F0804

E

Failure to Ensure Hot Foods Were Served at a Comfortable, Palatable Temperature

Hartford City, Indiana Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to ensure food was served at a comfortable and palatable temperature when mashed potatoes were observed to be excessively hot during meal service. During a dining observation, one resident verbally warned a tablemate that the mashed potatoes were very hot. At the same meal, another resident, who was non-verbal and being assisted by a hospice CNA, repeatedly lifted her fingers to her lips and widened her eyes immediately after receiving spoonfuls of mashed potatoes, initially refusing to open her mouth when they were re-offered. The CNA continued to offer the potatoes and held the spoon at the resident’s mouth until she accepted the bite, without looking directly at the resident during the interaction.

On a subsequent dining observation, the same resident again reacted by lifting her fingers to her mouth and widening her eyes after receiving mashed potatoes, prompting the CNA to ask if the food was too hot and to state she would allow the potatoes to cool. Dietary staff later checked the mashed potatoes and reported a temperature of 180°F, and a test tray confirmed the potatoes were uncomfortably hot for consumption, causing discomfort to the tongue and mouth. The resident’s record showed diagnoses of pneumonitis due to inhalation of food/vomit, dysphagia, anxiety, and dementia, with MDS and care plans indicating she was non-verbal, severely cognitively impaired, required assistance with eating, and needed staff to face her and make eye contact, ask yes/no questions, and anticipate her needs. The Administrator stated that hot food temperatures should range between 165°F and 200°F and described reheating practices to maintain a minimum of 135°F on the steam table, consistent with facility policy, but did not identify the mashed potatoes as too hot for consumption.