F0802

D

Insufficient Dietary Staffing Causing Late Meals and Improper Food Temperatures

Altoona, Pennsylvania Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient dietary staff to ensure meals were prepared, transported, and served at scheduled times and at appropriate temperatures and consistencies. Facility policies required timely meal distribution and proper temperature maintenance for hot and cold foods. Tray delivery logs showed scheduled lunch and dinner delivery times for each wing and the main dining room. On the identified survey date, lunch and dinner trays were repeatedly delivered significantly later than the scheduled times to all wings (A, B, C, D) and the main dining room. Staff interviews, including with an activity aide and nurse aides, indicated that late meals were a routine occurrence and that breakfast had also been delayed that morning.

Multiple specific observations documented substantial delays in meal service. Lunch trays for B wing, C wing, the main dining room, D wing, and A wing were between 50 minutes and 1 hour and 42 minutes late. Dinner trays for the main dining room and all wings were between 34 minutes and 1 hour and 7 minutes late. Residents were observed waiting in the dining room for meals, with one cognitively intact resident, independent with eating, verbally expressing frustration and hunger after waiting nearly an hour for lunch and striking the table. Another cognitively intact resident, requiring only set-up for eating, reported that dinner trays were late that evening and recalled a recent Sunday when dinner did not arrive until 8:45 p.m.

The facility also failed to maintain food at palatable and safe temperatures and appropriate consistencies, as required by its policies. A test tray on D wing showed hot foods (chicken breast with gravy, broccoli, mashed potatoes with gravy) below the required hot-holding temperature, and the chicken and broccoli were described as lukewarm and not palatable; the milk was above the cold-holding standard. During dinner service, a cognitively intact resident in the main dining room received chocolate ice cream that had completely melted to a liquid consistency and refused it. Additional observations of the B wing dinner cart showed single-serving ice cream containers so soft that lids popped off and liquid ice cream leaked out. Staff, including a nurse aide and the Nursing Home Administrator, confirmed that the ice cream was melted and not frozen or firm. The Dietary Director reported that three dietary staff members had called off that day, and the Nursing Home Administrator was observed working in the kitchen as a dishwasher.