Food was not consistently palatable, attractive, or served at an appetizing temperature on multiple halls. A test tray had room-temperature equipment, and the fish, corn, and coleslaw were served at temperatures or with quality issues that staff acknowledged did not meet expectations. Residents reported food that looked bad, tasted poor, was not hot, was repetitive, or was sometimes unidentifiable, and council minutes and grievance logs showed repeated food complaints over several months.
The facility failed to provide appetizing, palatable, and warm meals for multiple residents. Resident council minutes and resident interviews showed repeated complaints about cold food, inconsistent meal times, bland or overcooked items, too much chicken, and menu choices not being followed. Residents reported breakfast and lunch trays arriving cold or lukewarm, some meals being microwaved after delivery, and limited fresh fruit, vegetables, and dessert variety. One resident with pressure ulcers also reported being repeatedly served foods they disliked, despite documented preferences.
Surveyors found that meals were unappealing, poorly prepared, and not consistently served in a timely manner. A sample tray showed mixed and run-together vegetables, burnt bits in creamed corn, stringy green beans, bland unseasoned chicken, thin gray pudding with minimal flavor, and no butter for the roll. A resident with tracheal cancer and a pureed diet refused an untouched tray of unidentifiable pureed food, stating it looked unappealing and had no flavor. Another cognitively intact resident received a delayed lunch tray from a cart left in the hall and reported the food was cold and consistently terrible, citing past breakfasts of a glob of eggs, an unpalatable muffin, and dry cereal without milk. A third cognitively intact resident reported that food quality, consistency, and flavor had declined and that liquid eggs were used excessively, including at dinner, while the nutrition manager reported being unaware of these complaints and relying on meetings and floor staff to convey concerns.
Food and drink were not prepared or served at proper temperatures or in a palatable manner. A cook prepared pureed carrots and pork without following a recipe, adding unmeasured water and blending the food before placing it on the steam table. A dietary aide placed beverages on trays too early, and a cup of milk on a tray cart measured 56.5 degrees. A cognitively intact resident was also told by a CNA to wait for a weight check before eating breakfast and was left waiting over 45 minutes, leaving the resident with a cold meal and no morning coffee.
Residents repeatedly reported that meals were bland, cold, greasy, mushy, undercooked, or missing items, and that tray tickets often did not match what was served. Several residents said they had to request substitutions, extra food, or microwaved meals, while others complained that requested alternatives were not provided and portions were too small. Resident council minutes and grievances documented ongoing concerns about poor food quality, temperature, presentation, and accuracy of meal delivery.
Food quality and pureed recipe preparation were deficient when residents reported cold, burnt, overcooked, and poorly prepared meals, and a test tray shrimp item was dry and rubbery. A cook also added ingredients not listed on the pureed green bean recipe and did not consistently measure ingredients, while the DSD stated the gravy thickener measurements were not known and the liquid pump was not usually used as intended.
Food service failed to provide a palatable lunch item when a sampled chicken patty was found to be dry, difficult to chew, and lacking palatability. A CNA said the chicken was dry and hard for residents to chew, and a resident reported needing sauce to help the meat go down because it was so dry. The Dietary Mgr said he was unaware of the issue, and the DON stated meals were expected to be palatable and easy to consume.
Pureed Meal Preparation Did Not Follow Recipe: A cook was observed preparing pureed sausage by using unmeasured water and unmeasured thickener, then adjusting the mixture by sight and hand mixing until it appeared acceptable. The cook stated a recipe existed but relied on experience instead of following it. The recipe reviewed specified exact amounts of sausage, water or broth, and thickener to maintain recipe integrity and serving amount for residents on pureed diets.
The facility did not ensure that meals were palatable, visually appealing, or served at appropriate temperatures, as reported by several residents and confirmed by surveyor observations. Residents described the food as bland, repetitive, and unappetizing, with some supplementing their diets with outside food or modifying their meals to improve taste. A test tray review found food items to be unappealing in appearance, taste, and temperature, and the Food and Nutrition Service Manager cited budget limitations as a factor.
The facility did not maintain proper food temperatures during meal service, as food items were served below the required 140°F despite being transported on warm plates and in covered carts. Several residents without cognitive impairment reported that their meals were consistently cold or lukewarm, leading to dissatisfaction and, in some cases, decreased food intake. Staff were aware of ongoing complaints about food temperature and palatability, but the issue persisted.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.