Failure to Provide Food at Resident's Preferred Temperature
Penalty
Summary
The facility failed to provide food at an appropriate temperature according to a resident's preference, as required by their rights to choice and personal decision. One resident, who is cognitively intact and independent in eating, reported that receiving cold food, especially at breakfast, was a daily occurrence. The resident stated that requests to staff, particularly CNAs, to reheat food were often met with responses that staff were too busy or that the microwave was too far away. The resident also indicated that previous complaints to kitchen staff had not resulted in any changes. Another resident also reported receiving cold and unappetizing food and expressed reluctance to ask staff for reheating, believing the request would not be fulfilled. Staff interviews revealed inconsistent responses regarding whether the resident had requested food to be reheated. One CNA recalled reheating the resident's lunch upon request, particularly when the resident missed the initial meal service due to sleeping. Other staff members, including CNAs and an RN, either did not recall such requests or stated that the resident had not complained to them. The facility's policy requires that residents be provided with nourishing, palatable, and well-balanced diets that consider individual preferences, but observations and interviews indicated this was not consistently achieved for at least one resident.
Plan Of Correction
Corrective Action: Resident #104 and #04 were visited by the Director of Nursing and Food Service Director to determine if the resident's meal was served at an appropriate temperature and to their liking on 07/25/2025. Resident #104 and #04 stated that the meals are being served at the right temperature per their request. Staff A, B, and C were given a one-to-one education by the Director of Nursing regarding the importance of providing residents with meals at an appropriate heated temperature per their request. Identification of Residents: All residents in the facility have the potential to be affected by this alleged deficient practice. Systemic Changes: Ongoing in-services were initiated on 07/25/2025 by the Director of Nursing/designee to direct care staff regarding providing meals at appropriate temperatures per resident's request. The Interdisciplinary Team will conduct daily random rounds in resident rooms and dining rooms to ensure that residents are receiving their meals at an appropriate temperature per resident's preference. Meal temperatures will be discussed at the next Resident Council meeting per the resident's invitation, where the Dietician and/or designee will review and update any concerns with residents to ensure meals are served at an appropriate temperature per resident preference. Monitoring: The Director of Nursing and Food Service Director will conduct random food observation audits to check that food is served at temperatures per resident preference. This audit will be conducted daily for five days, then weekly for eleven weeks to ensure that resident meals leave the dietary department at the correct temperature and are served to residents at an appropriate temperature per resident's preference. The results and findings from audits will be reviewed and reported to the QAPI committee monthly for three months to ensure continued substantial compliance.