Failure to Serve Palatable and Timely Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable, attractive, and at safe and appetizing temperatures during a lunch meal service on the East Unit. Observations revealed that the meal cart, scheduled to arrive at 11:30 AM, was delayed and did not reach the unit until 12:23 PM, resulting in meal trays being distributed significantly later than planned. A test tray obtained after the last resident was served showed that hot food items, including beef tips, garden rice, and mixed vegetables, were served at temperatures below the facility's standard of 120 degrees Fahrenheit, with recorded temperatures ranging from 108.5 to 118.2 degrees Fahrenheit. The food was described as lukewarm, unpalatable in temperature and flavor, with the rice being hard and bland, and the vegetables unseasoned and bland. Only the brownie was found to be palatable. Resident and staff interviews, as well as a review of food committee meeting minutes and grievance forms, indicated ongoing concerns about meals being served cold and unpalatable, with residents attributing these issues to dietary department staffing shortages and delayed meal cart deliveries. One cognitively intact resident specifically reported receiving burnt and inedible food, and others consistently noted that meals arrived late and were frequently cold. The facility's own documentation and interviews confirmed that meals were not served at the expected times or at palatable temperatures and flavors.