Failure to Follow Approved Menus and Portion Sizes Resulting in Inadequate Meal Portions
Summary
Facility staff failed to ensure that meals were served according to the approved menus and portion sizes, resulting in residents receiving smaller portions than specified. The facility’s policies required use of standardized recipes and diet spreadsheets or similar tools, with serving portions based on the planned menu and approved by the registered dietician. On a dated menu specifying three chicken tenders, macaroni and cheese, mixed vegetables, and chilled peaches, observation showed a dietary staff member placing only two chicken strips on each resident’s plate. For pureed diets, the menu called for 2/3 cup pureed chicken tenders, 1/2 cup macaroni and cheese, and 2/5 cup mixed vegetables, but observation showed the same staff member serving only 1/2 cup pureed chicken tenders, 1/2 cup macaroni and cheese, and 1/4 cup mixed vegetables to residents receiving pureed meals. Two cognitively intact residents reported that they routinely did not receive enough food. One resident, with diagnoses including hemiplegia, type II diabetes, and major depressive disorder, stated that they received small portions almost every meal and that on one evening the only food provided was a chicken pot pie. Another resident, with diagnoses including pre-diabetes, depression, and diverticulitis, reported not getting enough food, describing a meal where they received a hotdog and only one teaspoon of sauerkraut, and stating that the food served on the survey day was more than they normally received. Both residents had care plans indicating that their dietary preferences were to be honored, with specific favorite foods identified. Multiple dietary and nursing staff interviews confirmed that menu portions and scoop sizes were not consistently followed and that residents frequently received less food than called for on the menus. One dietary staff member stated that menus posted by the Dietary Manager (DM) listed required quantities and that they saw the menu called for three chicken strips but were told by the DM to serve two. Another dietary staff member reported they did not really know how much food to cook and “eyeballed” amounts, and that when there was not enough food, the DM instructed staff to serve smaller portions; this staff member reported using smaller scoops for pudding and serving half the casserole portion specified on the menu. CNAs, an LPN, and a CMT reported that residents consistently received small portions, that one unit received about half the amount of food compared to the rest of the facility, that residents on pureed diets often did not get enough food, and that some meals consisted only of soup and bread or a sandwich and chips. The DM and RD both stated that staff were expected to serve the amounts specified on the menus, and the RD reported being told by various residents that they were not receiving enough food.
Penalty
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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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