Failure to Serve Hot Beverages at Safe Temperatures Resulting in Resident Burns
Summary
Facility staff failed to provide beverages at a safe temperature, resulting in harm to two residents. In one case, a resident with Parkinson's disease, who had documented tremors and weakness in her upper extremities, was served coffee without the requested ice, leading to severe burns on her mouth and throat. The resident's care plan and risk assessment had specified the need for lids on hot beverages and water-resistant clothing protectors, and her spouse routinely requested coffee with ice and a straw. On the day of the incident, a dietary server, in a rush, forgot to add ice to the coffee, and the resident's spouse, unaware of the omission, gave her the coffee through a straw. The coffee was hot enough to cause immediate pain, blistering, and ultimately required hospitalization, IV fluids, and the surgical placement of a feeding tube due to the resident's inability to swallow. Another resident experienced two separate incidents of spilling hot coffee, resulting in burns. This resident had multiple Hot Liquid Risk Assessments and care plan interventions, including the use of a specific cup with a lid and encouragement to use a clothing protector. Despite these interventions, the resident was served coffee at a temperature that caused partial-thickness second-degree burns over the lower abdomen and upper thigh in one incident, and redness on the thigh in another. The care plan interventions were not sufficient to prevent injury, and the temperature of the coffee was not monitored prior to serving. Observations during the survey revealed that coffee was brewed and served directly from a pot with a water temperature of 200 degrees Fahrenheit, and staff did not routinely check or monitor the temperature of hot beverages before serving them to residents. The facility's policy stated that hot beverage dispensers should not exceed 155 degrees, but this was not consistently followed. Staff interviews confirmed that temperature checks were not routinely performed, and the dietary server involved in the first incident acknowledged forgetting to add ice to the coffee, which was a standing request for the resident. These failures directly led to significant harm for both residents.
Penalty
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Two residents were served microwave-reheated items without a temperature check before service. A staff member reheated almond milk and chicken noodle soup, placed both on the counter, and they were later measured at 182 F and 190.4 F, respectively. Staff stated the kitchen checked temperatures, but the items were served before confirming they had cooled to a safe temperature.
A resident with cognitive impairment and a mechanically altered diet was left sitting at the dining table with an uncovered lunch tray for nearly 45 minutes without staff cueing or feeding assistance, despite needing supervision and help with meals. When an NA finally began feeding her, the meal items were found to be lukewarm or cold, and neither the NA nor the dietary manager reheated the food or replaced the tray.
Food portions were not served per recipe directions when a cook prepared sandwiches, pureed items, cake, and side items by estimation instead of measured amounts. The cook used tongs to add unmeasured meat, onions, and cheese to buns, served visibly different cake portions, and confirmed there were not enough pickles for all residents. The cook stated the portions were “eye balled” and that the spoons were inconsistent.
Food was not prepared to preserve nutritive value for 233 of 237 residents receiving kitchen-prepared meals. Vegetables, including pureed green peas, were cooked more than an hour before meal service and held in a steamer set at 212 to 220 degrees Fahrenheit. The Dietary Manager and an Assistant Cook confirmed the timing and holding conditions, and the facility policy stated fruits and vegetables were to be cooked to a holding temperature of 140 degrees Fahrenheit.
Food and beverages were not served at proper temperatures and were described as unpalatable during a lunch meal. Tray line issues included no plate warmer in use, cold drinks left unrefrigerated, and delayed tray delivery, and the test tray showed meat loaf, mashed potatoes, vegetables, milk, and coffee at suboptimal temperatures. Residents and an LPN reported the meal was cold, bland, dry, tough, or tasteless, and the FSD and RD gave differing expectations for hot and cold food temperatures.
A resident’s breakfast was served with pancakes at 110 degrees, below the stated hot food standard of 135 degrees, and the tray did not include the milk listed on the meal ticket. The resident and RP reported that coffee and milk were often missing and that breakfast food was frequently cold.
