Resident Burned by Hot Oatmeal Served by Unqualified Aide
Summary
A resident with diagnoses including encephalopathy, COPD, atrial fibrillation, protein-calorie malnutrition, dysphagia, and adult failure to thrive, who was assessed as moderately cognitively impaired and required supervision with eating, was served oatmeal at a temperature that caused injury. The resident was observed eating independently with set-up supervision in the dining room. An incident occurred when an aide, whose certification had expired and who was reportedly in training as a hospitality aide, fed the resident oatmeal that was visibly steaming. Another CNA witnessed the event and attempted to intervene, but the resident had already ingested the hot food, resulting in the resident making a crying noise and showing visible pain. Subsequent assessment by nursing staff revealed two white blisters on the roof of the resident's mouth, consistent with a burn from hot food. Documentation indicated that the incident was reported to the physician and the resident's family, and an incident report was submitted to the state health department. The aide responsible for feeding the resident was identified as having worked at the facility for only a short period, was not fully certified, and was supposed to be in a non-direct care role according to facility policy and staff interviews. Interviews with staff revealed inconsistencies in training and orientation, with some aides reporting they had not received in-service training on hot foods and liquids and had not undergone a formal orientation period. There was also confusion among staff regarding the roles and responsibilities of hospitality aides and aides in training, with some staff stating that such aides should not provide direct care or feed residents. The dietary manager was unaware of the incident and stated that food is typically checked for temperature before leaving the kitchen.
Penalty
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Surveyors found that meals were not consistently palatable, attractive, or maintained at safe and appetizing temperatures. Residents reported that food was often cold, tasteless, and not nutritious, and that trays, particularly those delivered to rooms, lacked condiments, with dinner described as the worst meal. Observation of a lunch service showed discrepancies between the posted menu and the food actually served, absence of garnishes or condiments, and a test tray with bland scalloped potatoes and gravy, under-temperature green beans, and no beverage. The Dietary Manager stated that frozen foods were used and often lacked flavor, and that only one staff member was scheduled for the dinner meal service each day.
The facility failed to maintain safe and appetizing food temperatures, as multiple residents reported that meals, particularly those delivered to rooms, were consistently cold and that staff would not reheat them. Surveyors observed open meal carts with trays left inside and additional trays on a hallway cooling rack, while staff admitted they did not know carts should remain closed between tray removals. Temperature checks showed that while food on the tray line was initially hot, a test tray delivered last had meat and side dishes well below required hot-holding temperatures, despite the food being palatable and visually appealing. The acting Dietary Manager confirmed the inadequate temperatures and limited use of insulated carts, and facility leadership acknowledged the failure to provide food at safe and appetizing temperatures.
The facility failed to ensure food and beverages were served at safe and appetizing temperatures, as required by its Food Preparation and Service policy. Multiple test tray assessments documented hot items such as meats, vegetables, and starches being served within the temperature danger zone, and cold items such as desserts, milk, juice, and sandwiches above the required cold-holding temperature. A resident with DM2, major depressive disorder, and anxiety, who was cognitively intact, reported receiving cold food all the time, and residents in a Resident Council meeting also reported cold food at mealtimes. During a test tray observation, surveyors found hot entrée and vegetable items to be room temperature or cold and beverages warm. Despite these findings, dietary leadership and the RD stated that hot food was always hot and that temperatures taken during audits were accurate, while the DON and Administrator expressed expectations that hot food be hot and cold food be cold.
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.
Staff failed to follow standardized recipes and facility policy for pureed food preparation and hot holding temperatures. A cook pureed beef pot roast and carrots for several residents on pureed diets using unmeasured amounts of water as a thinning agent instead of the prescribed juice, milk, or broth, and without measuring portions as required. Residents reported that meals in a dining room were not always hot, and resident council members stated that food was served cold. During a lunch service, staff in the dining room lacked an available food thermometer at the start of service, and subsequent checks showed pureed carrots, pureed beef pot roast, and hamburgers being held below the required 135°F hot holding temperature, in violation of facility policy and state code.
