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
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure meals were palatable and served at proper temperatures. Several residents reported that food was cold or could be warmer, and 15 confidential residents said meals were cold most of the time across all meal forms. During a test tray observation, 6 of 8 sampled items were cold, and staff stated the plate warmer was not functioning correctly and that meal temperature depended on how quickly trays were handled and served.
Pureed diet food was not prepared according to the facility recipe for two residents. A dietary aide processed smothered pork chops and gravy in a food processor without referring to the available recipe, while stating he knew what to add to thin or thicken food as needed. The dietary manager said she was still educating staff on proper procedures, and the facility policy required puree foods to be smooth, soft, and homogeneous with specific preparation guidelines.
Cold Food Served on Tray Line and at Point of Service: Hot menu items were observed at low temperatures on the tray line, with pureed items tasting lukewarm and not palatable. A test tray sent to the unit was later measured at 115 degrees F for pork, 97 degrees F for green beans, and 100 degrees F for rice, and both the surveyor and the Culinary Development Specialist described the food as cold, bland, and not hot or warm. Residents reported the food is always cold, sometimes requires reheating that staff are too busy to provide, and that they buy outside food or snacks because the kitchen meals are not hot enough.
Food was not consistently held or served at proper temperatures. A resident reported meals were always served cold, and several residents waiting for lunch said hot food was served cold at every meal. In the kitchen, the DM checked prepared food and found smoked sausage at 123 degrees Fahrenheit, below the facility policy for hot holding and serving temperatures. Another resident said food temperature concerns were discussed at every resident council meeting.
Unappealing and Poor-Tasting Meals Served to Residents: Residents reported that facility meals were not good, repetitive, and often required backup salads instead of the main meal. An observed lunch tray included carnitas that looked unappealing, appeared boiled, and had little flavor. A cook and the ADM both stated the food did not look good, and the ADM said there was no policy for food palatability.
A resident meal was served in a manner that did not match the posted menu and was found to be unappetizing and unpalatable. A test tray listed as stuffed pepper casserole, buttered corn, and mocha fudge cake was instead served with pistachio cake, and the casserole lacked visible peppers, consisted mainly of rice and meat sauce, and was described as having no flavor; the corn also lacked flavor. A resident later described the casserole as nasty with no flavor.
Cold Food Served to Residents
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for residents reviewed for food palatability. Residents #10, #30, #80, and #93 each voiced concerns that the food was cold or could be warmer. In addition, 15 confidential residents stated in interview that the food was cold for all three meal forms approximately 85% of the time, including food served in the dining area and in resident rooms. During a test tray observation, six of eight sampled food items were cold, including mechanical corn/peas, mechanical meat/spaghetti, mechanical mixed vegetables, puree Italian vegetables, puree meat/spaghetti, and puree bread. The DM was informed of a request for a test tray, and the survey team observed the sample trays delivered to the survey room. In interviews, the DA, DM, RD, and ADM stated that kitchen staff were responsible for monitoring meal palatability and that cold food could occur if tray transportation took too long, if meals were not served quickly enough, or if the plate warmer was not functioning correctly; the DM stated the plate warmer was not functioning correctly and was being replaced. The facility policy stated that food shall be served at proper temperatures, with hot foods hot and fresh and cold foods appropriately chilled.
Pureed Diet Preparation Not Followed
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature when pureed food was prepared for two residents on a pureed diet. On 06/02/26 at 10:29 AM, Dietary CC prepared pureed smothered pork chops by placing three pork chops from a warmer oven into a Robot Coupe food processor, then adding gravy from a separate container with a ladle. During the process, he did not refer to the recipe for the smothered pork chops that was available for him to follow. He also used a plastic spatula to scrape the food from the processor and continued processing after adding more gravy, then transferred the pureed pork chops into a clean metal container and covered and labeled it. At 10:35 AM, Dietary CC stated the facility had weekly menus each month that included recipes for each food and how they should be prepared, including pureed foods, but he had been preparing pureed food for a little while and knew what to add to thin or thicken food when needed. At 10:36 AM, Dietary BB stated she had been the dietary manager for only two weeks and was still educating staff on proper procedures. She stated she would re-educate Dietary CC to ensure he followed the recipes provided for the purees. The facility's Puree Food Preparation policy dated 02/01/26 stated puree foods should be prepared to prevent lumps or chunks and should have a smooth, soft, homogeneous consistency similar to soft mashed potatoes, with specific guidelines for additives by food type.