Unsafe Temperatures for Microwave-Reheated Food
Penalty
Summary
The facility failed to ensure food and beverages reheated in the microwave were served at a safe temperature for two residents. During meal service observation, a staff member reheated almond milk for Resident #24 in the microwave and placed it on the counter without measuring the temperature; the milk was then served and later measured at 182 F. In a separate event, a staff member reheated chicken noodle soup for Resident #15 in the microwave, placed it on the counter without checking the temperature, and the soup was served to the resident at 190.4 F. Staff involved stated that the kitchen checked temperatures, but the reheated items were served without a temperature check before service. Interviews showed that the staff member who reheated the items did not check temperatures after microwaving and described using stirring, reheating, and a gloved finger to judge hotness. The Kitchen Manager confirmed that microwave-reheated food must reach at least 165 F, but the facility’s policy only addressed minimum reheating temperatures and did not instruct staff to check for excessively hot food before serving. The report also cited FDA Food Code guidance that microwave-reheated TCS foods must reach 165 F and stand covered for 2 minutes, and an American Burn Association guide noting that microwaved foods and liquids may reach temperatures greater than boiling without bubbling.
Food Served at Unsafe Temperature and Resident Left Without Meal Assistance
Penalty
Summary
The facility failed to serve food that was palatable and at safe and appetizing temperatures for Resident 51. The resident’s quarterly MDS dated June 27, 2026 showed cognitive impairment, substantial/maximum assistance needed with eating, a mechanically altered diet, and diagnoses including cerebral infarction. Her care plan, initiated April 6, 2026, directed staff to cue and prompt her at mealtimes so she could feed herself as much as possible and to assist as needed. A physician’s order dated March 30, 2026 ordered a regular diet with mechanical soft, ground texture and nectar consistency liquids, with supervision and assistance with meals. On August 3, 2026, the resident was observed in the third-floor dining room with her lunch tray delivered and uncovered at 11:43 a.m. She remained seated with her eyes closed and did not attempt to feed herself at 11:50 a.m., 12:17 p.m., or 12:22 p.m., and no staff attempted to assist or cue her during that time. At 12:28 p.m., a nurse aide began feeding her, and the resident was receptive to food. When the meal temperatures were checked at that time, the spinach was 103 degrees Fahrenheit, the chicken 108.6 degrees Fahrenheit, the sweet potatoes 102 degrees Fahrenheit, and the milk 61 degrees Fahrenheit. Neither the nurse aide nor the dietary manager attempted to reheat the food or obtain another tray. The Nursing Home Administrator confirmed staff should have assisted the resident and should have heated her food or gotten another tray.
Food Portions Not Measured Per Recipe
Penalty
Summary
The facility failed to serve foods according to the recipe serving sizes to ensure residents received the correct amounts of protein and other nutrients. The cited recipe for the evening meal specified measured portions for the steak, onion, and cheese submarine sandwiches, potato wedges, pickle spears, and lemon poke cake, but during meal preparation the cook did not measure the meat, onions, cheese, or other components as directed. The cook stated they were preparing 30 servings and had 2 lbs, 2 oz of onions, but then weighed all 4 onions to a total of 2.5 lbs and began slicing them, placed the onions in the refrigerator, and later added an unmeasured amount of margarine and onions to the skillet. During meal service, the cook repeatedly served food by estimation rather than by the recipe portions. The cook removed frozen meat, cooked it, and then used tongs to place an unmeasured amount of meat and onion mixture into each bun, with a visible difference in the amount going into each sandwich. The cook also used the same tongs to add an unmeasured amount of cheese to each bun. For residents who required pureed foods, the cook added unmeasured amounts of the meat, onion, and cheese mixture to blender cups and pureed the food, including adding an unmeasured amount of milk and liquid grease. The cook also plated unmeasured amounts of the pureed meat and onion mixture onto residents’ trays. The cook further prepared and served desserts and side items without consistent portioning. The cake was sliced into unmeasured servings, with each serving visibly different in size, and some portions were pureed with milk. The cook confirmed there were 2 pureed diets, 1 chopped diet, and 1 bite sized diet, and also confirmed there were not enough pickles for all residents and no extras were available. At 6:04 PM, the cook stated the meat and onion mixture and cheese were not measured and that they had “eye balled” the sandwiches with the tongs, adding that the spoons were inconsistent and they thought the recipe said to use the tongs.
