Failure to Provide Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. Observations revealed that the steam table used to keep food warm was not fully operational, with three wells not working and the steamer out of service. As a result, some food items, such as zucchini and onions, were served at temperatures as low as 101.5°F, which is below the facility's policy requirement of at least 135°F for hot foods. Additionally, the zucchini and onions were served without seasoning or margarine, and the noodles were served without the required herbs or margarine, resulting in bland and unappetizing meals. The facility also lacked enough thermal pellet bases to keep all residents' meals warm, using them only for residents on the third floor, while others received only heated plates and dome lids. Interviews with dietary staff and consultants confirmed the issues with food preparation and temperature maintenance. Staff acknowledged that the lack of operational equipment negatively affected their ability to maintain proper food temperatures. During meal service, when the kitchen ran out of noodles and mushroom gravy, trays with thermal pellets were left sitting out while more food was prepared, and these pellets were not reheated before use. Test trays prepared for surveyors confirmed that the food was served at inadequate temperatures and lacked flavor, with the zucchini and onions specifically noted as cold and tasteless, and the noodles as warm but flavorless. Several residents were directly affected by these deficiencies. One resident with a history of chronic kidney disease, weight loss, and other medical conditions reported that meals were not tasteful and described lunch as terrible. Another resident with chronic respiratory failure, diabetes, and heart disease stated that the zucchini lacked flavor and the food was at room temperature. A third resident with cancer, diabetes, and malnutrition risk described the lunch as unappetizing and not warm enough. These findings were corroborated by reviews of medical records, care plans, and facility recipes, which specified the use of seasonings and proper food temperatures that were not followed during the observed meal service.