Failure to Provide Palatable and Safe Temperature Meals
Penalty
Summary
Surveyors identified that the facility failed to provide food and drink that was palatable, attractive, and at safe and appetizing temperatures for all residents reviewed. Multiple residents and their family members reported that meals were frequently served cold, unappetizing, and sometimes appeared undercooked or overcooked. During a resident council meeting, residents described food as cold, hard, and uncooked, and noted that staff did not always reheat food when requested. There were also complaints about inconsistencies between the meal ticket and what was actually received on the tray. Direct observations and tray testing confirmed that food temperatures were often outside the required ranges, with hot foods below 135°F and cold foods above 41°F. For example, one resident's lunch tray included a beef taco at 114.1°F, vegetables at 108°F, and jello at 56.5°F, with the ice cream already liquefied. Another test tray showed beef tacos at 112.6°F and 113.5°F, peas and carrots at 103.1°F, and several cold items such as yogurt, cottage cheese, and salad dressing well above the safe cold temperature threshold. Staff interviews corroborated these findings, with several CNAs and LPNs stating that food was often cold by the time it reached residents, and that delays in tray delivery were common due to slow elevators and staffing issues. Residents with various medical conditions, including chronic obstructive pulmonary disease, congestive heart failure, diabetes, end stage renal disease, and cognitive impairments, were affected by these deficiencies. Some residents reported that they often ate cold food rather than wait for a replacement, while others relied on family members to bring in outside food. Staff and management acknowledged ongoing complaints about food temperature and quality, citing issues with open carts, lack of insulated delivery systems, and logistical challenges in distributing trays promptly. Despite awareness of these problems, no effective changes had been implemented to ensure meals were consistently served at safe and appetizing temperatures.