Failure to Provide Nutritive, Palatable, and Attractive Meals Due to Missing Ingredients
Penalty
Summary
The facility failed to ensure that food prepared for residents was nutritive, palatable, and attractive, affecting all 119 residents who received meals from the kitchen. On the day in question, the main entrée, Skillet Lasagna, was served without key ingredients such as ground beef and parmesan cheese, and with insufficient amounts of mozzarella and ricotta or cottage cheese. Dietary staff confirmed they were instructed to prepare the dish with whatever ingredients were available, as the kitchen had not received all necessary supplies from the new food service company. Observations and interviews revealed that the lasagna lacked the expected appearance, texture, and flavor, and residents expressed dissatisfaction with the meal's quality and nutritional value. Multiple residents, all cognitively intact and with various medical conditions including diabetes, cardiac disease, depression, multiple sclerosis, chronic kidney disease, and cancer, voiced concerns about the food's appearance, taste, and nutritional adequacy. Resident council meeting notes also documented ongoing complaints about excessive starches and declining food quality. The facility's policy required staff to notify supervisors if ingredients were missing, but this protocol was not followed, resulting in the preparation and service of substandard meals.