Failure to Prepare and Serve Palatable, Appropriately Tempered Meals and Honor Resident Preferences
Penalty
Summary
The facility failed to ensure that food and beverages were prepared and served in a manner that maintained palatability, appropriate temperature, and honored resident preferences. Multiple residents reported that their meals were frequently served cold, dried out, or tasteless. Observations confirmed that food items such as oatmeal, soup, and bread were served cold or unappetizing, and a test tray revealed that cold items were not at the required temperature, with cranberry juice measured at 52 degrees and pudding at 71 degrees. Residents also expressed dissatisfaction with the repetitive menu and lack of variety, particularly noting the frequent serving of disliked items such as white bread and canned ham, despite documented preferences to the contrary. During meal preparation, staff did not consistently follow recipes or use measured ingredients for pureed diets, instead relying on visual assessment and unmeasured additions of water and thickener. The Food Service Supervisor acknowledged that recipes with specific measurements and the use of broth instead of water were intended to ensure consistency, nutritional value, and palatability, but these procedures were not followed. Additionally, staff failed to provide correct portion sizes as indicated on residents' tray cards, with only one scoop available for serving, resulting in residents not receiving their preferred or prescribed portion sizes. Resident interviews and record reviews further revealed that food preferences and dislikes documented in care plans were not honored. For example, a resident with a documented dislike of white bread continued to receive it with meals, and staff confirmed this was not acceptable. The lack of adherence to residents' dietary preferences and the improper preparation and serving of meals placed residents at risk of dissatisfaction with meals, decreased intake, and reduced quality of life.