Multiple residents and a family member reported that meals were bland, unappetizing, sometimes raw or over-roasted, difficult to chew, and often cold by the time they reached residents’ rooms, with no consistent offer of alternatives when food was disliked. Resident council minutes and grievances documented concerns about cold meals, limited variety, lack of fruit, and meals perceived as too high in carbohydrates. A test tray showed hot items, including chicken tenders and tater tots, were served at low temperatures, with mushy, cold textures and dry, tough meat, and there was no plate warmer used while CNAs, rather than dietary staff, passed trays on the halls after a change in kitchen operations.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were palatable, attractive, and maintained at safe and appetizing temperatures for residents consuming food prepared in the kitchen. During a Resident Council meeting, all 6 residents present reported that food was often cold, tasteless, and not nutritious, and that meal trays, especially those delivered to rooms, lacked condiments. They also stated that the dinner meal was usually the worst meal of the day. The 2022 FDA Food Code standard that hot food be maintained at 135°F or above and cold food at 41°F or below was cited as the applicable guideline. During observation of a lunch meal service, the posted menu listed roast beef with gravy, scalloped potatoes, seasoned green beans, a roll with margarine, coconut cake, and a beverage, but the meal actually served was roasted pork with gravy, scalloped potatoes, green beans, a roll with margarine, white cake, and a beverage, with no garnishes or condiments provided. When the last tray from the meal cart was tested, the scalloped potatoes were 135°F but tasted bland, the gravy was bland and tasteless, and the green beans were 128°F instead of the expected 135°F, and were described as bland and mushy; no beverage was present on the tray. The Dietary Manager stated that the facility used frozen food that often lacked flavor, confirmed the green beans should have been at 135°F, and reported that only one staff member was scheduled for the dinner meal service each day.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide food and drink at safe and appetizing temperatures, as required by policy and federal regulations. Facility policy specified that hot foods must be held at 140°F or above and cold foods at 45°F or below, and USDA guidance indicated poultry should reach 165°F and be held at 140°F or higher. Multiple residents reported that their meals were consistently cold, especially when delivered to their rooms, and that staff refused to reheat the food. Residents stated they chose to eat in the dining room to avoid cold food. In a confidential group interview, all participating residents reported that meals were consistently late and cold. Resident council minutes from two meetings also reflected concerns about meal temperatures. Surveyors observed breakfast service with metal kitchen carts left open between tray removals, with several trays remaining inside, and additional trays placed on a cooling rack in a hallway. Staff members acknowledged they were unaware that cart doors needed to be kept closed between removing trays. During a lunch observation, food on the tray line initially met or exceeded hot-holding temperatures for some items, but a test tray obtained when the last tray was delivered showed the sliced turkey at 48°F, mashed potatoes with gravy at 55.8°F, and diced carrots at 51°F. Although the food was described as palatable and visually attractive, it was not at an appealing or appetizing temperature. The acting Dietary Manager confirmed the low temperatures and reported that the facility had only one small insulated cart and two uninsulated metal carts for meal delivery. The Nursing Home Administrator confirmed the facility failed to provide residents with food at a safe and appetizing temperature.
Plan Of Correction
The facility will provide the residents with food and drink that is at safe and appetizing temperatures The tray line will be moved to the kitchen from the dining room to improve efficiency of meal production and improve meal temperatures. Equipment consisting of Thermal Pellet base/heating element and Thermal Dome will be purchased to add additional heated time to the food from the time the meal is planned until delivered to the resident. Ancillary staff as Activities Aide, Medical Records Clerk, Business office assistant will be utilized to assist with tray pass. The Nursing and Dietary staff will be educated by the Administrator/Designee on new process of tray line and meal delivery to the residents and that during meal delivery the cart door must remain closed when not in use. Audits will be completed by the Administrator/Designee on providing the residents with food and drink that is safe and appetizing temperatures. The last tray served will have food temperatures taken to provide safe and appetizing temperatures three times a week at different meal times and then weekly ongoing Results of these audits will be presented to the QAPI committee for review and recommendations
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide food and drink at safe and appetizing temperatures in accordance with its own Food Preparation and Service policy. The policy, dated 2001, defined the temperature danger zone as above 41°F and below 135°F, and required potentially hazardous foods to be maintained at or below 41°F or at or above 135°F. Multiple Providence Pavilion Test Tray Assessment documents for various meals showed hot foods such as baked ravioli, baked chicken, rice pilaf, carrots, rosemary chicken, mushroom rice, au gratin cauliflower, broccoli, mashed potatoes, beef stroganoff, and carrots being served at temperatures between 118°F and 132°F, which were within the policy’s stated danger zone. Cold items such as apple bar, milk, cold ham and cheese sandwich, pudding, juice, and lemonade were recorded at temperatures between 42°F and 61°F, also within the danger zone. During a test tray observation, surveyors tasted the beef stroganoff, broccoli, and lemonade and described them as room temperature, cold, and warm, respectively. Resident feedback corroborated these findings. One resident, admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and anxiety, and assessed as cognitively intact with a BIMS score of 14/15, stated she received cold food all the time. Residents attending a Resident Council meeting also reported receiving cold food at mealtimes. Despite these reports and documented tray temperatures in the danger zone, the Dietary Manager stated she preferred hot food served at 130°F and reported that steam tables were turned on one-half hour before meal service. The RD reported that she conducted sanitation walkthroughs and test trays and stated that hot food was always hot and that recorded temperatures showed this, and further indicated that department heads passed trays and took temperatures during test tray audits. The DON and Administrator both stated their expectations that residents receive food at proper temperatures, with hot food hot and cold food cold, but the documented observations and resident interviews showed that this was not consistently occurring.
