Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure meals were palatable and served at preferred and appetizing temperatures, as evidenced by resident interviews, resident council minutes, and direct observation of food temperatures. In a confidential group interview, six of nine residents reported that food delivered at mealtimes was often cold, with one resident stating it was sometimes cold and other times lukewarm. Residents reported that meal trays sat in the serving window or in delivery carts for extended periods, contributing to cold food temperatures. One resident described purchasing hairnets online in an attempt to help deliver trays due to ongoing staffing problems and expressed distress that the facility would not allow this, noting that trays frequently stacked up in the serving window because there were not enough staff to deliver them promptly. Resident council meeting minutes over multiple months documented ongoing, unresolved complaints about cold or lukewarm food and beverages, including room trays, dining room meals, and coffee that was sometimes pre-poured and served lukewarm or cold. A cognitively intact resident with a history of left tibia/fibula fractures, who required staff assistance for bathing and toileting, reported that both breakfast and lunch were cold and that this occurred frequently because staff were late checking blood sugar. During observation of a lunch meal service on A Hall, surveyors measured the temperatures of items on the last tray from a food cart and found milk and juice at 59 degrees Fahrenheit and hot items (chicken breast and sliced cooked carrots) at 106–107 degrees Fahrenheit, which did not meet the FDA Food Code standards for hot and cold holding. The facility’s own policy required prompt meal service with resident preferences accommodated, but the observations and interviews showed this was not consistently achieved.
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