F0804

E

Failure to Maintain Palatable Food and Safe Serving Temperatures

Martinsburg, West Virginia Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure food and beverages were palatable and maintained at safe and appetizing temperatures, as required by facility policy. The policy stated that hot foods must be held at greater than 135°F and cold foods at less than 41°F. During the survey, interviews with 18 of 23 sampled residents revealed consistent complaints that hot foods were being served cold and that meals were not palatable. A test tray served to surveyors showed the Salisbury steak tasted bland and the scalloped potatoes had minimal flavor and were barely warm. Resident council and food committee minutes documented that residents, as a group, agreed the food was cold, and the Dietary Manager acknowledged hearing these complaints.

Surveyors observed the meal service process, noting that a staff member placed approximately 12 plates on the counter and the cook then added each meal item one by one to all plates, taking up to 10 minutes before the plates were served or placed on trays. Trays for room delivery were loaded onto a meal cart and transported to hallways after the cart was full, further delaying service. Temperature checks by the Dining Manager on test trays showed cold items above required cold-holding temperatures, including peaches at 52.2°F and milk at 48.0°F and 51.1°F. During a noon meal observation, multiple residents reported that hotdogs and soup were cold or only semi-warm, and that ice cream was very soft. The Dining Manager confirmed that the hotdog and soup were too cold and that the ice cream and milk were too warm, demonstrating that hot foods were not consistently served hot and cold foods were not consistently served cold across multiple hallways and meals.