Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served in a timely manner and at appropriate temperatures, resulting in multiple residents receiving cold or incorrect meals. Observations and interviews revealed that residents frequently experienced delays in meal service, with food often arriving cold or not matching their orders. Staff interviews confirmed that complaints about food temperature and accuracy were common, and that the process for collecting and fulfilling meal orders was inconsistent. The use of an electronic meal ticket system, which required nursing assistants to collect meal preferences the day before, was identified as a source of confusion and errors, with some residents not being asked for their preferences and others receiving meals they did not order. Resident council meeting minutes over several months documented ongoing concerns about cold food, late meal service, and errors in meal orders. Residents reported that staff did not always offer to reheat food, and that requests for assistance were sometimes ignored due to staff being busy. Specific residents described receiving cold, unappetizing, or incorrect meals, with one resident noting that ice cream was completely melted upon delivery and another stating that food was overcooked and inedible. Staff interviews corroborated these issues, with both nursing and dietary staff acknowledging the persistence of complaints and the disconnect between order collection and meal delivery. Direct observation during meal service confirmed that food temperatures did not meet facility expectations, with test trays showing temperatures below the required 135 degrees Fahrenheit. The facility's policy on food temperatures and serving times was requested but not provided. The deficiency affected all residents who consumed food from the facility kitchenettes, as the issues with timeliness, temperature, and order accuracy were systemic and ongoing.