Failure to Follow Menu Recipes and Meal Tickets Results in Incomplete and Improperly Prepared Meals
Summary
The facility failed to maintain the nutritive value of food by not following the prescribed menu recipe for baked ziti with meat sauce and by not ensuring that residents received all items ordered on their lunch trays. During observation, a dietary staff member prepared baked ziti without measuring the required amounts of sauce, cottage cheese, and shredded cheese as specified in the facility's recipe. The staff member was unsure of the container measurements and used a jarred sauce product instead of preparing the sauce according to the recipe, which could affect the nutritional content, especially for residents on salt-free diets. Additionally, two residents did not receive all the food items listed on their meal tickets; specifically, pureed garlic bread was missing, and a pureed brownie was served instead of a moist iced brownie. The registered dietitian confirmed that not following meal tickets and recipes could impact the quality, taste, nutritional value, and caloric intake of the meals provided. The facility's policy required menus to be served as written unless substitutions were necessary, but this was not adhered to during the observed meal service.
Penalty
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The facility failed to consistently provide palatable meals at appetizing temperatures, in correct portion sizes, and within posted mealtimes. Several residents and a family member reported that food tasted poor, portions of meat were very small, meals relied heavily on noodles and mashed potatoes, hot and cold foods were served together on the same plate, cold items arrived warm, ice cream was melted, menus were inaccurate, and dinner was sometimes served late in the evening. During surveyor observation, hot and cold items on the tray line were at safe temperatures and matched the menu, but a main entrée was initially served at half the prescribed portion size. A test tray delivered to one hall after the posted lunch period showed that while some items remained warm, the main entrée had cooled to a non-palatable temperature, and the late service and temperature findings were confirmed by facility leadership and dietary staff.
The facility failed to maintain palatable food temperatures during meal service, as food on the tray line was initially above 180°F and later served at inadequately low temperatures, with a test tray showing ham at 101.1°F and collard greens at 111.0°F. During the same meal, staff ran out of proper plate lids and used ill-fitting plate bottoms, and the RD reported not performing tray line audits or being aware that cold food was a problem. Several residents reported concerns about the taste and temperature of their meals, and review of the food service policy revealed no standard for food temperatures at the point of service.
The facility failed to maintain appetizing food temperatures for residents receiving room tray service. Food committee notes documented ongoing complaints about the temperature of room-delivered meals, and a resident reported that meals were not always warm and staff would not reheat them. Observations of the tray line showed significant delays between food preparation, holding in satellite kitchen steam tables, plating, and delivery, with some trays sitting for extended periods before leaving the kitchen. A test tray taken from a room tray cart showed multiple hot items at only lukewarm temperatures while one vegetable item was not warm, despite facility policy requiring that food and beverage temperatures be maintained during transport.
Food was not prepared in a manner that conserved flavor and appearance, as evidenced by a resident repeatedly receiving chicken noodle soup without broth, resulting in bowls of dry noodles that had to be eaten with a fork, and by broccoli consistently served in a mushy, watery state that did not hold its shape. Staff, including dietary personnel, acknowledged that the soup tin contained no broth and that the broccoli always became mushy due to the way it was cooked on the stovetop in a tin on low heat.
The facility failed to ensure meals were served at a palatable temperature, as required by its food quality policy. Resident council minutes and multiple interviews with residents and a family member described food that was frequently cold or not palatable, and residents reported that warming plates were not always used. During an observed lunch service, hot foods that began at appropriate temperatures were significantly cooler by the time the last tray cart was delivered, and a test tray taste test confirmed the hot items were not at an acceptable or palatable temperature, affecting all residents receiving meals from the kitchen except those on NPO status.
The facility failed to provide palatable meals at safe and appetizing temperatures, affecting at least two residents and potentially all receiving kitchen-prepared meals. A resident who depended on staff for all ADLs reported that food was not always hot by the time assistance was provided, while another cognitively intact resident who ate independently reported that meals were frequently cold and unappetizing. Surveyors observed that while hot foods on the steam table initially met temperature standards, trays were then placed on delivery carts without heat or refrigeration, and a test tray later showed inadequately cooled dairy items and hot foods that were not maintained at appropriate temperatures. The Dietary Director acknowledged that cold items were not held at proper temperatures and that the hot foods were not warm or seasoned to a palatable standard, contrary to the facility’s policy requiring nourishing, palatable, and attractive meals.
