Food was not served at palatable temperatures for 1 of 1 trays tested on the East Hall Unit. Surveyors found the hot food tasted cold, with the BBQ sandwich, green beans, cubed potatoes, soup, chocolate pudding, and hot water all below the facility’s stated hot-food temperature standard. The Dietary Manager stated hot foods should be 135 degrees F or greater and cold foods should be 41 degrees F or lower, and the facility policy matched those temperature requirements.
Food was not consistently held or served at proper temperatures. A resident reported meals were always served cold, and several residents waiting for lunch said hot food was served cold at every meal. In the kitchen, the DM checked prepared food and found smoked sausage at 123 degrees Fahrenheit, below the facility policy for hot holding and serving temperatures. Another resident said food temperature concerns were discussed at every resident council meeting.
A resident with severe cognitive impairment sustained burns after spilling coffee in her lap during meal service. The coffee temperature logs showed 195 F readings, while the facility’s log form called for 150 F to 160 F, and the DON stated the aide recorded the coffee maker’s LCD display instead of checking the coffee with a probe. The resident was sent to the ER and later found to have full-thickness burns to both inner thighs.
Food was not served at a palatable temperature on the West unit. During an observation of supper trays from a covered food cart, pureed grilled cheese measured 125 degrees Fahrenheit and mashed potatoes with gravy measured 128 degrees Fahrenheit. The Dietary Director stated food should have been 135 degrees Fahrenheit at the point of service, and the facility policy required potentially hazardous food to be maintained below 41 degrees or above 135 degrees Fahrenheit.
Staff failed to follow standardized recipes and facility policy for pureed food preparation and hot holding temperatures. A cook pureed beef pot roast and carrots for several residents on pureed diets using unmeasured amounts of water as a thinning agent instead of the prescribed juice, milk, or broth, and without measuring portions as required. Residents reported that meals in a dining room were not always hot, and resident council members stated that food was served cold. During a lunch service, staff in the dining room lacked an available food thermometer at the start of service, and subsequent checks showed pureed carrots, pureed beef pot roast, and hamburgers being held below the required 135°F hot holding temperature, in violation of facility policy and state code.
Food was not consistently palatable or served at proper temperatures. Dietary staff were unaware of checking steam table temps before service, and meal observations found pureed and mechanical soft items below acceptable temps, with a test tray described as cold, bland, and difficult to chew. Multiple residents and a family member reported that food delivered to rooms was often cold and unappealing, and a later tray check found hot items at 110 to 113 degrees Fahrenheit, below the 135-degree threshold stated by the Regional Dietary Manager.
Surveyors found that meal service failed to provide adequate food temperature, quality, and portion sizes. Observations showed overcooked meatloaf with very small portions and soup bowls filled only a quarter of the way. Multiple residents reported being consistently hungry after meals and described portions as suitable for a young child. Residents also stated that food, especially breakfast items and meals served in rooms, was often cold. A tray temperature check confirmed substandard temperatures for scrambled eggs and sausage links, despite a facility policy requiring TCS foods to be held at or above 135°F.
Surveyors found that hot foods, specifically mashed potatoes, were served at an uncomfortably high temperature, causing observable discomfort to a non-verbal, cognitively impaired resident with dysphagia and pneumonitis. During assisted feeding by a hospice CNA, the resident repeatedly raised her fingers to her mouth and widened her eyes after bites of mashed potatoes, and initially refused further bites, while the CNA continued to offer the food and did not consistently make eye contact. A test tray and dietary temperature check showed the potatoes at 180°F and uncomfortably hot for consumption, while the Administrator cited a hot food range of 165–200°F and facility policy focused on maintaining minimum holding temperatures rather than assessing palatability.
Meals Served at Inappropriate Temperatures: Residents reported that meals were cold or lukewarm, and all residents at a Resident Council meeting said food was not hot when served. Surveyors observed hot items on the steam table, but a test tray from the 200-hall was much cooler and tasted cool. The Kitchen Manager said a heating element on the heating plates had failed and a replacement was pending.
Meals were not consistently served at a palatable temperature on the 100 Hall. Two residents reported receiving meals that were often cold or lukewarm, including meals eaten in-room and in the common area. During meal observation, a grilled cheese sandwich on the last tray measured 107 F, and the DOD stated he was unsure of the correct serving temperature, despite identifying 135 F as the hot food holding temperature.
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