The 92-bed facility failed to serve food at safe and appetizing temperatures throughout multiple hallways, with staff unable to produce any temperature records for hot food items during the three-day inspection.
Resident #58 told inspectors the problems had persisted for months. "The food is terrible, they have not updated any meal preferences with me, I asked the manager almost three months ago," the resident said. "The food is cold, we are last to get meals sometimes they run out, I usually do not get what I ask for. When they send us food, generally it is all mixed together."
When inspectors asked the Director of Dining to check milk temperatures on the west hall beverage cart on December 15, the thermometer read 54 degrees Fahrenheit. The director acknowledged this exceeded the FDA food code requirement of 41 degrees or below by 13 degrees.
The same resident's lunch that day illustrated the facility's food presentation problems. Staff served a turkey burger with lettuce, tomato and baked beans on a single plate, with the beans running underneath the hamburger bun. "I wish they would have put those beans in a bowl," the resident told the inspector.
The Food Service Director later confirmed the beans were indeed running into the hamburger bun when she reviewed the meal presentation.
Temperature monitoring appeared nonexistent across the facility. When an inspector asked employee #152 for lunch menu food temperatures on December 17, he said the cook was supposed to write them on production sheets. But when he provided a copy of that day's sheet, no temperatures were recorded.
"The cook did not write them down," the employee acknowledged.
The violations affected residents throughout the facility. Inspectors found temperature problems on four of five hallways they tested for milk temperatures, and the single meal tray they examined failed temperature standards.
Resident #58's complaints extended beyond temperature to basic food service operations. The resident said staff had ignored requests to update meal preferences made three months earlier, and meals often arrived incomplete. "Sometimes they run out," the resident explained, describing frequently not receiving requested items.
The mixing of different foods on single plates appeared to be standard practice rather than an isolated incident. The resident described this as a recurring problem: food items "generally" arrived mixed together rather than properly separated.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to residents. However, the combination of improperly stored dairy products and inadequate food temperature monitoring created ongoing food safety risks.
The Food Service Director's acknowledgment that she had never updated the complaining resident's meal preferences despite months of requests highlighted broader communication failures between dietary staff and residents.
The facility's inability to produce basic temperature logs during the inspection suggested systematic failures in food safety protocols. Without documented temperatures for hot foods, inspectors could not verify whether meals met safety standards before reaching residents.
The warm milk discovery on beverage carts indicated problems extended beyond the kitchen to food distribution throughout the facility. Dairy products stored above safe temperatures can harbor dangerous bacteria, particularly concerning for elderly residents with compromised immune systems.
Resident #58's description of being "last to get meals" suggested the facility struggled with timely food distribution, contributing to temperature problems as prepared foods sat cooling while staff completed their rounds.
The baked beans running into the hamburger bun represented more than poor presentation. It demonstrated how the facility's approach to meal service failed to maintain food quality and resident dignity during what should be an enjoyable part of daily life.
Three months after initially requesting meal preference updates, Resident #58 continued receiving unwanted food combinations while watching beans soak into bread.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willows Center from 2025-12-22 including all violations, facility responses, and corrective action plans.