NEW BRAUNFELS, TX - Federal health inspectors cited Legend Oaks Healthcare and Rehabilitation in New Braunfels for food safety violations during a March 2025 survey after staff served meals to residents on dishes that had not been properly dried, with visible standing water still present on divided plates.
Wet Dishes Served to Residents Despite Visible Water
During the inspection conducted on March 27-28, 2025, surveyors documented that dietary staff at the facility located at 2468 FM 1101 served food on divided plates that still contained drops of standing water. The issue was identified when a grilled cheese sandwich was plated and delivered to a resident on a dish that had not been fully air-dried following the sanitization process.
The violation falls under F-tag 0812, which governs food procurement, storage, preparation, and service in skilled nursing facilities. The deficiency was classified at a level indicating minimal harm or potential for actual harm, with multiple residents potentially affected by the practice.
What makes this citation particularly notable is that multiple members of the facility's own staff — from dietary workers to the Director of Nursing to the administrator — all acknowledged the practice was dangerous and should not have occurred.
A dietary resource at the facility told inspectors that the undried divided dish "could cause cross contamination" and "could make residents very sick." The staff member explained that the plate should have been removed from service the moment liquid was observed, but admitted she had been focused on checking other plates in the kitchen and failed to catch the one that was ultimately served.
The dietary supervisor who personally served the grilled cheese sandwich on the wet plate acknowledged to inspectors that he had not noticed the standing water at the time of service, but confirmed it posed a cross-contamination risk. He noted that the facility's standard procedure calls for dishes to be air dried before use.
Why Standing Water on Dishes Poses a Health Risk
For the general public, a few drops of water on a plate may seem like a minor issue. In a nursing home setting, however, the risk is significantly elevated. Nursing home residents frequently have compromised immune systems, chronic illnesses, and reduced ability to fight off infections. What might cause mild discomfort in a healthy adult can lead to serious gastrointestinal illness, hospitalization, or worse in an elderly or medically fragile person.
Standing water on sanitized dishes can harbor and transfer bacteria between food items, particularly on divided plates where different foods occupy separate compartments. When water pools on a surface that then contacts food, it creates a pathway for bacterial cross-contamination — meaning pathogens from one source can migrate to another through the liquid medium.
Common foodborne pathogens such as Salmonella, E. coli, and Listeria can thrive in moist environments. In vulnerable populations like nursing home residents, infections from these organisms can progress rapidly to dehydration, sepsis, and in severe cases, death. The U.S. FDA Food Code specifically addresses contamination prevention protocols during food preparation and service for this reason.
Facility's Own Policies Were Not Followed
Inspectors reviewed two of the facility's internal policies and found that staff had failed to follow their own established procedures.
The facility's Handling Clean Equipment and Utensils policy states that clean equipment and utensils must be handled properly to prevent contamination, with staff required to avoid touching parts that will come in contact with food.
More directly applicable, the facility's Cleaning Dishes/Dish Machine policy specifically requires that dishes be air dried on dish racks and then inspected for cleanliness and dryness before being put away for use. The policy clearly establishes a two-step verification process — drying followed by inspection — that was not carried out in this instance.
The Director of Nursing told inspectors that the potential for cross-contamination from improperly dried dishes "could have the potential for causing infections." She added that responsibility for catching the problem should have been shared across multiple staff members — if the issue was not identified in the kitchen, it should have been caught during tray distribution.
The facility administrator echoed this assessment, stating that "residents could get sick if there was cross contamination from not properly handling the dishes" and placing responsibility on both the dietary supervisor and the cook on duty.
Multiple Layers of Oversight Failed
This violation highlights a systemic breakdown in the facility's food safety protocols rather than an isolated mistake by a single employee. The dish passed through multiple hands — from the dishwashing station, to plating, to the dietary supervisor who served it — without anyone identifying the visible standing water.
According to standard food safety practices in healthcare settings, facilities are expected to maintain multiple checkpoints in the food preparation and service chain. These include the dishwashing and drying stage, a visual inspection before dishes are stored or used, a check during food plating, and a final review before trays are delivered to residents. At Legend Oaks, each of these checkpoints failed to catch the problem.
The FDA Food Code (2022) requires food employees to take measures to prevent cross-contamination during food preparation, including when working with clean equipment and utensils. The code mandates that contamination prevention occur "as often as necessary" during food service operations.
What Happens Next
Following the identification of deficiencies, facilities are required to submit a plan of correction to the Centers for Medicare & Medicaid Services detailing how they will address each cited violation and prevent recurrence. Legend Oaks Healthcare and Rehabilitation must demonstrate that it has implemented measures to ensure dishes are properly dried and inspected before being used for food service.
The full inspection report for Legend Oaks Healthcare and Rehabilitation in New Braunfels is available through the CMS Care Compare database. Families of current and prospective residents are encouraged to review the complete survey findings, which cover 33 pages of documented observations from the March 2025 inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legend Oaks Healthcare and Rehabilitation - New Br from 2025-03-28 including all violations, facility responses, and corrective action plans.
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