observations. Residents reported that by the time meal trays arrived in their rooms, hot foods and beverages were often lukewarm or cold. Resident Council meeting minutes from two separate months documented ongoing concerns about cold breakfast items, particularly eggs. During surveyor observations, significant delays were noted between the arrival of meal trucks and the distribution of trays, with some residents waiting up to an hour to receive their meals. Residents requiring assistance with meals consistently received their trays at the end of the meal pass, regardless of when their trays arrived on the unit. Further observations revealed that meal truck doors were left open during the meal pass, potentially contributing to the loss of food temperature. A test tray conducted with a nurse showed scrambled eggs at 113.1°F, which was described as lukewarm. The Food Service Director (FSD) acknowledged that hot food should be at least 140°F and palatable, but was unaware that residents needing assistance were served last, resulting in extended wait times and cold food. The FSD also stated that she had not observed the meal pass process on the affected unit and was therefore unaware of the inefficiencies impacting food temperature.

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