Food Served at Improper Temperatures and Limited Meal Alternatives
Summary
Facility staff failed to ensure prepared food items were served at a safe and appetizing temperature, failed to monitor the internal temperature of hot foods held on the steam table, failed to offer a variety of meal substitutions, and failed to use preparation and hot storage methods that preserved the palatability of food items. The facility policy required proper hot and cold temperatures during food distribution and service and stated that temperatures of foods held in steam tables were to be monitored throughout meal service, but the policy did not include required serving temperatures to residents. The census was 55. Resident #57, who was cognitively intact and had diagnoses including dementia, depression, and psychotic disorder, reported that coffee was cold, that staff brought three half-filled mugs of lukewarm coffee instead of filling a large insulated cup, that breakfast milk was insufficient for cereal, and that French toast and sausage were lukewarm. Resident #11, who was cognitively intact and had diagnoses including depression, psychotic disorder, and schizophrenia, reported that meat, especially pork, was tough, that the only substitute commonly offered was a peanut butter and jelly sandwich, that there were very few fresh alternatives, and that some food was too hot to eat. Resident #18, who had moderate cognitive impairment and diagnoses including obstructive uropathy, diabetes, and depression, reported that food was cold about half the time and that there were very few alternative options unless a peanut butter and jelly sandwich was desired. Resident #4, who was cognitively intact and had diagnoses including obstructive uropathy and diabetes, reported that meals delivered to the room were barely warm and often had to be reheated before eating. Observation and record review showed that the only alternate food items available for meals were deli meat sandwich, grilled cheese, peanut butter and jelly sandwich, chips, or cottage cheese, and residents were observed being offered peanut butter and jelly sandwiches as the only substitute option. In the kitchen, peanut butter and jelly sandwiches made the prior day were stored in an open plastic container on a counter with a use-by date four days after they were made. During breakfast preparation, multiple batches of French toast were placed on the steam line in a metal container with parchment paper between batches, the oven was not used as a holding area even though it was empty, and no temperatures were taken for the third and fourth batches when completed. At the end of service, the test tray showed French toast at 113.5 degrees and sausage patty at 105.2 degrees, and the French toast was described as soggy, lukewarm, and lacking cinnamon flavor while the sausage was cold to the taste. The DM stated that the French toast was soggy because the oven was not used to keep it hot and free from condensation, that spices should be measured exactly, and that food temperatures should be taken before service and for each batch. The Administrator stated that sausage patties served at 105 degrees were too cold, that temperatures should be taken before service and before the last tray is served, and that alternate food items should be made to order rather than pre-made or served in a plastic bag.
Penalty
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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.
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