Meals were not consistently served hot or on time. Hall trays sat before being delivered, and a resident reported cold food and repeated delays. During a noon meal observation, dietary staff were ready to serve but nursing staff were not present in the dining room, delaying tray service; a test tray from the hall cart was later found lukewarm, with potatoes at 124.5F and chicken at 127.2F. The dietary manager said dietary could not serve without a CNA or nurse present, and the DON acknowledged this had been an ongoing problem with residents complaining of late, cold food.
Food was not maintained at a palatable, attractive, and safe appetizing temperature for two cognitively intact residents. One resident reported meals were often horrible, over seasoned, greasy, warm only if delivered right away, or cold if delayed, while another stated diet restrictions were ignored and substitute items such as grilled cheese were burnt or inedible. Surveyors also observed watery eggs, dark toast, and breakfast items at 94 degrees on the meal tray and watery eggs on the serving line.
Pureed Food Prepared Without Following Recipe: The facility failed to prepare puree foods according to the recipe for two residents ordered pureed diets. An aide pureed Asian fried rice with plain water instead of broth, and the mixture had no flavor until salt was added. The DM and dietician stated the recipe called for broth to be used to achieve the proper consistency and palatability, and the residents involved had diagnoses including dementia, dysphagia, and Alzheimer's disease with physician orders for pureed foods.
Cold Food Served on Tray Line and at Point of Service: Hot menu items were observed at low temperatures on the tray line, with pureed items tasting lukewarm and not palatable. A test tray sent to the unit was later measured at 115 degrees F for pork, 97 degrees F for green beans, and 100 degrees F for rice, and both the surveyor and the Culinary Development Specialist described the food as cold, bland, and not hot or warm. Residents reported the food is always cold, sometimes requires reheating that staff are too busy to provide, and that they buy outside food or snacks because the kitchen meals are not hot enough.
Food Served Cold and Unappetizing: Two residents received meals that were cold and not palatable, with one resident reporting an untouched lunch tray was cold when delivered and eggs tasted refrigerated. A test tray later showed hamburger, pasta, peas, and pineapple at low temperatures, with no warming element used on the tray cart, and the kitchen food temp log had missing cook, hold, service, and cold food temperatures. The DON confirmed hall trays had no way to keep food warm and were passed on an open shelf cart.
Cold Meal Temperatures: A resident who ate meals in her room stated food was often cold when delivered, and several other alert and oriented residents reported the same concern in resident council meetings. During meal delivery, trays were placed on a non-insulated open-to-air cart, and a test tray delivered to a resident room showed food temperatures of 109.4°F for chicken, 94.2°F for potatoes, and 88.5°F for carrots; another resident stated her lunch was cold, and an Activities staff member said residents had complained about food temperatures.
Hot foods were not kept at safe temperatures during meal service. Meal trays were checked in the kitchen at proper temperatures before service, but temperatures dropped substantially after delivery to the floors, including one floor where the test tray measured as low as 90 F. The DSD acknowledged the temperatures were not acceptable and noted the second floor did not use the same insulated hotbox carriers as other floors. Residents with intact cognition reported that meals, including breakfast eggs and lunch items, were often served cold, and the resident council president said this concern had been raised repeatedly in food committee meetings.
Cold Food Served to Residents: A resident council and multiple residents reported that hot food and room trays were often served cold, and one resident said ice cream arrived melted. Residents stated trays were sometimes delivered without thermal food covers, foil was being used, and the microwave did not properly heat food. The ADM acknowledged ongoing complaints and said room trays were plated at the same time and sat on racks in the halls, allowing the food to cool before service.
Cold food was served to multiple residents, with breakfast and lunch items observed below the facility’s hot-food standard. A resident reported breakfast items were cold, including sausage at 86 degrees F and milk at 51 degrees F, while other residents said food was frequently cold or barely warm and one resident sent cold food back. Refused lunch trays were also measured below acceptable temperatures, and resident council and food committee minutes documented ongoing complaints that food arrives cold.
Poor Food Quality and Meal Presentation: Residents reported that meals were often unappealing, poorly prepared, and sometimes inedible. During meal observations, the surveyor noted brown fried rice with very small pieces of chicken, limp zucchini in watery fluid, and ravioli that residents had to trim before eating. Residents also described burnt eggs and watery hot cereal, and the posted menu did not match the weekly menu provided by the Dietary Manager.
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