F0804

E

Failure to Provide Hot, Palatable Meals to Residents Receiving Room Trays

Marshall, Illinois Survey Completed on 01-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to consistently provide hot, palatable meals at safe and appetizing temperatures to residents receiving room trays, despite having a Food Temperatures Policy requiring hot foods to be held at 135°F or above and reheated to 165°F for at least 15 seconds. A test tray served on 12/30/25 at 12:50 PM contained a fish fillet, vegetables, pasta, bread, and peach cobbler; the internal temperature of the fish fillet was measured at 130°F and felt cold to the touch. The facility’s grievance log from 9/25/25 to 12/1/25 documented two grievances related to cold food during that period. The Dietary Manager acknowledged awareness of resident concerns about cold food from a resident council meeting about a month prior and stated that hot pucks were used for breakfast and lunch but not for supper, and that shoestring fries cooled rapidly after cooking and temperature checks.

Multiple cognitively intact residents reported that food delivered to their rooms was frequently or consistently cold. One resident who eats in her room stated that the food is cold every time and that the heaters under the trays do not work. Another resident described the food as gross and often cold, citing a recent meal where the hamburger was served with fries that were ice cold. Additional residents reported that the food was so-so and often cold, that their only complaint was that room-delivered meals were always cold, and that the food was often cold and very institutionalized. Several CNAs corroborated these concerns, stating that residents receiving room or hall trays often complained that their food was cold, attributing this in part to dietary staff not placing heating pucks under plates and to delays in delivering meals to residents who do not eat in the dining room.