Failure to Provide Palatable, Timely, and Safe-Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported that their meals were consistently cold and served late, with some stating that they did not like the taste or quality of the food. Observations confirmed that meal trays were often delivered to certain halls significantly later than scheduled mealtimes, and that only one staff member was distributing trays per hall, resulting in further delays. The facility used non-insulated metal carts for meal delivery, which contributed to the food cooling before reaching residents, especially those served last. Several residents with complex medical histories, including malnutrition, diabetes, and cardiovascular conditions, were affected by these deficiencies. One resident with paraplegia and protein-calorie malnutrition reported always receiving cold food and not informing management, while another resident with severe cognitive impairment was noted by family to have ongoing complaints about late and cold meals. A third resident with multiple chronic illnesses stated that her food was usually cold and not to her liking, and that staff refused to reheat meals due to concerns about cross-contamination. Staff interviews corroborated these complaints, with dietary aides and CNAs acknowledging that meals were frequently late and cold, and that there was a shortage of dietary aides, particularly on certain shifts. Documentation review revealed a pattern of grievances related to cold and unappetizing food, with several residents reporting cold or burnt meals over multiple months. Resident council minutes also reflected ongoing concerns about meal timeliness, with no documented follow-up. Staff interviews indicated that management was aware of the issues, but there were no effective interventions in place to address delays in meal service or to ensure that food was served at appropriate temperatures. The facility's food temperature control policy required hot foods to be held at 140°F or above, but observations and interviews indicated that this standard was not consistently met due to operational and staffing challenges.