Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
Facility staff failed to serve palatable food on the Rosewood Unit, as observed during a survey. On the evening of 09/22/2025, a test tray containing lasagna with meat sauce, sliced carrots, green beans, and mashed potatoes was sent from the kitchen to the Rosewood Unit. The tray was followed by a surveyor and a dietary district manager, who observed the process. Upon arrival, the last dinner tray was served to a resident, and the food temperatures were measured: lasagna at 127°F, green beans at 117°F, carrots at 113°F, and potatoes at 112°F. The food was then sampled by two surveyors and the dietary district manager, who stated that the food could have been warmer and was not palatable, noting it should have been at least 130°F. The executive director, vice president of operations, and regional director of clinical services were informed of these findings, and no further information was provided before the survey exit.