F0804

E

Failure to Provide Palatable, Properly Prepared and Temperature-Controlled Meals

Woodland Park, Colorado Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents consistently received palatable food with acceptable taste, texture, and temperature, as required by its own policy. The facility’s Standardized Menus policy stated that residents would receive nourishing, palatable meals to meet nutritional needs and that menus would be planned to be appetizing and culturally appropriate. However, the policy lacked specific procedures or quality control measures to ensure food was served at acceptable taste, texture, and temperature, and did not address prevention of overcooking, undercooking, dryness, or burned food items, nor did it include a process to assess meal palatability prior to service.

Multiple resident representatives and residents reported ongoing concerns about food quality, including temperature, taste, and texture. One resident representative stated that food issues had been ongoing and discussed in resident group meetings, with some recent improvement but persistent problems such as runny eggs. Another representative reported that food was often cold, ice cream was soupy, and that a resident was not awakened for breakfast and instead received cereal with milk much later than her usual meal time, disrupting her normal meal pattern. The same representative later described watery potato soup, mushy broccoli, an undercooked hard baked potato, cold french fries, and tough meats such as beef, noting that the resident sometimes ate at her daughter’s home and that she felt guilty leaving the resident at the facility.

In a resident group interview with seven alert and oriented residents, participants reported that food was served cold, pork was impossible to chew, other meats were tough, and meal delivery took hours despite having reported these concerns to facility leadership. Individual resident interviews further detailed that eggs were served runny with excess moisture, food lacked taste and was lukewarm, meals were bland, and requested items such as cheeseburgers and condiments were either incorrect, delayed, or missing. One resident reported that pork was served in strings, french fries were not crisp and were cold, and that she felt the facility did not care about residents. Another resident stated the food was horrible, did not taste good, and that when she voiced concerns to the dietary manager and operations manager, she was told the food was as good as it was going to get, leading her to obtain her own sliced meat and cheese multiple times per week.

Direct observations by surveyors corroborated these complaints. One resident’s breakfast tray contained toast that was burned on both sides and very hard to chew, which the resident could not eat, and scrambled eggs that were very moist and slightly wet, with a napkin saturated from absorbing excess moisture; the resident stated she had repeatedly reported runny eggs to the dietary manager without resolution. Another resident was observed eating only oranges for breakfast and stated she did not like the facility’s scrambled eggs, describing them as fake, and preferred eggs at her daughter’s house. A test tray evaluated by four surveyors showed that shrimp over pasta was served at approximately 106°F, tasted cool or cold on the palate, the pasta was dry and slightly firm, and no butter was provided for the dinner roll.

Record review showed that resident council meeting minutes and grievance forms documented repeated dietary concerns, including cold food and food quality issues, and referenced hot carts and meal covers being ordered to address temperature concerns. However, during the survey, hot carts were observed still in their delivery boxes outside the main entrance and had not been implemented. Staff interviews revealed that the dietary manager acknowledged complaints about overcooked and chewy meats and stated she did not know what could be done to make meat tender. She also stated that eggs should not have been runny but could not explain why runny eggs were served. The cook, who had prior restaurant and baking experience but no prior hospital or nursing home cooking experience, identified challenges in meeting different dietary textures and expressed surprise about burned toast and runny eggs, stating she cooked eggs thoroughly. The DON reported that staff were expected to monitor meal tickets and check food temperatures before trays left the kitchen and again on the floor, and that unpalatable food should be returned for replacement, but the repeated resident complaints and surveyor observations demonstrated that residents continued to receive food that was not consistently palatable in taste, texture, or temperature.