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F0804
E

Failure to Serve Palatable Food at Safe and Appetizing Temperatures

Oak Creek, Wisconsin Survey Completed on 10-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food was palatable and served at a safe and appetizing temperature for five cognitively intact residents. Multiple residents reported that their meals were often cold or lukewarm, with some noting that changes in the kitchen or delivery system had resulted in more frequent cold meals. Resident council notes also documented complaints about milk sitting out all day and food being cold due to delayed delivery. These concerns were corroborated by interviews with residents and the Registered Dietitian, who confirmed an increase in complaints about cold food and the absence of a pellet system to keep food hot. Direct observations of meal service revealed that while food temperatures were within appropriate ranges when initially prepared in the kitchen, significant drops in temperature occurred by the time meals were served. For example, a test tray plated and placed on a cart showed hot food items dropping below the expected 130 degrees Fahrenheit by the time they were served, with cold items also exceeding the recommended temperature. The facility's policy required food to be served at safe and appetizing temperatures, but the observed practices and resident feedback indicated this standard was not consistently met.

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