Failure to Serve Food and Beverages at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages were served at palatable and safe temperatures, resulting in multiple residents receiving lukewarm or cold hot foods and partially frozen beverages. Observations and interviews revealed that residents consistently received meals that were not at the appropriate temperature, with several residents reporting that their food was often cold upon delivery. Staff frequently offered to reheat food, but some residents declined due to concerns about food quality after reheating, such as eggs becoming too dry and difficult to chew. In some cases, residents expressed frustration and hesitancy to eat meals due to the persistent issue of cold food. Residents with various dietary orders, including cardiac, diabetic, pureed, and regular diets, were affected by the deficiency. Cognitively intact residents repeatedly voiced concerns about the temperature and quality of their meals, with some reporting that their complaints had been raised to the Resident Council and facility administration over several months without improvement. Observations included instances where hot foods arrived without visible steam, beverages were served cold or partially frozen, and meal items did not match the tray tickets. Staff interviews confirmed that reheating food was a common practice, and administrative staff were also involved in meal delivery and setup. Facility leadership, including the Dietary Manager, DON, and Administrator, acknowledged awareness of ongoing complaints regarding food temperature and palatability. The Dietary Manager stated that replacement trays should be offered instead of reheating, but there was no documented evidence of daily test tray records. Staff reported that meal trays were delivered promptly upon arrival to the units, yet the issue persisted, with many trays requiring reheating. The deficiency was further substantiated by staff and resident interviews, as well as direct observations of meal service and food temperatures.