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.
Dietary staff did not consistently temperature-test pureed meals for four residents on pureed diets. Observations and interviews revealed that food was sometimes served below the required temperature, and food temperature logs showed multiple days with missing records for pureed meals, contrary to the facility's safe food handling policy.
Food Served at Unappetizing Temperature: A meal observation found lunch trays delivered on a non-insulated cart to a dining room, with test tray temperatures showing chicken at 104 degrees and rice and black beans at 120 degrees. The Kitchen Manager questioned the thermometer, then could not use a digital thermometer because batteries were unavailable, and the food was tasted and found not hot. Residents also reported that the food was bad and often cold, and one CNA said she passed all room trays and got drinks by herself.
Food Served at Unsafe and Unappetizing Temperatures: Three residents raised concerns at a resident council meeting about food taste, variety, and temperature. A meal tray tested later showed a hoagie sandwich that felt and tasted cold at 107.7 F and fries that were cold at 96.7 F, despite the facility policy stating hot foods must be held at 135 F or greater throughout the service process.
Cold and Unappetizing Meal Service: Food was served at improper temperatures and lacked flavor during meal service. A tray checked at the nurses' station had Salisbury steak, corn, and potatoes below serving temperature, and a sample tray was described as bland, chewy, cold, dry, and lacking flavor. A resident on contact isolation reported receiving ice-cold meat and potatoes, while residents and a CNA reported frequent complaints about cold food, poor quality, and incorrect meal orders.
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