F0804

F

Failure to Provide Palatable, Proper-Temperature Meals and Prevent Food Contamination

Youngstown, Ohio Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The facility failed to ensure meals were palatable, attractive, and served at safe and appetizing temperatures, and did not consistently prevent possible contamination during meal service. Multiple residents with significant medical conditions, including diabetes, heart disease, respiratory failure, Parkinson’s disease, morbid obesity, depression, and protein-calorie malnutrition, reported that their meals were often served cold and frequently provided in Styrofoam take-out containers rather than on regular plates. Resident Council minutes from two consecutive months documented resident concerns about food being served cold. Several residents stated they had not received a hot meal in months and that meals were usually or often served in Styrofoam containers.

Observations of the lunch tray line showed that while initial hot food temperatures were within or above expected ranges (tomato soup at 206.9°F and sweet potato fries at 187°F), the ham and cheese sandwiches were at 44.3°F at the start of service. During tray line, a staff member was observed using a gloved hand to retrieve hamburger buns and cheese slices and then continuing with other tray line tasks without changing gloves or performing hand hygiene, and she confirmed she had not followed infection control measures. Additional sweet potato fries retrieved from the oven appeared black on the ends, and staff confirmed they were burnt. The kitchen also ran out of soup bowls for approximately five to six residents, causing about a 10-minute delay while dishes were washed, and the last few residents received a different soup (chicken noodle) because the tomato soup had run out.

The Dietary Manager reported that trays were normally passed within 1 hour 15 minutes to 1 hour 20 minutes and acknowledged that Styrofoam containers had been used for a two- to three-week period when the dish machine needed repair. She also confirmed that hot foods should be at least 135°F and cold foods between 40°F and 55°F by the time residents received them. A test tray taken when the last resident was served showed chicken noodle soup at 146°F, sweet potato fries at 81°F, and a sandwich at 60°F; the Dietary Manager confirmed the fries were cold, soggy, and burnt, and the sandwich was not at an appropriate temperature for service. Another staff member confirmed they often did not have enough dishes and had to wash breakfast dishes to have enough for lunch, yet still sometimes ran short. The Administrator acknowledged awareness of resident concerns about meals being cold upon delivery. These findings demonstrated the facility did not follow its policy requiring nourishing, palatable, well-balanced meals served within 45 minutes of scheduled mealtime, with trays inspected to ensure food was attractive and at safe, appetizing temperatures.