Staff failed to follow standardized recipes and facility policy for pureed food preparation and hot holding temperatures. A cook pureed beef pot roast and carrots for several residents on pureed diets using unmeasured amounts of water as a thinning agent instead of the prescribed juice, milk, or broth, and without measuring portions as required. Residents reported that meals in a dining room were not always hot, and resident council members stated that food was served cold. During a lunch service, staff in the dining room lacked an available food thermometer at the start of service, and subsequent checks showed pureed carrots, pureed beef pot roast, and hamburgers being held below the required 135°F hot holding temperature, in violation of facility policy and state code.
Surveyors found that meal service failed to provide adequate food temperature, quality, and portion sizes. Observations showed overcooked meatloaf with very small portions and soup bowls filled only a quarter of the way. Multiple residents reported being consistently hungry after meals and described portions as suitable for a young child. Residents also stated that food, especially breakfast items and meals served in rooms, was often cold. A tray temperature check confirmed substandard temperatures for scrambled eggs and sausage links, despite a facility policy requiring TCS foods to be held at or above 135°F.
Surveyors found that hot foods, specifically mashed potatoes, were served at an uncomfortably high temperature, causing observable discomfort to a non-verbal, cognitively impaired resident with dysphagia and pneumonitis. During assisted feeding by a hospice CNA, the resident repeatedly raised her fingers to her mouth and widened her eyes after bites of mashed potatoes, and initially refused further bites, while the CNA continued to offer the food and did not consistently make eye contact. A test tray and dietary temperature check showed the potatoes at 180°F and uncomfortably hot for consumption, while the Administrator cited a hot food range of 165–200°F and facility policy focused on maintaining minimum holding temperatures rather than assessing palatability.
Dietary staff did not consistently temperature-test pureed meals for four residents on pureed diets. Observations and interviews revealed that food was sometimes served below the required temperature, and food temperature logs showed multiple days with missing records for pureed meals, contrary to the facility's safe food handling policy.
A resident reported concerns about cold food, and during a subsequent meal observation, a supper tray was served with BBQ chicken, mashed potatoes, and spinach at temperatures below the facility's required minimum of 135°F. The dietary aide noted the steam table had been turned off shortly before the tray was tested, resulting in food that was not served at an appetizing or safe temperature. This deficiency had the potential to affect 71 residents on regular diets.
A resident reported that meals were sometimes served cold, and food temperature checks during a meal revealed that hot foods were below the facility's preferred standard of 120°F. Facility guidelines require monitoring and investigation of food temperature complaints, but observations showed these were not consistently met.
A CNA was observed passing lunch trays alone, and food temperatures on the 600 hall were found to be below required standards, with items such as chicken and vegetables measured well under the facility's policy for hot food holding. Fourteen residents receiving room tray service were potentially affected.
Two residents received meals that were not at a palatable or proper temperature, with one resident unable to cut her sausage and reporting cold food, and another resident leaving half her meal uneaten due to it not being hot. Both residents indicated this was a recurring issue, and food was observed sitting in the hallway before delivery, contrary to facility policy.
Surveyors found that the facility did not provide palatable or properly heated food, with residents receiving repetitive meals and food served at incorrect temperatures. Several residents reported cold and unappetizing meals, and a test tray confirmed that both hot and cold items were not within required temperature ranges. The Dietary Manager acknowledged menu substitutions, insufficient caloric intake, and lack of insulated carts for meal delivery.
Twelve residents, many with complex medical conditions, reported that meals were repetitive, poorly seasoned, sometimes cold, and served in small portions. Residents described food as unappetizing, with some noting spoiled smells, tough meat, and overcooked or flavorless items. Direct observation confirmed issues with meal presentation and preparation.
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