Failure to Provide Palatable and Properly Prepared Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature, as required by facility policy. Observations during a lunch service revealed that menu items were not prepared or served according to the approved menu and recipes. Substitutions were made without proper documentation or consultation with the Registered Dietitian, such as replacing fried rice with white rice, pepper steak with baked chicken for modified diets, and substituting desserts without ensuring appropriate texture for pureed diets. Additionally, some menu items were omitted entirely, and staff did not follow recipes for certain dishes. Temperature checks showed that food items left the kitchen at appropriate temperatures but were not maintained during transport and service, resulting in meals being served below the required hot holding temperature of 135°F. Test trays conducted after meal service revealed that several food items were not warm enough, had undesirable textures, and lacked seasoning. The pureed foods were not consistently smooth, with some containing gristle or bean strings, and the pureed bread was described as grainy and pasty. The Food Service Director acknowledged not routinely conducting test trays or tasting pureed foods prior to service. Interviews with dietary staff and the Registered Dietitian confirmed that recipes were not always followed, substitutions were not properly logged, and the menu was not consistently adhered to for modified diets. The Registered Dietitian also stated that test trays were not being performed as required. These actions and inactions resulted in the failure to provide residents with meals that were palatable, attractive, and served at safe and appetizing temperatures, potentially affecting all residents receiving meals from the facility.