Food Held Too Long at High Temperature Reduced Nutritive Value
Penalty
Summary
The facility failed to ensure food prepared for residents was cooked to preserve nutritive value for 233 of 237 residents receiving food prepared in the kitchen. The deficiency involved vegetables that were cooked more than one hour before meal service and held in the steamer with the temperature set between 212 and 220 degrees Fahrenheit. The facility’s Diet Type Report dated 7/27/26 showed that 233 of 237 residents consumed food prepared in the kitchen. The facility’s Food Preparation and Service policy stated that fresh, frozen, or canned fruits and vegetables are cooked to a holding temperature of 140 degrees Fahrenheit. On 7/28/26 at 0936 hours, the Dietary Manager stated puree preparation had been completed by the cook and tray line started at 1030 hours, and verified the vegetables were prepared more than one hour before meal service. On 7/28/26 at 1040 hours, an observation of the steam table with the Assistant Cook showed covered serving pans containing cream of rice, pureed pork and tortilla taco, pureed chicken, and pureed green peas vegetables. The Assistant Cook acknowledged the findings and stated puree preparation was started after returning from lunch at 0900 hours and that the pureed green peas were kept on the steamer at 212 to 220 degrees Fahrenheit.
Food and beverages served at improper temperatures and were unpalatable
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures for a second-floor South unit lunch meal. The facility policy required food to be handled and served in a safe, sanitary, and controlled manner, with hot foods held at 135 degrees Fahrenheit or above and cold foods at 41 degrees Fahrenheit or below. During the meal service, the tray line began without a plate warmer in use, milk and juice cartons were removed from refrigeration and left on top of the line without refrigeration, and coffee was poured while tray preparation continued. A ticketing error occurred when dinner tickets were accidentally placed on trays instead of lunch tickets, requiring staff to redistribute the correct tickets while plating continued. The first caddy left the kitchen at 12:08 PM and the second caddy left at 12:13 PM, but tray delivery on the unit was delayed as staff delivered trays from the first caddy before the second caddy arrived. The last resident tray was not delivered until 12:36 PM. When the test tray was sampled at 12:37 PM, the meat loaf with gravy was 115.3 degrees Fahrenheit and described as spicy, dry, and cool to the palate; mashed potatoes with gravy were 117.3 degrees Fahrenheit and cool to the palate; Capri blend vegetables were 94.8 degrees Fahrenheit, watery, bland, tasteless, and cool to the palate; lemon pudding was 77.3 degrees Fahrenheit and warm; milk was 55.2 degrees Fahrenheit and warm to the palate; and coffee was 107.7 degrees Fahrenheit, bitter, and cool to the palate. The LPN who tasted the tray stated the meat loaf tasted terrible and was cold, the mashed potatoes were bland and cool, and the vegetables had no taste and were cold and mushy. Residents reported similar concerns about the meal quality and temperature. One resident stated lunch was not tasty and was sent back to the kitchen because it was cold. Another resident stated the food was terrible, often served cold, soggy, and tasteless, and like it had been taken right out of the refrigerator. Additional residents stated the meat loaf was cold, hard, too dark, burnt at the edges, or disgusting, and the vegetables were cold, hard, tasteless, or tough to bite into. The FSD stated hot foods should be served at 140 degrees Fahrenheit and cold drinks at 40 degrees Fahrenheit, while the RD stated hot foods were expected to be served at 165 degrees Fahrenheit and should not go below 140 degrees Fahrenheit, and that milk at 55 degrees Fahrenheit was in the danger zone. Staff also stated residents frequently complained about cold food and lack of taste.
Breakfast Tray Missing Items and Served at Improper Temperature
Penalty
Summary
Food and drink were not consistently served at a palatable temperature and all items listed on a resident’s meal ticket were not delivered for Resident #15. The resident’s responsible party reported that the resident had complained about not receiving coffee, not receiving milk for oatmeal, and being served cold breakfast food. The resident also stated that coffee and milk were not always provided and that the food was often cold, leading the resident not to eat it. During a surveyor observation, pancakes served to the resident measured 110 degrees, below the stated hot food temperature of 135 degrees, and no milk was present on the breakfast tray. The unit manager was present during the observation and confirmed the surveyor’s findings. Review of the resident’s breakfast meal ticket showed the resident was to receive 8 ounces of milk.
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