Failure to Serve Palatable and Properly Heated Food to Residents
Penalty
Summary
The facility failed to serve palatable, attractive, and safely heated food to residents, as evidenced by observations, interviews, and record reviews. During a lunch meal observation, food items such as carrots, mashed sweet potatoes, ham, and beans were served at temperatures ranging from 114 to 120 degrees Fahrenheit, which did not meet the facility's stated requirement of 120 degrees Fahrenheit or above for hot foods. Multiple residents reported receiving cold food on several occasions, and this concern was documented in resident council meetings and individual concern reports. Staff interviews confirmed that residents frequently complained about the temperature of their meals, and some staff acknowledged that food was not always hot when served. Several residents affected by this deficiency had significant medical conditions, including diabetes, HIV, paraplegia, pressure ulcers, chronic kidney disease, and cognitive impairments. Care plans for these residents indicated risks related to nutrition and blood glucose fluctuations, making the provision of appropriate and palatable meals particularly important. Despite these needs, residents consistently reported dissatisfaction with the temperature of their food, with some refusing to eat cold meals and expressing feelings of neglect and disappointment. Interviews with dietary and nursing staff revealed a lack of clear responsibility and communication regarding the maintenance of food temperature from the kitchen to the point of service. The facility was operating without a dietary manager at the time, and staff reductions in the kitchen contributed to a hectic environment, further impacting meal service. Facility policies required food temperatures to be maintained at acceptable levels during all stages of preparation and service, but these policies were not effectively implemented, resulting in repeated instances of cold food being served to residents.