F0812

D

Failure to Serve Hot Foods at Safe Temperatures

Chicago, Illinois Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The facility failed to distribute and serve food in accordance with professional standards by providing lunch meals at unsafe and unsatisfactory temperatures to two cognitively intact residents. One resident had medical diagnoses including type 2 diabetes mellitus, lymphedema, and bilateral below-knee amputations, and another resident had chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, and mild cognitive impairment. On 01/20/26 at 12:29 p.m., both residents’ lunch trays were observed delivered to their bedside. At 12:30 p.m., the Dietary Manager measured the temperature of the pork shoulder meat on both trays and found it to be 96.6°F. The Dietary Manager stated that the food temperature should be at least 145°F and confirmed that the trays were cold.

The Dietary Manager reported that residents had informed her they were receiving cold food and that she had needed to come to the nursing units to ensure trays were passed out in a timely manner. A CNA stated that residents had complained about receiving cold food and that when residents complained, she reheated their food in a microwave and informed dietary staff, but residents remained upset because they wanted their food served hot initially. One resident stated that the food he receives is served cold and that staff tell him to have the CNA warm it up, but he feels the food should already be hot. The facility’s “Food Preparation and Service” policy, reviewed 07/2025, specifies that potentially hazardous foods must be maintained below 41°F or above 135°F, and that previously cooked food must be reheated to an internal temperature of 165°F for at least 15 seconds, indicating that the observed food temperatures were within the documented danger zone.