Improper Holding and Service Temperatures for Breakfast Trays
Summary
The facility failed to provide palatable food at safe and appetizing temperatures when breakfast trays were not properly covered and were left on a cart for an extended period before delivery. Facility policy dated January 22, 2026, required all hot foods to be held at greater than 135°F and cold foods at less than 41°F. A dietary tracking form showed that breakfast trays for the Bayside unit were delivered to the unit at 7:40 a.m. on April 20, 2026. At 8:09 a.m., surveyors observed a breakfast cart on Bayside containing nine undelivered breakfast trays, with two trays having protective lids only partially covering the dishes, leaving the eggs exposed. At 8:18 a.m., the Regional Dietary Manager arrived on the unit and the trays were still on the cart; temperature checks showed the uncovered eggs at 103°F and the covered eggs at 112.8°F. The Regional Dietary Manager confirmed that the trays should have been fully covered and that the eggs were cold, not palatable, and should not be served to residents.
Plan Of Correction
Eggs were immediately discarded upon discovery of temperatures less than 135-degrees with fresh breakfast items offered to the residents. The Dietary Manager and/or designee will re-educate current in-house dietary department staff as well as newly hired and agency dietary staff regarding proper placement of dome covers for maintenance of food temperatures. The Director of Nursing and/or designee will re-educate current in-house nursing staff as well as newly hired and agency staff to monitor dome cover placement upon meal delivery with need to take temperatures for palatability and/or have the food items replaced. Random audits will be completed by the Dietary Manager and/or designee weekly for 4 weeks then every other week for 4 weeks to assure palatability. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not provide meals that were palatable or served at safe, appetizing temperatures. Multiple residents reported that the food was bland, dry, and not hot enough, and observations confirmed that food items were served below required temperatures and were unappealing in appearance and taste. The Dietary Manager acknowledged ongoing complaints and cited limited seasoning options and poor quality of delivered ingredients as contributing factors.
Three residents were served food that was burnt, watery, and unappetizing in both taste and appearance. Staff confirmed the poor quality and presentation of the meal, and residents reported dissatisfaction, with some refusing to eat. The Certified Dietary Manager identified improper cooking methods as a cause, and the facility lacked a policy on food palatability.
A resident received a lunch meal where the fish was served at 111°F, below the facility's required temperature of 135°F, resulting in the food being cold and unpalatable. Observations revealed confusion on the tray line and delays in serving, contributing to the deficiency.
A resident with multiple medical conditions, including digestive issues, reported that food was sometimes cold and unpalatable. Observations showed that while food left the kitchen at appropriate temperatures, it arrived lukewarm by the time it was served, with some items below the required 135°F. Staff and policy confirmed the expectation for hot food service, but the deficiency was observed in practice.
Surveyors identified that several residents received meals that were tough, overcooked, mushy, or bland, with staff acknowledging that food was intentionally overcooked to meet temperature requirements. Multiple residents expressed dissatisfaction with the taste and texture of their meals, indicating a failure to provide palatable and properly prepared food as required by facility policy.
Multiple residents and a family member reported that meals, especially breakfast and dinner, were often served cold, with food temperatures observed to be below required standards. Staff confirmed that the use of insulated plates instead of metal plates contributed to the issue, and only certain halls had access to metal plates due to supply limitations. Facility policy required hot foods to be held at 135°F or higher, but sampled food items were served well below this temperature, affecting the palatability and safety of meals for all residents.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Observations during meal service revealed that food items, including chicken, mashed potatoes, and baked beans, were served at temperatures below the facility's required standard of 135 degrees Fahrenheit for hot foods. The chicken was noted to be dry, small in portion size, and unappetizing, while the mashed potatoes had a strong garlic flavor and the baked beans were watery and lacked flavor. Milk was also served at an inappropriate temperature. Multiple residents reported that the food was bland, dry, and not hot enough, and the Dietary Manager confirmed receiving several complaints about the quality and temperature of the food. Further review of resident council minutes indicated ongoing concerns about the quality of meals, specifically mentioning watery mixed vegetables. The Dietary Manager stated that limited seasoning options and reliance on frozen food items contributed to the poor quality and lack of variety in meals. Additionally, some fresh vegetables delivered to the facility were often spoiled and had to be discarded. The facility's own policies require that residents receive nourishing, palatable, well-balanced meals prepared and served at appropriate temperatures, but these standards were not met, as evidenced by direct observation, resident feedback, and staff interviews.
