F0812

E

Failure to Verify Grilled Chicken Temperatures Before Meal Service

Newhall, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe and sanitary food preparation practices by not verifying the internal temperature of grilled chicken before service. The facility’s menu for a specified week listed BBQ pork as the lunch entrée on a particular date, and grilled chicken was used as a substitute for residents who did not consume pork. During kitchen observations on that date, the cook (CK 1) was seen checking internal temperatures of foods on the tray line but did not check the internal temperature of the grilled chicken before plating and distribution. CK 1 later acknowledged in an interview that she did not check the temperature of the grilled chicken and recognized that failure to do so could result in residents becoming ill.

Several residents were identified as receiving or potentially receiving the substituted grilled chicken. One resident with Alzheimer’s disease, type 2 DM, and HTN was on a regular, easy-to-chew diet with meat to be cut up and had documented dislikes of pork, ham, bacon, and sausage. Another resident with dysphagia, type 2 DM, and HTN had orders for a CCHO, NAS, minced and moist diet with mildly thick liquids for lunch only for oral gratification. A third resident, admitted with pancreatic cancer and muscle wasting/atrophy, had a regular puree diet with mildly thick liquids and documented dislikes of bacon, ham, and pork. A fourth resident with dysphagia, COPD, and CKD was on a CCHO, NAS, regular texture diet with thin liquids and had documented dislikes of pork chops and pork. These residents’ diet orders and documented dislikes made them candidates for the grilled chicken substitution instead of the scheduled pork entrée.

On the observed lunch service date, CK 1 placed grilled chicken onto plates and into meal carts for distribution at specific times without verifying the internal temperature. Later, CK 1 placed a piece of grilled chicken into a blender to prepare a puree for a resident whose diet had been changed, again without prior temperature verification. The Dietary Supervisor stated in an interview that food temperatures should be taken at the tray line prior to service and that failure to do so means food may not be at required limits. The DON stated that food temperatures are to be taken before food goes out and that if not done, food may arrive at the wrong temperature, with potential for residents not eating, weight loss, hunger, gastrointestinal issues, and foodborne illness. Review of the facility’s “Meal Service” policy, last reviewed on a specified date, showed that Food and Nutrition Services staff are required to take food temperatures prior to meal service, with hot foods such as meats to be served at 160°F–180°F and hot entrées to be above 120°F at delivery, which was not followed for the grilled chicken.