Failure to Provide Palatable, Properly Portioned, and Timely Meals
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food that was palatable, attractively presented, at appetizing temperatures, in accurate portion sizes, and within the posted mealtime schedule. Multiple residents reported that meat portions were very small, that meals contained a lot of noodles, and that leftovers were combined into new meals. Several residents and a family member described the food as terrible, with poor taste, frequent serving of mashed potatoes, and uncertainty about what they were eating. One resident stated that food was almost always cold, that cold items such as milk and yogurt were warm, that hot and cold foods were placed on the same plate (for example, lasagna and salad), and that ice cream arrived melted to a milkshake-like consistency. Another resident reported that dinner sometimes was not served until after 7:00 P.M., and another stated that the menu was not correct. Surveyor observation of the lunch tray line on a specific date showed that while hot and cold items were at safe temperatures and the correct menu items were served, the beef and broccoli stir fry was plated in only one four-ounce scoop for both regular and puree textures instead of the two four-ounce scoops specified on the diet spreadsheet, until the error was identified. A test tray for the 200-hall showed that trays began being prepared after the posted lunch period and that the test tray did not leave the kitchen until well into the posted mealtime, with service to that hall occurring later than the posted lunch hours. When the test tray was checked after delivery, the mini egg roll and soft fried noodles were warm, but the beef and broccoli stir fry measured 104 degrees Fahrenheit, which was not at a palatable temperature. Facility leadership and dietary staff confirmed the late meal service, the test tray findings, and the initial under-portioning of the beef and broccoli stir fry.
Failure to Maintain Palatable Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure food was served at a palatable and appetizing temperature, as evidenced by observations of the tray line and resident and staff interviews. During a lunch meal service, food on the tray line was observed to be above 180°F, and later, when a test tray was checked, the baked ham measured 101.1°F and the collard greens 111.0°F, which the Dietary Manager acknowledged should have been hotter. During the same meal service, the facility ran out of proper plate lids and used plate bottoms that did not fit tightly, compromising temperature maintenance. The Registered Dietitian reported that she did not conduct tray line audits and was unaware that cold food was a problem. Multiple residents interviewed reported concerns with the taste and temperature of the food. Review of the facility’s “Food Service Distribution” policy showed there was no standard for temperatures of food delivered to residents. This deficiency affected five interviewed residents and had the potential to affect all residents receiving meals prepared by the kitchen, excluding those identified as NPO.
Failure to Maintain Appetizing Food Temperatures for Room Tray Service
Penalty
Summary
The facility failed to ensure food was served at appetizing temperatures, affecting residents who received meals on room trays. Food committee meeting notes over several months documented resident complaints about food temperatures for room tray deliveries, and residents met with dietary leadership to discuss adjusting the food delivery route. One resident reported that while the food was seasoned well, it was not always warm enough and staff would not reheat it; the resident obtained a microwave to heat her food but was not allowed to keep it and therefore had to eat the food as served. The Director of Dining Services (DDS) explained that all food was cooked in the main kitchen, transported to satellite kitchens, held on steam tables, and then plated for both dining room and room tray service, with insulated plates and covers used to help maintain warmth. Direct observation of the lunch tray line showed delays between food leaving the main kitchen, being placed in the satellite kitchen steam tables, and being plated and delivered, particularly for room trays. On one day, a cart left the main kitchen at 11:32 A.M., arrived at the second-floor satellite kitchen at 11:37 A.M., and food was not placed in the steam table until 11:43 A.M.; dining room meals were plated first at 11:58 A.M., and room trays were not plated until 12:22 P.M., with the first cart of room trays not leaving until 12:37 P.M., meaning at least one tray sat for 15 minutes before leaving the kitchen. On another day, a test tray placed on the last cart of room trays was delivered and immediately temperature-checked, revealing crumb baked sole at 147°F, chicken tenders at 120°F, green beans at 109°F, braised lima beans at 119°F, fruit at 56°F, and cream of cauliflower soup at 131°F. The DDS confirmed that several items were only lukewarm and that the green beans were not warm, and facility policy required that food and beverage temperatures be maintained during transport.
