Failure to Maintain Appetizing Food Temperatures for Room Tray Service
Summary
The facility failed to ensure food was served at appetizing temperatures, affecting residents who received meals on room trays. Food committee meeting notes over several months documented resident complaints about food temperatures for room tray deliveries, and residents met with dietary leadership to discuss adjusting the food delivery route. One resident reported that while the food was seasoned well, it was not always warm enough and staff would not reheat it; the resident obtained a microwave to heat her food but was not allowed to keep it and therefore had to eat the food as served. The Director of Dining Services (DDS) explained that all food was cooked in the main kitchen, transported to satellite kitchens, held on steam tables, and then plated for both dining room and room tray service, with insulated plates and covers used to help maintain warmth. Direct observation of the lunch tray line showed delays between food leaving the main kitchen, being placed in the satellite kitchen steam tables, and being plated and delivered, particularly for room trays. On one day, a cart left the main kitchen at 11:32 A.M., arrived at the second-floor satellite kitchen at 11:37 A.M., and food was not placed in the steam table until 11:43 A.M.; dining room meals were plated first at 11:58 A.M., and room trays were not plated until 12:22 P.M., with the first cart of room trays not leaving until 12:37 P.M., meaning at least one tray sat for 15 minutes before leaving the kitchen. On another day, a test tray placed on the last cart of room trays was delivered and immediately temperature-checked, revealing crumb baked sole at 147°F, chicken tenders at 120°F, green beans at 109°F, braised lima beans at 119°F, fruit at 56°F, and cream of cauliflower soup at 131°F. The DDS confirmed that several items were only lukewarm and that the green beans were not warm, and facility policy required that food and beverage temperatures be maintained during transport.
Penalty
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The facility failed to consistently provide palatable meals at appetizing temperatures, in correct portion sizes, and within posted mealtimes. Several residents and a family member reported that food tasted poor, portions of meat were very small, meals relied heavily on noodles and mashed potatoes, hot and cold foods were served together on the same plate, cold items arrived warm, ice cream was melted, menus were inaccurate, and dinner was sometimes served late in the evening. During surveyor observation, hot and cold items on the tray line were at safe temperatures and matched the menu, but a main entrée was initially served at half the prescribed portion size. A test tray delivered to one hall after the posted lunch period showed that while some items remained warm, the main entrée had cooled to a non-palatable temperature, and the late service and temperature findings were confirmed by facility leadership and dietary staff.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
The facility failed to ensure meals were palatable, attractive, properly cooked, and maintained at safe serving temperatures, and did not consistently follow its own dietary policies. Multiple residents with various chronic conditions, including DM, CHF, dementia, and neurologic impairments, reported that food was often burnt or undercooked, bland, and usually lukewarm rather than hot. Surveyors observed sausages and other items on a steam table at 60–65°F with no visible steam or water under the pans, mechanically altered meats that were dry and unappealing, and pureed meatloaf that appeared orange, coarse, and burnt around the edges. A test breakfast tray showed cold or lukewarm eggs, biscuits, and sausage, with only oatmeal at a higher temperature. Staff admitted they had not taken required food temperatures, temperature logs were blank, a thermometer used for temping was inaccurate, and the steam table had been operated with insufficient water. The kitchen also lacked a scale to verify meat portions, and a grievance about cold soup and inadequate portion size was documented as resolved without any investigation of temperature or quantity concerns.
The facility failed to ensure meals were served palatable and at safe, appetizing temperatures. Multiple residents who ate in their rooms reported their food was always cold. Surveyors observed a CNA transporting a meal cart with doors left open during tray pass and a resident with bilateral hand contractures whose meal lid was removed several minutes before feeding began. In another observation, an RN opened a meal cart to check trays and a CNA passed trays on two halls with the cart door open before a sample tray was tested, revealing coleslaw and fruit served too warm and hot items, including shrimp and tater tots, below the dietary manager’s stated hot-holding expectations. The dietary manager and ADMIN confirmed that foods should be served within appropriate temperature ranges, and the facility’s policy required residents receive a nourishing, palatable diet.
