Unpalatable and Improperly Prepared Food Served to Residents
Summary
The facility failed to prepare palatable food for residents on regular consistency textured diets, as evidenced by multiple observations and interviews. During a lunch meal, several residents received popcorn shrimp that had a white, hard coating and was not browned, making it difficult to chew. Residents who received the shrimp either struggled to eat it or removed it from their mouths due to its unappetizing texture and appearance. Interviews with these residents confirmed that the shrimp was unappetizing and difficult to chew, resulting in their inability to consume the meal. Further investigation revealed that the shrimp was prepared in an oven rather than a deep fryer, which was the appropriate method for this product. The cook confirmed that the facility did not have a deep fryer, leading to the shrimp remaining white and the coating becoming harder. The registered dietitian verified that the shrimp should have had a golden brown appearance and a coating that was easily chewed. Review of the facility's food production and safety policy indicated that foods are to be prepared by methods that maintain, develop, and enhance flavor, which was not followed in this instance.
Plan Of Correction
F804 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to provide residents on a regular diet with palatable food affecting residents 20, 39, 35, 5, 28, 2, 34, 12, 33, 198, 38, 8, 17, 27, 43, 29, 3, 13, 32, 22, 10, 26, 31, 25, 24, 7, 23, and 37. Step 1: Dietary Manager provided identified residents alternate menu items at their request. This was completed on 6/2/25. Step 2: Dietary Manager to audit current food supply to ensure we have ability to prepare the items properly for the best outcomes in taste and presentation. Audit completed to be by 6/30/25. Dietary manager will adjust weekly order to ensure menu items can be prepared by the kitchen appliances. Step 3: RRD to provide education on 6/18/25 to Dietary Manager to order alternative items when a specific way of preparation is unavailable at the facility. Step 4: To monitor and maintain ongoing compliance, RRD/Designee will audit menu and preparation process weekly X4, then monthly x2 to ensure that menu items are being prepared properly with the equipment Urbana kitchen has available. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. --- F812 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to prepare food in a sanitary manner affecting 45 residents that received food from the facility kitchen. Observation 1: DM did not have arm coverings on while preparing food and she has a diagnosis of psoriasis. Observation 2: Cook #250 failed to wear gloves nor did she sanitize her hands after touching her face when reassembling the food processor. Step 1: Regional Dietitian educated DM on dress and personal hygiene and instructed to don a jacket and/or arm coverings, completed 6/4/25. Step 2: Regional Dietitian educated Cook #250 on handwashing in the kitchen, handling and storage of equipment and utensils, which included information on avoiding handling equipment that will come in contact with food, the drying of wet equipment, and the use of disposable gloves in the kitchen. Handwashing competencies.
Penalty
Resources
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Cold food served to residents: Multiple residents reported that meals delivered to their rooms were cold, with one resident needing staff to reheat breakfast and another stating reheated food came back hard. Surveyors also tasted lunch test trays on two occasions and found items cold, while the dietary cook, DA, RD, and ADM acknowledged complaints or expectations related to serving food at proper temperatures.
Meals were not consistently palatable, attractive, or served at an appetizing temperature for several residents. Residents reported cold food, bland taste, and poor texture, including mechanical meals that were not warm and a resident who said he had almost choked on a mechanical diet item. Surveyors observed sample tray items that were cold, mushy, chunky, tough, or had no flavor.
Meals Served Unattractive and Unpalatable: During an observed meal service, spaghetti noodles became dried and gummy as trays were plated, portions were inconsistent, and the final tray had to be scraped from the steam table pan. Residents were served corroded, spotted silverware and dishes with hard water residue, and a resident reported overcooked, flavorless food, mushy vegetables, and food brought to her room that was never hot. Food committee minutes noted water spotting and menu preferences, but did not address food temp, palatability, consistent portions, or fresh produce.
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.
Food was not consistently served at an appetizing temperature for two residents with intact cognition. One resident reported meals were not always warm and that ice cream arrived nearly melted, while another said hot food in the dining room was usually not hot. Surveyors observed a sample tray with lemon chicken at 130 degrees and broccoli at 105 degrees, below the 135-degree minimum identified by the RD and CDM.