Unpalatable and Unattractive Food Served to Residents
Penalty
Summary
The facility failed to ensure that food served to three residents was palatable, attractive, and prepared to an appropriate consistency. Observations during a lunch meal revealed that the meatloaf had burnt edges and required scraping to serve, the mashed potatoes were runny and watery, and the rice was clumped together. These issues were confirmed by staff present on the tray line, who acknowledged the poor quality and presentation of the food. A test tray further demonstrated that the food was unappetizing in appearance, with burnt meatloaf pieces and watery mashed potatoes that had spilled over the plate, affecting the overall presentation. Taste testing confirmed the meatloaf was hard and burnt, and the mashed potatoes lacked flavor and proper consistency. Interviews with the affected residents revealed dissatisfaction with the food, with one resident stating she did not like the taste, another refusing to eat lunch due to the unappetizing appearance of the meat, and a third reporting that the meat was burnt and the rice overcooked. The Certified Dietary Manager confirmed the issues with the food and attributed the burnt meatloaf to the use of an incorrect pan size. Additionally, the facility administrator acknowledged that there was no policy or procedure in place regarding food palatability.
Failure to Serve Food at Safe and Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature, as required by its own Food Temperature Guidelines. During observation of the lunch tray line, it was noted that there was confusion regarding which carts had been served, and meals were being held in a warmer while waiting for residents to decide on their dining location. A test tray prepared directly from the steam table showed the fish was served at 111 degrees Fahrenheit, which was below the facility's standard of greater than 135 degrees at point of service. The fish was reported to taste cool, and a resident later stated that the fish served for lunch was cold and unappetizing.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and warm temperature, as required by policy. During an interview, a cognitively intact resident with multiple medical diagnoses, including digestive system issues and concerns regarding food and fluid intake, reported that food was sometimes cold and did not always taste good. Observations of the tray line and test tray process revealed that while food temperatures were initially within acceptable ranges when leaving the kitchen, by the time the food was served on the 100 Hall, temperatures had dropped. Specifically, the smoked sausage and brussel sprouts were found to be lukewarm, with temperatures below the desired threshold for hot food service. Staff interviews confirmed that the expectation was for hot foods to be delivered at or above 135 degrees Fahrenheit. Policy reviews indicated that food should be served as soon as possible after preparation and held at a minimum of 135 degrees Fahrenheit. Despite these guidelines, the observed food temperatures upon service did not consistently meet these standards, and the food was not always palatable or at an appetizing temperature for residents.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
Surveyors found that the facility failed to ensure meals were palatable, affecting three residents reviewed for food. Observations included a lunch meal consisting of a peppered hamburger patty, buttered noodles, green beans, and white cake. A test tray revealed the meat was crispy around the edges and tough, the noodles were overcooked and mushy, and the green beans were bland. The Dietary Manager acknowledged that the noodles were intentionally cooked softer due to resident complaints about hardness, but admitted the foods were overcooked to achieve the required temperature for the beef patties. Resident interviews confirmed dissatisfaction with the meal quality. One resident stated the noodles and beef patty were overdone, another described the food as processed, tough, and unappetizing, and a third resident complained about the meat being tough and referred to it as 'mystery meat,' also noting the noodles were mushy and fish was hard when served. The facility's policy on food palatability emphasized serving meals that are nutritious, safe, and acceptable in taste, appearance, and texture, but these standards were not met during the observed meal service.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served to residents at a safe and palatable temperature, as evidenced by multiple resident and family interviews, staff interviews, direct observation, and policy review. Several residents reported that their meals, particularly breakfast and dinner, were often served cold, especially when delivered to their rooms or to the 300 hall, which was the last to receive trays. One resident's daughter expressed concern due to her father's poor appetite, which was further impacted by the cold food. Direct observation confirmed that food items such as eggs and oatmeal were served below the required temperature, and the taste was not palatable. The Assistant Dietary Manager acknowledged that the use of insulated plates instead of metal plates contributed to the issue, and that only two halls had access to metal plates due to supply limitations from the previous company. Review of the facility's policy indicated that hot foods should be held at 135 degrees or higher to ensure safety and palatability, and reheated foods should reach 165 degrees. However, sampled food temperatures were significantly below these standards, with eggs at 92.5 degrees and oatmeal at 119 degrees. The facility census was 87, and there were no residents who were NPO (nothing by mouth), indicating that all residents could potentially be affected by this deficiency.
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