Cold Meal Service and Inadequate Temperature Control
Summary
The facility did not ensure that residents were served food that was palatable, attractive, and at a safe and appetizing temperature. During the Resident Council meeting on 12/12/2025, six of seven alert and lucid residents in attendance reported that hot meals were being served cold. The Ombudsman also stated that residents regularly complain about hot food being served cold throughout the facility, not just on one unit, and Resident Council minutes from 6/2025 through 10/2025 documented ongoing concerns about food temperatures. During lunch meal service observations on 12/16/2025, surveyors requested test trays from four units. On the Akahai Unit, the last tray was served at 12:10 PM and the test tray temperatures were 127 degrees Fahrenheit for roast beef, 123 degrees Fahrenheit for mashed potatoes, and 121 degrees Fahrenheit for green beans. On the [NAME] Unit, the last tray was served at 12:37 PM and temperatures were 125.4 degrees Fahrenheit for mashed potatoes and 120 degrees Fahrenheit for green beans. On the Olakino Unit, the last tray was served at 12:52 PM and temperatures were 129 degrees Fahrenheit for roast beef and 130.5 degrees Fahrenheit for green beans. On the Imua Unit, only 5 heated pellet bottoms were observed for approximately 18-20 resident trays, and the last tray served at 12:55 PM had temperatures of 124 degrees Fahrenheit for roast beef and 111 degrees Fahrenheit for green beans. Interviews identified factors contributing to the cold food service. A resident stated hot meals were often served cold because staff took a long time to deliver food to rooms, and another resident stated breakfast was not eaten because it was delivered cold. An LPN stated trays for residents eating in their rooms were on the same meal truck as dining room trays, with dining room residents served first, causing room trays to wait until dining room service was completed. The Food Service Director stated heated pellet bottoms were missing for some Imua trays and that all trays should have them, and also stated they were unaware that separate meal trucks were not being used for Akahai and [NAME] unit residents who ate in their rooms. The Administrator stated there should have been enough heated pellets for all resident meals and that dining room residents should have been served on a separate meal truck from residents eating in their rooms.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Food was served at unacceptable temperatures for a resident with DM, GERD, and CKD. The resident stated hot food is always cold and that this is a frequent problem, so she usually does not ask for reheating because cold food is normal in the facility. During a breakfast tray observation, the French toast, eggs, sausage, and apple juice were all documented at low temperatures, and the CM stated she was not sure what an acceptable food temperature should be upon delivery.
Food was not served palatable or at an appetizing temperature for several residents. A resident said vegetables were mushy and the meal was cold, and during a meal observation the DON and surveyors sampled regular and puree trays that were bland, warm enough only in part, or cold. In a resident group, several residents said the food was cooked hard and they could tell when the Dietary Manager cooked. The DON, Dietitian, and Administrator all acknowledged expectations that meals be palatable and served at an appetizing temperature.
Food was not consistently temped before leaving the kitchen, and a test tray showed both hot and cold items served at improper temperatures. The DAM could not produce food temp logs, dietary staff only recorded four item temps before tray line, and a tray sent to a hall had a ham & cheese sandwich, coleslaw, lettuce and tomato, and mixed fruit all outside expected temp ranges. Residents also reported that room trays were often hot when they should be cold and cold when they should be hot.
Food was served at temperatures below what residents expected and below the facility’s stated standard. Several cognitively intact residents reported warm foods were sometimes served cold or cooler than desired, and one resident said food lacked taste. During an observed breakfast delivery, hot items measured 118 degrees and 115 degrees after the tray was delayed and then delivered to the resident. The CDM and Administrator stated food delivered to residents should be at or above 135 degrees, and the policy required hot foods to be hot and cold foods to be cold.
Meals were not kept at proper temperatures and were not palatable. A resident reported the food was often cold, tasteless, and had tough meats. Surveyors observed a chicken ranch wrap and vegetable soup at proper holding temperatures at the start of dinner service, but by the end of service the chicken strips in the wrap had fallen to 83 degrees F and the wrap was bland, cold, and soggy. The DM confirmed the chicken strips were outside safe holding temperatures.
Meals Served Below Required Temperatures: Multiple residents reported that food was cold, lacked variety, and did not taste good, with some noting inadequate portions. During a breakfast tray line observation, an NHA checked a test tray after it reached the unit and found the breakfast burrito at 80 F, cream of wheat at 100 F, coffee at 110 F, and juice at 30 F, all below the facility's stated serving temperature standards.
Food Served at Unacceptable Temperatures
Penalty
Summary
Food was not served at palatable temperatures for Resident #31, who was admitted with multiple diagnoses including diabetes, gastroesophageal reflux, and chronic kidney disease. During an interview, the resident stated that hot food is always cold, that she generally eats in the dining room, and that most of the time this is a problem. She also stated that she normally does not ask for her food to be reheated because cold food is normal in the facility. On a later observation, a breakfast tray was requested from the kitchen and delivered by the CM, and the food temperatures were documented as French toast at 84 F, eggs at 93 F, sausage at 79 F, and apple juice at 51 F. When the temperatures were reviewed, the CM stated she was not sure what an acceptable food temperature should be upon delivery.