Cold Food Served on Tray Line and at Point of Service
Penalty
Summary
The facility failed to provide food at a palatable and appetizing temperature during lunch tray line service. On 05/26/26, the chef took temperatures of multiple hot food items on the tray line, including pork chop at 161 degrees F, green beans at 172 degrees F, rice at 147 degrees F, mechanical soft pork chop at 145 degrees F, pureed pork chop at 141 degrees F, pureed rice at 145 degrees F, and pureed green beans at 131 degrees F. During tray line service, the chef pulled plates from a stack of ceramic and melamine plates that were not heated, and there was no heated pellet system in place. The surveyor tasted the pureed rice, pureed green beans, and pureed pork on the tray line and found them lukewarm, not hot, and not palatable. The Culinary Development Specialist stated the tray line holding temperatures should be at least 135 degrees F, with an aim of 150-155 degrees F, and that food below 150 degrees F should be reheated before being plated. The Food Service Director stated food should be between 145-160 degrees F when it reaches the resident and that if food is served below 135 degrees F in the kitchen, it could not reach 145 degrees F at the resident. The Consulting Registered Dietitian stated hot food should be held at least 165 degrees F and should not be below 135 degrees F at point of service. The facility’s policy stated food is to be palatable, attractive, and served at a safe and appetizing temperature. A test tray was prepared, sent to the unit, and then checked after meal distribution. The temperatures on the test tray were pork chop at 115 degrees F, green beans at 97 degrees F, and rice at 100 degrees F. The surveyor tasted the food and found it cold and bland. The Culinary Development Specialist also tasted the tray and stated the rice tasted cold, the green beans were not hot or warm, and the pork was not hot and tasted dry. Residents interviewed stated the food was always cold, that they had learned to eat cold food, that they sometimes bought delivery food or snacks because the kitchen food was cold, and that staff were often too busy to reheat meals. One resident stated the food was cold at lunch and another said the food was always cold and not appealing when served that way.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure food temperatures were at an appetizing temperature and kept at safe holding temperatures. A resident reported that breakfast, lunch, and dinner meals were always served cold, and during a dining observation, residents waiting for lunch stated that food that was supposed to be hot was served cold at every meal in the dining room. In the main kitchen, the Dietary Manager used a thermometer to check prepared food and found smoked sausage at 123 degrees Fahrenheit, stating it needed to be reheated; he also stated he preferred all food to be held at 150 degrees Fahrenheit, while the facility policy indicated hot food in the steam table should be at least 135 degrees Fahrenheit and arrive at greater than or equal to 120 degrees Fahrenheit when served. Another resident stated resident council discussed food temperature concerns at every meeting and that food that was supposed to be hot was normally served cold.
Unappealing and Poor-Tasting Meals Served to Residents
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for residents. During interviews, Resident #7 said the food was not good and that she rarely ate it, stating she often had to get the backup meal, mainly salads, and had reported the food as a problem. Resident #13 also said the food was not good and that he rarely ate it, stating he would have to get the backup meal, mainly salads. Resident #28 said he liked living in the facility but reported that he got the same food over and over, that there were times when the food was unappealing, and that it often did not taste good. During observation of a lunch tray, the meal consisted of black beans, corn, carnitas, and a tortilla. The carnitas did not look appealing and appeared to have been boiled, and it had little flavor and tasted like it was boiled. A cook stated that the food shown did not look appealing and that residents could have lost weight if they did not eat it. The ADM also stated that the food did not look good and that he would not eat it unless someone made him. He further stated that they were in the process of getting a different food provider and that there was no policy for food palatability.
Unappetizing and Unpalatable Meal Served
Penalty
Summary
The facility failed to ensure meals were served in a manner that maintained an appetizing appearance and palatability. During observation of a test tray on 5/21/26 at 11:46 am, the lunch meal listed on the facility menu as stuffed pepper casserole, buttered corn, and mocha fudge cake was instead served as stuffed pepper casserole, corn, and a pistachio cake. The stuffed pepper casserole lacked an appetizing appearance because it consisted primarily of rice and meat sauce and did not contain visible peppers. The casserole was tasted and found to lack flavor, and the corn also lacked flavor. In an interview later that day, Resident #11 described the stuffed pepper casserole as nasty with no flavor.
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