Federal inspectors visiting the 71-bed facility found sliced pork being served at 108 degrees Fahrenheit, mashed potatoes and gravy at 120 degrees, and green beans at a cold 86 degrees during the November 24 lunch service. The facility's administrator, who holds a food handler's certificate, confirmed the test tray "were not warm enough to be palatable."
The cook told inspectors the kitchen "is a mess because there are not enough staff." She explained that kitchen workers "do their best but can't keep up" with basic food safety requirements.
Temperature monitoring had essentially stopped. The facility could not provide any temperature logs for meal service. Equipment temperature logs for November showed spotty documentation, with readings recorded only on November 8 and November 10-14 for walk-in coolers and freezers. No other temperatures were documented.
On November 23, inspectors watched as the cook failed to obtain temperatures for country fried steak, mashed potatoes with gravy, mixed vegetables, spaghetti, or green beans before serving them to residents. The cook later confirmed she had "never checked food temperatures for food service" during her year as the main cook responsible for all three daily meals, five to six days per week.
Kitchen sanitation had deteriorated badly. Inspectors found the reach-in cooler, vegetable freezer, and meat freezer contaminated with "an unknown pink sticky liquid spilled on the bottom shelf along with dozens of pieces of food debris."
The cook acknowledged that temperature logs posted on coolers and freezers "are not completed as they should be." She said hot food service temperature logs "have not been completed since she started a year ago."
A Regional Certified Dietary Manager explained the risks to inspectors. The facility "should be checking the temperatures of all the coolers, freezers, dishwashing cycles and food service temperatures," the manager said. "Not checking those temperatures could cause a food borne illness."
The violations affected all residents at the facility. Federal standards require nursing homes to maintain food at safe temperatures and follow professional food service standards to prevent illness among vulnerable elderly residents.
The cook's admission revealed the scope of the problem. As the primary person responsible for meal preparation nearly every day for an entire year, her failure to monitor temperatures meant residents had been potentially exposed to unsafe food temperatures for months.
The facility's inability to produce meal service temperature logs suggested systematic failures in food safety oversight. While some equipment temperatures were sporadically recorded, the complete absence of hot food temperature monitoring indicated management had not ensured basic food safety protocols were followed.
When the administrator tested food temperatures herself, the readings confirmed what residents had been experiencing. The sliced pork, a protein that requires proper heating to prevent bacterial growth, measured only 108 degrees. Green beans served at 86 degrees were barely above room temperature.
The contaminated equipment presented additional risks. The pink liquid and food debris found throughout refrigeration units created conditions for bacterial growth and cross-contamination. These unsanitary conditions, combined with inadequate temperature control, compounded the potential for foodborne illness.
The cook's statement that staff "can't keep up" pointed to broader operational problems. Understaffing had apparently led to the abandonment of basic food safety practices that protect residents from illness.
The Regional Certified Dietary Manager's warning about foodborne illness highlighted the serious health risks facing residents. Elderly nursing home residents are particularly vulnerable to food poisoning due to weakened immune systems and underlying health conditions.
The facility's systematic failure to monitor food temperatures for an entire year, combined with unsanitary kitchen conditions, had put all 71 residents at risk of preventable illness from the meals they depended on for nutrition and health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sullivan Healthcare & Senior Living from 2025-11-25 including all violations, facility responses, and corrective action plans.
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