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.
Improper Puree Preparation and Inadequate Hot Holding Temperatures
Penalty
Summary
The deficiency involves failure to properly prepare pureed foods according to facility policy and standardized recipes, and failure to maintain appropriate hot holding temperatures for multiple menu items. During observation, a cook pureed beef pot roast and carrots for seven residents on pureed diets by adding unmeasured amounts of hot water to the food processor until the desired consistency was reached, then adding a small scoop of juice from the main roasting pan. The Dietary Manager stated that staff used water as a thinning agent during pureeing and then added a small amount of juice afterward, despite the written recipe for beef pot roast directing staff to count and measure portions and to use juice, milk, or broth as needed to achieve the desired consistency. The facility’s pureed food preparation policy required use of standardized recipes, specified that milk, broth, soup, gravy, and margarine be used to thin pureed food instead of water (unless water was mixed with a thickening agent), and required that pureed hot items be prepared while maintaining a temperature above 135°F. The deficiency also includes failure to maintain and verify safe and appetizing food temperatures during meal service. One resident reported that meals in the second-floor dining room were not always hot, and three resident council members reported that food served during meal services was cold. When surveyors requested food temperatures in the second-floor dining room during a lunch service, the staff member present did not have a food thermometer available in the serving area and had to obtain one from the main kitchen, by which time meal service had already started. Temperature checks then showed pureed carrots at 128°F, pureed beef pot roast at 103°F, and hamburgers at 119°F, all below the facility’s policy requirement that hot foods be held at 135°F or above throughout service. The Dietary Manager confirmed that these items were not at appropriate holding temperatures and could not be served, contrary to the facility’s food temperature policy and applicable Indiana Administrative Code requirements.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures for multiple residents. Several residents reported that the food was bland, horrible, disgusting, or generally “not good,” and one resident stated that if she did not like what was served, staff did not offer an alternative and that she repeatedly received dark meat she did not like. A family member reported that a resident with a poor appetite received chicken that was dry and needed more moisture. Resident council minutes documented concerns that hamburgers were sometimes too raw, vegetables were roasted to the point of tasting burned, pork chops were difficult to cut or chew, and that food delivered to rooms was cold by the time it arrived when CNAs passed trays. Surveyors’ direct observation of a test tray showed that hot items were not maintained at appetizing temperatures and were of poor quality. After the last tray was plated and placed in the cart, CNAs—not dietary staff—were responsible for passing trays to residents, and there was no plate warmer between the plate and the plastic base. When the test tray was checked, the chicken tender and tater tots were below typical hot-holding temperatures, with the tater tots described as mushy and cold and the chicken tender as dry, tough to chew, and salty. The cold item, a carrot coin salad, was measured at a chilled temperature. Grievances documented that meals were served too cold and that residents were dissatisfied with the variety, fruit options, and perceived high carbohydrate content of the meals. The Dietary Manager acknowledged that dietary staff no longer delivered trays to residents after a change in ownership and attributed cold food to CNAs not passing trays quickly enough, while the Administrator acknowledged there had been complaints about food quality.
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