Cold food served to residents
Penalty
Summary
The facility failed to serve food and drink at a palatable, attractive, and safe appetizing temperature for residents in the kitchen and on meal trays delivered to resident rooms. Multiple residents reported that meals were cold when received in their rooms. Resident #63 stated that food was always cold when eaten in the room and that he had to ask staff to warm it up and bring it back because he could not eat cold food. Resident #91 stated the food was not good and was served cold, and Resident #103 stated his food usually arrived cold. Resident #75 was overheard yelling for breakfast because her plate was cold; staff reheated the plate and returned it, and she stated that every time her food was brought to her room it was cold and, after reheating, it came back hard. Resident #19 also stated the food was always cold. Surveyors observed and tasted meal trays during lunch meal sampling on two separate occasions. On one occasion, the regular test tray included beans, spinach, and a meat patty with gravy, and all of the food on the tray was cold when tasted by two state surveyors. On another occasion, the test tray included a Philly cheesesteak sandwich, mashed potatoes, red potatoes, green beans, mixed vegetables, a tossed salad, and cheesecake, and the green beans and mixed vegetables were cold when tasted by two state surveyors. The dietary cook stated he was aware of residents complaining that their food was cold and said it depended on which staff members were working on the floor because some CNAs worked faster than others. The DA stated she was responsible for putting meal trays on carts to go to the floors and that the food was hot when it came out of the kitchen, while the RD stated she was aware of some complaints about cold food and expected hot foods to be served according to standardized guidelines of 120 degrees. The ADM stated her expectation was that food would be delivered at a safe and warm temperature according to policy.
Meals Served Cold and Poor in Texture and Flavor
Penalty
Summary
Food and drink were not provided in a palatable, attractive, and safe appetizing temperature for five residents, including Residents #8, #60, #99, #101, and one confidential resident. Several residents voiced concerns that meals were cold, lacked flavor, or had poor texture. Resident #99 said some foods were not really good and had no flavor or taste. Resident #101 reported that mechanical meals were not even warm and said he had almost choked once about a month earlier. The confidential resident stated that eggs were very cold in the mornings, lunch tasted like old food, and the meat was particularly poor. Resident #60 said the food did not look or taste good, was sometimes cold, and that the meat served at lunch was tough. Resident #8 stated that the food was bland, cold most of the time, and that spaghetti was sometimes not drained enough and vegetables were not drained well.
Meals Served Unattractive and Unpalatable
Penalty
Summary
The facility failed to provide meals that were attractive and palatable during one observed meal service. During observation of the lower-level dementia unit meal service, spaghetti with meatballs and sauce, garlic toast, lettuce salad, mashed potatoes and gravy, and canned pears were prepared and plated. The noodles were served in inconsistent portions, and as the meal service continued they became dried and gummy in appearance; the final tray required scraping noodles from the bottom of the steam table pan. The only vegetable offered for residents on altered texture diets was mashed potatoes and gravy served with the spaghetti. Red plate covers had dried white hard water residue, and silverware had a dull gray, spotted, corroded appearance with white residue visible on observation. A resident reported that food was overcooked, lacked flavor, and that seasonings were not provided to add to food served. She stated she often ate soup because of the overcooked foods offered, that vegetables were served pooled in liquid and cooked to mush, and that fresh vegetables were not offered. She also reported that food brought to her room was never hot and that dishes and utensils were unappetizing because of heavy water spots and discoloration. Food committee minutes reviewed by surveyors discussed water spotting on dishes and silverware, differences in preparation of menu items, and menu likes and dislikes, but did not address food temperature, palatability, consistent serving sizes, or availability of fresh fruits and vegetables. The dietary manager acknowledged the noodles had become overcooked by the end of meal service and should not have been served, and both the maintenance supervisor and registered dietitian identified hard water residue as an ongoing problem affecting the appearance of meal service.
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.
Food Served at Inadequate Temperatures
Penalty
Summary
Food and drink were not consistently served at an appetizing temperature for 2 of 15 residents reviewed, including Resident #3 and Resident #94, both of whom had BIMS scores of 15 indicating intact cognitive functioning. Resident #3 stated that food was not always warm and reported that ice cream ordered from the facility was almost the consistency of chocolate milk. Resident #94 stated that hot food was never hot in the dining room, except on the day of interview, and that there had only been one other time when the food had been hot. During observation of room tray preparation and delivery, a sample tray was checked and the lemon chicken measured 130 degrees and the broccoli measured 105 degrees. The Regional Dietician stated that food should be warmer when served and at a minimum of 135 degrees, and the CDM stated that she would like to see food served at 135 degrees or warmer. The facility policy stated that proper hot and cold temperatures are maintained during food service and distribution.
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