Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature to two residents who were cognitively intact, as evidenced by their BIMS scores. Both residents reported that hot foods were served cold or cool on multiple occasions, with one resident specifically stating that food had been served cold in the past week. During meal service observation, staff removed food from the oven and placed it on a stove top that was not turned on, and one of the burners was broken. Staff did not report the broken burner, and food was held on the stove without heat. Temperatures of the food at the start of service were within appropriate ranges, but by the end of service, some items had dropped below the expected holding temperature, with mashed potatoes at 121 degrees and beef stroganoff at 130 degrees. Staff reheated a plate in the microwave for one resident but failed to check the temperature before serving it. Staff interviews revealed inconsistent understanding of required holding and serving temperatures, with expectations ranging from 135 to 150 degrees for holding and 165 degrees for reheating. The facility's policy required hot foods to be served at a minimum of 120 degrees and held at 140 degrees or above, but these standards were not consistently met. Staff and dietary management acknowledged that residents had complained about cold food, and the issue was not communicated or addressed effectively.