Oakwood Rehab and Nursing Center failed to maintain proper temperatures for cold foods served to residents, with orange juice reaching 50 degrees and deli sandwiches stored improperly next to steam tables, according to a September inspection report.
The problems began early on September 29, when inspectors found that a resident identified as R6 had his breakfast tray delivered at 9:37 AM while he was still at dialysis. The tray included an 8-ounce carton of whole milk and a 4-ounce cup of orange juice. R6 didn't return to eat until 11:30 AM, nearly two hours later.
Other residents complained directly about the temperature problems. At 9:44 AM, one resident told inspectors that "the food that is supposed to be cold is hot" and "the orange juice is served warm." Another resident made identical complaints 34 minutes later. A third resident described cold foods as "served warm" and said "the quality is poor."
The most concerning discovery came during the lunch service at 11:33 AM. Inspectors found deli sandwiches wrapped in clear plastic sitting directly on the tray line counter next to the steam table. A dietary aide explained that ham sandwiches were made fresh that day, but turkey sandwiches had been prepared the day before.
The turkey sandwich showed obvious signs of deterioration. It contained wilted lettuce and cheese that appeared to be melting from the heat exposure. When inspectors tested the ham sandwich temperature, it registered 70 degrees Fahrenheit.
Two residents received these improperly stored sandwiches on their room trays around noon.
Administrator testing confirmed the temperature violations. At 12:06 PM, the facility administrator measured drinks from a test tray and found orange juice at 49.8 degrees and milk at 46.7 degrees.
The next morning, the interim dietary manager tested orange juice directly from the dispenser at inspectors' request. It measured 50.7 degrees. The manager admitted that "the juice dispenser does not keep juices cold."
This contradicted what the facility's dietitian told inspectors. The dietitian stated that orange juice "should come out cold from the dispenser" and that cold items should be 40 degrees at the serving station and at least 45 degrees when served to residents.
The facility's own written policies required much stricter temperature controls. The serving and tray line policy mandated that temperatures be measured and recorded at every meal, with cold foods maintained at 41 degrees. The policy specified that if items weren't at correct temperatures, "action will be taken so that the temperatures are restored."
The policy also required that cold foods be "prepared, dipped into individual serving dishes and chilled prior to service" and that cold beverages be "added at the end of tray line to maintain the temperature."
None of these protocols appeared to be followed during the inspection.
The violations affected all five residents whose food service was reviewed during the inspection. Federal regulations require nursing homes to ensure food is served at safe and appetizing temperatures, both for resident safety and quality of life.
Improper food temperatures can pose health risks to elderly residents, who may have compromised immune systems. Warm temperatures also encourage bacterial growth in dairy products and other perishable items.
The inspection found that basic food safety equipment wasn't functioning properly, with juice dispensers unable to maintain cold temperatures and sandwiches stored in areas where heat from steam tables could cause cheese to melt and lettuce to wilt.
The facility's failure to follow its own written temperature monitoring procedures suggests systemic problems in the dietary department's oversight and quality control processes.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to residents, but noted that the problems affected multiple residents across different meal services and food types.
The temperature violations represent a fundamental failure to provide residents with palatable, safely prepared food, a basic requirement of nursing home care that directly affects residents' nutrition and daily quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakwood Rehab and Nursing Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
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