The 75-bed facility failed to keep meals at safe temperatures during service, with breakfast foods dropping as much as 84 degrees between the kitchen and residents' rooms, federal inspectors found during a September complaint investigation.
Resident #53 told inspectors on September 24 that breakfast was "always cold so he no longer eats breakfast." He had reported the problem to certified nursing assistants, but nothing improved. Staff would offer to reheat his food, but he didn't want reheated meals.
Another resident, #4, said food was "frequently cold by the times the trays were passed." She ate anyway because she was hungry, but would prefer warmer food.
The temperature problem had persisted for months. Residents complained at a September 8 council meeting that they didn't like most of the food because of repeated menus, dry meat, and lack of seasoning. Meeting minutes showed the concern remained unresolved.
Inspectors witnessed the temperature failures firsthand during breakfast service on September 25. Dietary Manager #529 checked food temperatures in the kitchen at 7:30 a.m. Sausage patties registered 172 degrees, waffles were 136 degrees, and oatmeal was 165 degrees.
The problems began during transport and distribution.
Hallway trays headed to the 100-hallway at 7:55 a.m. Staff began distributing meals at 8:01 a.m. and finished at 8:11 a.m. By then, the sausage patties on the last tray had cooled to 101 degrees. The waffles measured just 88 degrees.
An inspector obtained a test tray from the dietary manager. The sausage patty was "lukewarm and was dry, and difficult to swallow." The waffles were "cool to taste and dry as well."
Dietary Manager #529 confirmed the food wasn't warm and acknowledged the sausage patties were dry. She explained that staff used to use plate warmers to maintain food temperatures, but the machine was "too hot for the staff to handle."
Special gloves were supposed to be ordered so staff could safely operate the warming equipment. They were never purchased.
The administrator told inspectors during an interview that staff should have been using the plate warmers to keep food warm during service.
Oak Grove Manor's own policy requires hot food items to stay above 135 degrees after cooking. The policy, dated 2021, states that temperatures should be checked periodically "to ensure hot foods stay above 135 degrees F during the holding and plating process."
The breakfast service violated this standard dramatically. Sausage patties fell 71 degrees below the minimum temperature requirement. Waffles dropped 47 degrees below the safety threshold.
Federal regulations require nursing homes to serve food that is "palatable, attractive, and at a safe and appetizing temperature." Oak Grove Manor failed on multiple counts, with meals that were both unsafe and unappetizing by the time they reached residents.
The violation affected all 75 residents who receive meals from the facility's kitchen. Many residents depend entirely on the nursing home for nutrition, making temperature control essential for both safety and quality of life.
Inspectors classified the harm as minimal or potential for actual harm. But for Resident #53, the impact was concrete: he had given up on breakfast entirely rather than continue eating cold food every morning.
The temperature failures represented ongoing problems investigated under two separate complaint numbers, indicating multiple residents or family members had contacted state authorities about food quality issues at Oak Grove Manor.
The facility's own equipment could have solved the problem. The plate warmers sat unused because management failed to provide basic safety equipment that would allow staff to operate them safely.
Instead, residents continued receiving meals that cooled to room temperature during the ten-minute distribution process, leaving them with food that was dry, difficult to swallow, and far below safe serving temperatures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Grove Manor from 2025-09-25 including all violations, facility responses, and corrective action plans.