Failure to Prepare and Serve Palatable, Safe, and Nutritious Food
Penalty
Summary
Surveyors identified that the facility failed to ensure food was prepared and served in a manner that conserved nutritive value, flavor, and maintained safe and appetizing temperatures. Observations revealed that the lead cook did not follow standardized recipes for preparing pureed foods, specifically omitting required thickeners and substituting additional broth and meat to achieve desired consistency and flavor. The cook stated this was based on personal experience rather than adherence to recipes, and acknowledged that substitutions were made frequently to improve taste. The dietician and speech language pathologist both confirmed that recipes should be followed to ensure nutritional adequacy and safety, and expressed concern that deviations could not guarantee consistent nutrition or safe food texture for residents. Surveyors also documented that food served to residents was often cold and lacked flavor. During a test tray observation, food temperatures were recorded well below recommended hot holding standards, with eggs at 90.7°F, toast at 81.5°F, and coffee at 118.2°F. Residents consistently reported through interviews and resident council meetings that food was served cold, both in the dining room and in resident rooms, and that the quality and palatability of meals were poor. Resident council minutes over several months reflected ongoing complaints about cold food and lack of flavor, with staff responses indicating attempts at training and use of plate warmers, but with continued dissatisfaction from residents. Multiple residents affected by this deficiency had significant medical conditions, including congestive heart failure, hypothyroidism, anemia, chronic kidney disease, diabetes, hemiplegia, and dementia. Cognitive assessments indicated that some residents were cognitively intact while others had moderate to severe impairment. Despite these vulnerabilities, the facility did not ensure that food preparation and service met the required standards for safety, nutrition, and palatability, as evidenced by both staff interviews and direct resident feedback.