Improper Food Preparation Affecting Soup Consistency and Vegetable Texture
Penalty
Summary
Failure to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature was identified through observations, test trays, and interviews. During a lunch meal, one resident on the Lifebridge Unit, which was the last hall to be served, received two bowls of what appeared to be pasta salad on his tray at approximately 1:25 P.M. The resident clarified that both bowls were supposed to be chicken noodle soup, but there was no broth in either bowl, and he was eating the contents with a fork. He stated that he requested two bowls of chicken noodle soup daily for lunch and that sometimes there was broth, but usually he had to eat the soup with a fork. A CNA confirmed that the resident had received two bowls of chicken noodle soup without broth. On a subsequent lunch observation, the same resident again received two bowls that were supposed to be chicken noodle soup; one bowl had no visible broth and the other had only a small amount of liquid at the bottom. The Dietary Manager, present during this observation, acknowledged that the noodles appeared to be soaking up the broth and verified that the soup tin in the kitchen contained no broth, only noodles and carrots, and appeared dry at the bottom. Additional observations during the dinner tray line showed that broccoli being served did not maintain its shape and appeared mushy and watery. When a test bowl of broccoli was served later in the meal service, it still did not hold its shape and had a mushy, watery texture. An interview with a dietary staff member revealed that the broccoli was cooked on the stovetop in a tin on low heat, and he confirmed that the broccoli always became mushy. These findings demonstrated that food was not being prepared by methods that conserved nutritive value, flavor, and appearance, affecting items such as chicken noodle soup and broccoli and having the potential to impact all 86 residents in the facility.
Failure to Maintain Palatable Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were served at a palatable, appetizing temperature in accordance with its policy titled “Food: Quality and Palatability.” Resident council minutes documented that residents had complained of cold food. Multiple resident and family interviews corroborated these concerns: one resident stated the food was not palatable, another resident’s family member reported the food was not always hot, another resident stated the food “sucks,” and another resident reported the food was not always warm. During a resident council meeting, several residents reported that food was frequently cold and that the kitchen was not always using warming plates to keep food hot. The facility identified eight residents on NPO status who did not receive food from the kitchen, and thus the issue had the potential to affect all other residents receiving meals. Surveyors directly observed a lunch meal service and documented food temperatures at the start of service and at the end of tray delivery. At the start of service, hot dogs measured 190°F, baked beans 175°F, and coleslaw 32°F. By the time the last hallway cart was completed and delivered, a test tray on that cart showed significantly reduced temperatures: 105°F for the hot dog, 109°F for the baked beans, and 36°F for the coleslaw. A taste test of the hot dog and baked beans determined the food was not at a palatable temperature. The district manager who took the temperatures and participated in the taste test confirmed that the hot dog and baked beans were not at an acceptable or palatable temperature. This failure to maintain palatable temperatures occurred despite the facility’s written policy requiring food to be palatable, attractive, and served at a safe and appetizing temperature.
Failure to Maintain Palatable and Safe Meal Temperatures During Tray Service
Penalty
Summary
The facility failed to ensure that meals provided from the kitchen were palatable and maintained at safe and appetizing temperatures for residents, affecting at least two residents and potentially all residents receiving kitchen-prepared meals. One resident, admitted with a fracture of the lower end of the right radius, anxiety disorder, morbid obesity, and requiring assistance with all ADLs including eating, had a regular diet with thin liquids and intact cognition per a BIMS score of 13. This resident reported that food was not always hot by the time staff were able to assist with meals. Another cognitively intact resident, admitted with bilateral patella fractures, osteoporosis with current fracture, CHF, and CKD, and who was independent with eating, also had a regular diet with thin liquids and reported that meals were frequently cold and did not taste good. Surveyor observations of the meal service showed that hot foods on the steam table initially met appropriate temperatures, but meal trays were then loaded onto 11 delivery carts that had no heat or refrigeration sources. Disposable Styrofoam plates and cups with dome lids and paper bowls for soup were used due to dish machine repairs. When a test tray was evaluated after the last resident tray was served, several items were found at inadequate temperatures: yogurt at 73°F, milk at 61.3°F, mashed potatoes at 132.4°F, mechanical chicken at 101.3°F, and pureed bread at 119.3°F. The Dietary Director confirmed that cold items were not held at appropriate temperatures and stated that, from a personal perspective, the hot foods were not warm enough and some items were bland and needed more seasoning. The facility’s Community Dining and Meal Service Policy required that individuals be provided with nourishing, palatable, attractive meals that support nutritional and special dietary needs, which was not met under these observed conditions.
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