Samaritan Nursing: Burned Food, Cold Meals - WI
The complaint investigation on August 25-26 found the facility repeatedly served food at unsafe temperatures and failed to monitor holding temperatures that prevent foodborne illness. Hot food measured as low as 77 degrees Fahrenheit — nearly 60 degrees below the federal safety standard of 135°F.
During lunch service on August 25, inspectors watched staff serve ham steak with baked sweet potato to residents on the fourth floor. One resident immediately told staff the sweet potato was burned and declined to eat it. Staff removed the plate and brought an alternative meal.
Inspectors observed four other residents' sweet potatoes that day, noting all contained black peels and edges. The facility's posted menu listed the meal as ham steak with baked sweet potato, cauliflower, and fruited gelatin.
"The food was terrible," the resident who refused the burned sweet potato told another resident at the table, according to the inspection report.
The temperature violations were more extensive. On August 26, a dietary aide measured holding temperatures in the steam table during lunch service at the inspector's request. Steamed rice registered 91°F, sweet and sour chicken measured 87°F, and broccoli was 77°F.
Federal food safety standards require hot food to be held at 135°F or above to prevent harmful bacteria growth. The temperatures documented at Samaritan were designed to reduce foodborne illness risk by ensuring pathogens are destroyed during cooking.
The dietary aide who took the measurements was unaware of minimum holding temperatures and didn't know what steps to take when food fell below safety standards, inspectors found.
Food Service Director told inspectors that staff should take holding temperatures before serving and notify the kitchen if temperatures drop below minimums. But the director acknowledged that minimum holding temperatures were not routinely monitored at the end of meal service.
The director said there were concerns that steam rollers weren't holding proper temperatures and maintenance had been notified. The facility was recommended to replace the steam rollers.
Four residents of six sampled told inspectors about ongoing food quality problems. One resident on a soft bite diet typically received food that was "mushy and usually cold," according to a family member who spoke on the resident's behalf. The family member suspected the cold temperatures might explain why the resident didn't always eat meals.
Another resident described the food as "mediocre and institutional tasting." A third called it "gross and not palatable."
The fourth resident explained a specific problem with meal service: "Staff put cold food on the same tray and under the same food cover as hot food which made the cold food warm and gross."
Medical records showed one resident typically ate 50-75% of meals. On the day inspectors observed lunch, that resident ate approximately half the meal of ground ham, mashed cauliflower, and cut-up sweet potato.
The inspection documented violations affecting at least four residents but noted the practice "had the potential to affect more than 4 of the 67 residents residing in the facility."
Federal regulations require nursing homes to ensure food is palatable, attractive, and served at safe and appetizing temperatures. The 2022 FDA Food Code specifies that time and temperature control foods must be maintained at 135°F or above for hot items and 41°F or below for cold foods.
Samaritan Nursing and Rehab received a citation for minimal harm or potential for actual harm related to food temperature safety violations. The facility serves 67 residents in West Bend.
The complaint investigation found systematic problems with both food preparation and temperature monitoring that put residents at risk for foodborne illness while serving meals that residents consistently described as unpalatable or inedible.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Samaritan Nursing and Rehab from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Samaritan Nursing and Rehab in West Bend, WI was cited for violations during a health inspection on August 26, 2025.
Hot food measured as low as 77 degrees Fahrenheit — nearly 60 degrees below the federal safety standard of 135°F.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.