Food Not Served Palatable or at Appetizing Temperature
Penalty
Summary
Food and drink were not provided in a palatable manner and were not served at an appetizing temperature for 4 of 18 residents reviewed, including Resident #28 and 3 anonymous residents. Resident #28 stated during interview that the vegetables were mushy and the food was cold. During a lunch meal observation, the DON and six surveyors sampled a tray containing pinto beans with sausage, rice, and mixed vegetables, and the DON stated the regular and puree diets did not meet her expectations for flavor or temperature. She said the pinto beans with sausage and mixed vegetables could be warmer, the rice and mixed vegetables were bland, and the puree pinto beans with sausage, rice, and mixed vegetables were cold. During a confidential resident group meeting, 3 residents stated the food was cooked hard and said they could tell when the Dietary Manager cooked. The Dietary Manager said she had only been employed for about 3 weeks and had not had complaints about food. The Dietitian said she was not aware of any food concerns. The DON and Administrator both stated they expected food to be palatable and served at an appetizing temperature, and the DON said the Dietary Manager was responsible for ensuring this. The facility policies reviewed stated meals should be attractively prepared, appetizing, palatable, and served at a safe and appetizing temperature.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable and served at safe, appetizing temperatures. The facility failed to ensure all food was temped before leaving the kitchen and failed to ensure hot foods were served hot and cold foods were served cold. Healthcare Services Group policies cited in the report stated that food should be prepared to conserve nutritive value, flavor, and appearance, and that food should be served at proper safe and appetizing temperatures. The report also states that all foods are to be prepared in accordance with the FDA Food Code. On 06/29/26 at 11:01 AM, the Dietary Account Manager could not produce the June 2026 food temperature logs and stated she could not find them. When the surveyor asked for any food temperature logs for 2026, the DAM stated she had checked the trash and everywhere but still could not find them. Later that day, before tray line started, dietary staff only recorded temperatures for four regular consistency food items: BBQ Chicken, Coleslaw, [NAME] Beans, and a Ham & Cheese Sandwich. A regular consistency test tray sent to Dogwood Hall at 12:51 PM was checked at 1:02 PM, and the recorded temperatures were 67.5 F for the Ham & Cheese Sandwich, 68 F for Coleslaw, 79.3 F for Lettuce and Tomato, and 55.2 F for Mixed Fruit. During Resident Council on 07/01/26, residents stated that when they ate in their rooms, cold food was hot and hot food was cold, and that the food was the correct temperature only when they ate in the dining room.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature for 4 of 8 residents reviewed: Resident #5, Resident #8, Resident #14, and Resident #23. Resident #5, who had a BIMS of 15, stated that warm food was occasionally served cold and that he would like it warm, but he did not ask staff to rewarm it because he thought they would do so. Resident #8, who had a BIMS of 15, stated the food had no taste and was served cool once in a while. Resident #14, who had a BIMS of 13, stated she mostly ate soup at dinner and that the soup was not as warm as she would like; she also stated lunch was not always as hot as she would like and that she never asked staff to warm it because she thought they would. Resident #23, who had a BIMS of 15, stated the food was frequently served cooler than she would like and was cold sometimes, and she also did not ask staff to heat it because she thought they would if needed. An observation of breakfast tray delivery on the hall showed a resident’s tray was taken back to the end of the hall dining room, then later delivered after the resident was assisted to the table. When the sample tray reached the kitchen for a temperature check, the cream of wheat measured 118 degrees and the scrambled eggs measured 115 degrees. The CDM stated the temperatures should have been higher when the resident received the meal and said she would like to see food delivered at or above 135 degrees. The Administrator stated the policy documented that food delivered to the resident should be 135 degrees or above, and the facility policy also directed staff to ensure hot foods are hot, cold foods are cold, and that the resident is ready to receive the meal.
Meals Served at Improper Temperature and Not Palatable
Penalty
Summary
The facility failed to ensure meals were palatable and served at proper temperature for residents receiving meals from the kitchen. During an interview, Resident #7 stated the food was terrible and was often cold, tasteless, and had tough meats. On the dinner menu review, the meal included a chicken ranch wrap, side salad, vegetable soup, and yellow cake. At the start of dinner service, surveyors observed the chicken strips in the wrap at 170 degrees Fahrenheit and the vegetable soup at 178 degrees Fahrenheit. By the end of dinner service, the test tray showed the chicken strips in the wrap had dropped to 83 degrees Fahrenheit and were falling, and the wrap was described as bland, cold, and soggy. The Dietary Manager confirmed the chicken strips were outside safe holding temperatures.
Meals Served Below Required Temperatures
Penalty
Summary
Meals were not served at an appealing and palatable temperature. During resident interviews, multiple residents reported ongoing concerns about the quality, taste, temperature, variety, and portions of meals served by the facility. Residents stated that food tasted awful, did not taste good, was room temperature, was usually cold, was rarely served hot, and that meal portions were inadequate. On 6/26/2026, the surveyor observed a breakfast tray line and requested that a test tray be placed on the last insulated meal cart designated for Unit 1. The cart was loaded with breakfast trays, left the kitchen, and arrived on Unit 1. After the last tray was served, the NHA took temperatures from the test tray and found the breakfast burrito at 80 F, cream of wheat at 100 F, coffee at 110 F, and juice at 30 F. The surveyor informed the NHA that the hot food items and coffee were significantly below the facility's recommended serving temperatures. A review of the facility's Food Temperature Control policy showed recommended serving temperatures of 155-160 F for meat protein, 160-170 F for starch and vegetables, 130-160 F for hot liquids, and below 40 F for cold foods; the breakfast burrito, cream of wheat, and coffee were below those ranges.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.