The facility failed to ensure meals were served at safe and palatable temperatures, contrary to its policy requiring hot foods to be maintained at 135°F and reheated if below acceptable temperatures. Several residents, including individuals with diabetes, chronic kidney disease, and anorexia, reported that their food was frequently or usually cold, which discouraged eating for at least one resident. Surveyors observed breakfast and lunch service where hot items such as sausage, eggs, cream of wheat, pasta with meat, and mixed vegetables were served at temperatures between 80.7°F and 120°F and described as cold or lukewarm, with trays transported in uncovered carts and plates left uncovered. Staff, including dietary management and the Administrator, acknowledged that food was expected to be delivered at safe, palatable temperatures and returned to the kitchen if too cold, but this was not consistently done.
Failure to Provide Palatable, Properly Portioned, and Timely Meals
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food that was palatable, attractively presented, at appetizing temperatures, in accurate portion sizes, and within the posted mealtime schedule. Multiple residents reported that meat portions were very small, that meals contained a lot of noodles, and that leftovers were combined into new meals. Several residents and a family member described the food as terrible, with poor taste, frequent serving of mashed potatoes, and uncertainty about what they were eating. One resident stated that food was almost always cold, that cold items such as milk and yogurt were warm, that hot and cold foods were placed on the same plate (for example, lasagna and salad), and that ice cream arrived melted to a milkshake-like consistency. Another resident reported that dinner sometimes was not served until after 7:00 P.M., and another stated that the menu was not correct. Surveyor observation of the lunch tray line on a specific date showed that while hot and cold items were at safe temperatures and the correct menu items were served, the beef and broccoli stir fry was plated in only one four-ounce scoop for both regular and puree textures instead of the two four-ounce scoops specified on the diet spreadsheet, until the error was identified. A test tray for the 200-hall showed that trays began being prepared after the posted lunch period and that the test tray did not leave the kitchen until well into the posted mealtime, with service to that hall occurring later than the posted lunch hours. When the test tray was checked after delivery, the mini egg roll and soft fried noodles were warm, but the beef and broccoli stir fry measured 104 degrees Fahrenheit, which was not at a palatable temperature. Facility leadership and dietary staff confirmed the late meal service, the test tray findings, and the initial under-portioning of the beef and broccoli stir fry.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Palatable, Properly Cooked, and Safely Held Meals
Penalty
Summary
The deficiency involves the facility’s failure to prepare and serve food that was palatable, attractive, and maintained at safe and appetizing temperatures, as well as failure to follow its own policies for temperature monitoring and standardized menus. Multiple cognitively intact residents reported longstanding concerns about the quality, taste, and temperature of meals. One resident with diagnoses including type 2 DM with neuropathy, emphysema, heart failure, and hepatomegaly stated the food had "not been good" for a long time, reported repeatedly voicing concerns to several administrators without change, and described food as overcooked or burnt and, at times, undercooked or frozen. This resident produced photographs taken in the facility showing burnt pancakes and grilled cheese sandwiches with 50–75% of the surface blackened, an undercooked grilled cheese with raw tomato and onion next to lightly buttered bread, and plain toast with hash browns that appeared light white, unseasoned, stiff, and undercooked/frozen. Surveyors directly observed meal service problems in the kitchen and dining room. During a lunch service, a cook was seen plating Polish sausages from a steam table where the sausages were of ununiform color and doneness, ranging from light tan to dark golden brown and leathery, and the mechanically altered sausage appeared ground and dry. The cook stated the sausages had been boiled and that darker ones were more done because they stuck to the bottom of the pan, acknowledged the very done sausages did not look appetizing, and admitted not checking food temperatures before plating or serving. No steam or heat was observed around the steam table, and when temperatures were finally checked at the surveyor’s request, the Polish sausage, pureed sausage, and baked beans measured between 60–65°F. The dietary manager confirmed the expectation that cooks should take temperatures when cooking is finished, during holding, and right before serving, and that hot foods should be held at 135°F. The manager also confirmed there was no water/steam under the pans at that time and that the food should not have been served at those temperatures. Additional observations showed ongoing issues with palatability, temperature, and appearance. Several residents eating lunch reported their meals were not warm, describing them as lukewarm, lacking seasoning, bland, and generally not good, with one resident comparing the food to cat food and another stating the food was usually not very warm. A test breakfast tray prepared under observation showed the biscuit at 94°F, sausage patty at 101.5°F, eggs at 90.5°F, and oatmeal at 147.5°F; the surveyor