Improper Cold Food Temperature Monitoring
Penalty
Summary
The facility failed to ensure that food was served in accordance with professional standards for food service safety, specifically in the Madison dining room. During a lunch meal observation, the temperature of two yogurt containers was measured at 60 and 62 degrees Fahrenheit, which is above the normal range of below 41 degrees Fahrenheit. The facility's policy on food safety clearly states that potentially hazardous foods, such as yogurt, must be maintained at or below 41 degrees Fahrenheit to prevent the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. The Dietary Supervisor, upon measuring the yogurt temperatures, acknowledged the increased risk for infection and gastrointestinal issues if food is served outside the proper temperature range. The Food Service Director confirmed that the temperature of cold food items is checked when placed on resident trays and stored in a walk-in refrigerator until service. However, the trays were delivered to the dining room approximately 22 to 27 minutes before the temperature was checked, leading to the yogurt being served at an unsafe temperature. The Administrator was unaware of the issue until notified during the survey process.
Plan Of Correction
Plan of Correction: Approved January 28, 2025 Plan of Correction F812 SS:D I. Immediate Action a. All residents' trays in the (NAME) dining room receiving yogurts on 12/30/24 was immediately removed from the trays and replaced with new items from the kitchen transported to the dining room on ice by the Food Service Director. All residents receiving yogurt at meals have the potential to be affected by this practice. No residents were affected. b. The Dietary Supervisor received 1:1 education on 1/16/25 by the Assistant Director of Nursing with the Food Service Director present on transporting all yogurt and milk on ice to the assigned serving area and adding items to tray at the time the tray is being served to the resident to ensure the items are served within the safe temperature. Any items identified outside the safe temperature zone must be immediately discarded. All items requiring refrigeration must be refrigerated. c. The Food Service Director was in serviced on 1/16/25 by the RN (ADNS) on transporting all yogurt and milk on ice to the assigned serving area and adding items to tray at the time the tray is being served to the resident to ensure the items are served to the resident within the safe temperature. All food items requiring refrigeration must be refrigerated and any items identified outside of the safe temperature zone must be immediately discarded. II. Identification of Others a. All residents receiving yogurt at meal services have the potential to be affected by this deficient practice. No residents were affected. b. An audit was conducted on 1/16/25 by the Food Service Director including temperature check of all yogurts for resident in house receiving yogurt at meals with no negative findings. III. System Changes a. The Policy and Procedure Titled Food Safety/Storage/Distribution/Service Procurement General dated 6/2024 was reviewed on 1/16/25 by the Medical Director, Food Service Director and the Administrator with no changes made. b. All Dietary employees will be re-in-service on the Facility’s Policy Titled Food Safety/Storage/Distribution/Service/Procurement by the Food Service Director and the Educator/Designee. IV. Quality Assurance a. An audit tool was created by the Administrator to conduct random temperature checks for all residents receiving yogurt and milk at random meals to identify any unsafe temperature to ensure items are stored and served at a safe temperature. b. Audits will be completed by the Food Service Director daily x 30 days then bi-weekly x 4, then monthly x 2 months and quarterly x 3 quarters until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Administrator immediately and addressed by the Food Service Director/Designee immediately. d. All results of the audits will be brought to the QAPI committee quarterly x 4 to review and discuss any unfavorable trend that may prevent achieving 100% compliance. V. Person Responsible Administrator. VI. Completion date: 2/25/25