Failure to Provide Palatable, Adequate, and Properly Tempered Meals
Penalty
Summary
The facility failed to provide adequate portions of palatable food, served at an appetizing temperature, to multiple residents. Residents and their family members reported dissatisfaction with the quality, temperature, and portion sizes of the meals. Specific complaints included food being bland, flavorless, unrecognizable, and often served lukewarm or cold. Some residents, including those with visual impairments, were unable to identify their food, and staff were reportedly unable to provide information about the meals being served. There were also reports of food items being substituted due to shortages, such as sandwiches being made with hamburger buns instead of bread, and waffles being served without syrup due to lack of supplies. Observations and interviews revealed that residents frequently received small portion sizes, with some meals described as insufficient, such as a breakfast consisting of half a glass of orange juice, a hard-boiled egg, and a piece of toast. Residents with specific dietary needs, such as those requiring supplements or extra portions due to medical conditions, did not consistently receive appropriate food or supplements. There were also instances where residents received food inconsistent with their ordered diets, and staff had to improvise to make the food suitable for consumption, such as moistening dry ground meat with mayonnaise packets when gravy was unavailable. Test tray observations confirmed that food was served at temperatures below recommended levels, with hot foods such as chicken tenders, green beans, and stuffing measured at 104°F, 113°F, and 128°F, respectively, upon delivery to the unit. Dietary staff acknowledged shortages of key items like Magic Cups and yogurt, and nursing staff reported ongoing issues with cold food, small portions, and missing supplements. These findings were corroborated by multiple interviews with residents, family members, dietary staff, and nursing staff, all indicating persistent problems with food quality, temperature, and adequacy.