found the biscuit and eggs cold, the sausage lukewarm, and only the oatmeal significantly hotter. On another day, pureed meatloaf on the steam table appeared orange, coarse, dry, pate-like, and burnt/blackened around the edges, which the dietary manager agreed was not how it should look. A cook also acknowledged that pork portions for renal diet residents looked dry and burnt around the edges, were of varied sizes, and could not be portioned with a scoop as required; the kitchen did not have a working scale to verify meat portions. The facility’s own records and staff interviews demonstrated noncompliance with established dietary policies. The temperature log for one of the observed days was blank, and the cook confirmed that breakfast temperatures had not been taken. The dietary manager admonished the cook and stated staff knew they should be taking temperatures. When thermometers were checked in ice water, one thermometer used for food temping read approximately 25°F lower than other calibrated thermometers, and the dietary manager stated that even after reheating, the food only reached 120°F with the other thermometers, confirming it had not been at the required temperature. A maintenance director later reported that a service company found no mechanical issues with the steam table and attributed the prior temperature problems to insufficient water in the table, noting only about half an inch of water had been present when at least three inches were needed to generate steam. A resident grievance about cold soup and inadequate soup portion was documented as resolved without any investigation or action regarding soup temperature or portion size, despite facility policies requiring nourishing, palatable meals, adherence to standardized menus, and daily recording of food temperatures to ensure proper serving temperatures.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide food and drink that were palatable, attractive, and maintained at safe and appetizing temperatures during meal service. Confidential resident interviews revealed that multiple residents who ate meals in their rooms on two different halls reported their food was always cold. During one observation of meal service, a CNA pushed a meal tray cart down a hall with both cart doors open during tray pass, only closing them briefly when transitioning between halls and then leaving them open again while passing trays. In another observation, a meal tray was placed in front of a resident with bilateral hand contractures, and the warming lid was removed several minutes before an unidentified CNA began feeding the resident, allowing additional time for the food to cool. During a separate observation of meal tray preparation and delivery, the surveyor arranged to receive a tray from the last cart sent out of the kitchen. The cart for two halls was delivered to nursing staff, and an RN opened the cart to check tray accuracy. A CNA then began passing trays on one hall with the cart door open, moved the cart to the next hall, and continued tray pass before the surveyor retrieved the sample tray at the end of the pass. Temperature checks on this tray showed coleslaw at 86.0°F, boiled shrimp at 96.4°F, tater tots at 97.5°F, hushpuppies at 103.6°F, and fruit at 70.9°F, which were not within the dietary manager’s stated expectations that cold items be closer to 40°F and hot items not be under 100°F. The dietary manager and the administrator both acknowledged that foods should be served within appropriate temperature ranges and that the coleslaw and shrimp temperatures were incorrect. The facility’s Food and Nutrition Services policy stated that each resident is to be provided with a nourishing, palatable, well-balanced diet that meets nutritional and special dietary needs while considering resident preferences.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure food and beverages were served at safe and palatable temperatures, as required by its dietary food preparation policy dated 7/5/23, which specified that warm foods should measure at 135°F and that items not at acceptable serving temperatures should be reheated or chilled to proper temperatures. Multiple cognitively intact and moderately cognitively impaired residents reported that their meals were frequently or usually cold. One resident with type 2 diabetes stated the food tasted terrible and was always cold. Another resident with chronic kidney disease reported that food was most always cold when delivered. A resident with anorexia stated that food was most always served cold and that this contributed to not wanting to eat. Additional residents reported that food was served cold a lot of the time or could sometimes be cold. Surveyor observations of meal service confirmed that food was not consistently maintained at appropriate temperatures. During a breakfast observation on the 300 south hallway, meals were served in Styrofoam boxes, and measured temperatures showed a sausage patty at 81.5°F, scrambled eggs at 80.7°F, and cream of wheat at 118°F, all described as cold. At a lunch observation on the 200 hallway, the room tray cart was uncovered and plates had no coverings, with pasta and meat measuring 120°F and described as lukewarm, and mixed vegetables at 108°F and described as cold. Interviews with the Regional Certified Dietary Manager, another staff member, and the Administrator confirmed that facility expectations and policy were for food to be delivered at safe and palatable temperatures and that staff should return food to the kitchen if it was too cold, indicating that these expectations were not met in practice.
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