Health inspection·October 14, 2023

F800 483.60 Provided Diet Meets Needs of Each Patient §483.60 Food and nutrition services. The facility must provide each patient with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each patient. 72335 (a)(3) Dietetic Service – Food service (a) The dietetic service shall provide food of the quality and quantity to meet each patient's needs in accordance with the physicians' orders and to meet “The Recommended Daily Dietary Allowance,” the most current edition, adopted by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, and the following (3) Patient food preferences shall be adhered to as much as possible and substitutes for all food refused shall be from appropriate food groups. Condiments such as salt, pepper or sugar shall be available at each meal unless contraindicated by the diet order. 72349 (a) (1) (2) Dietetic service – Equipment and Supplies (a) Food supplies shall meet the following standards: (1) At least one week's supply of staple foods and at least two days' supply of perishable foods shall be maintained on the premises. Food supplies shall meet the requirements of the weekly menu including the therapeutic diets ordered. (2) All food shall be of good quality and procured from sources approved or considered satisfactory by federal, state or local authorities. Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used. The facility failed to provide a nourishing, well-balanced diet and dietary needs and choices by failing to: 1. Prepare second (2nd) menu option to Patient 1 for lunch on 8/30/2023 due to food items were not purchased 2. Provide Patient 2 fresh fruits and vegetables on 8/30/2023. 3. Follow menu and standardized recipe for Patient 3 on 8/30/2023 due to unavailable food supplies such as sausages, powdered onions and powdered garlic. Available food supplies were limited to one (1) day at hand. 4. Provide silverware to Patient 3 for lunch service on 8/30/2023. These deficient practices placed patients on regular (diet with no restrictions) and therapeutic diets (meal plan that controls certain foods and nutrients) at risk of potential decreased nutrient intake causing unintentional weight loss (weight loss without trying). 1. A review of Patient 1's Admission Record indicated the facility initially admitted the patient on 5/26/2021 with diagnoses that included essential (primary) hypertension (HTN, high blood pressure), hyperlipidemia (high levels of fats in the blood), and age-related osteoporosis (a condition that weakens the bones). A review of Patient 1's Minimum Data Sheet (MDS-a standard assessment tool that measures health status), dated 6/1/2021, indicated the patient was cognitively (a mental process that take place in the brain, including thinking, attention, language, learning, memory and perception) intact. The MDS indicated that Patient 1 needed supervision and set up only when eating. A review of Patient 1's Physician diet order, dated 8/9/2023, indicated Patient 1 ' s diet was Renal diet (diet that is limited in protein, sodium, potassium and phosphorus), regular texture consistency (no restriction). During an interview with Patient 1 on 8/30/2023 at 10:26 a.m., Patient 1 stated, "I don’t really like the food and I don’t eat a lot of what they cook." Patient 1 stated that the facility served a lot of rice, chicken, mixed vegetables and that there were no variety. Patient 1 stated she requested sandwiches instead of the regular meal tray. During a review of the facilities document titled, "Diet Guide Sheet," for Wednesday lunch, dated 8/30/2023, indicated the menu has two options for Regular, Large portions, Small portions, Consistent Carbohydrate diet (CCD, diet for people with high blood sugar), 2 grams Sodium Diet (diet provided for people with HTN), CCD 2 grams Sodium Diet, CCD Renal Diet, Renal Diet (diet provided for people with Kidney problems), Therapeutic Lifestyle Changes (TLC) Diet (diet provided for people with heart disease). a. The following foods will be served to Option 1: Regular, Large portion, small portions, CCD, 2 grams Sodium, CCD 2 grams Sodium, CCD Renal Diet, Renal diet, TLC diet: - Open-faced Roast Pork Sandwich - Herbed Green Beans - Mashed Potatoes - Dinner Roll - Lemon Cake with Lemon icing b. The following foods will be served to Option 2: Regular, Large portion, small portions, Consistent Carbohydrate diets: - Salisbury Steak - Brussels Sprouts - Buttered Noodles - Dinner Roll - Lemon Cake with Lemon Icing The following foods will be served to Option 2: 2 grams sodium, CCD 2 grams sodium, CCD Renal, Renal, TLC - Low salt (LS) Salisbury Steak - Brussels Sprouts - Buttered Noodles - Dinner Roll - Lemon Cake with Lemon Icing During a concurrent observation in tray line (area to assemble patient meals) and interview with the Dietary Supervisor (DS) on 8/30/2023 at 11:55 a.m., there were no Salisbury steak, buttered noodles and Brussels Sprouts prepared. DS stated that buttered noodles were not available and that mashed potatoes were being given as an alternative. During an interview with Cook 1 on 8/30/2023 at 1:05 p.m., Cook 1 stated, "I did not cook buttered noodles because there were no butter and noodles available in the kitchen." During an interview with the DS on 8/30/2023 at 3:44 p.m., DS stated, "Buttered noodles were not prepared for today as mashed potatoes were in stock." DS stated they received the wrong noodles from the supplier. DS stated the second menu options were not prepared as none of the patients requested for it. A review of facility invoices from dairy vendor invoice number WEB153220, dated 8/28/2023, indicated there was no butter ordered. A review of the facility invoices from food vendor invoice number 645792484, dated 8/28/2023, indicated elbow macaroni was ordered and there were no Salisbury steak and Brussels sprouts ordered. A review of the facility's policy and procedure (P&P) titled, "Menus," revised 9/2017, indicated menus will be planned in advance to meet nutritional needs of the patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. The P&P indicated menus will periodically be presented for patient review, including the patient council menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items." 2. A review of Patient 2's Admission Record indicated the facility initially admitted the patient on 7/23/2022 and was re-admitted on 2/24/2023 with diagnoses that included dysphagia (difficulty swallowing), mild protein-calorie malnutrition (condition due inadequate intake of protein and calories), and essential (primary) HTN. A review of Patient 2's MDS, dated 7/6/2023, indicated the patient was cognitively intact. The MDS indicated Patient 2 needs supervision and set up only when eating. A review of Patient 2's Physician diet order, dated 2/24/2023, indicated an order for Patient 2 to receive a regular diet (diet with no restrictions), regular texture consistency (no restriction). During an interview with Patient 2 on 8/30/2023 at 10:34 a.m., Patient 2 stated he preferred more fresh mixed fruits and fresh vegetables. Patient 2 stated he informed the nurses however, there were no fresh fruits and vegetables available in the kitchen. Patient 2 stated that the kitchen served a lot of peas as a vegetable and there were no variety Patient 2 stated, “There was a daily menu posted on the wall. Sometimes they follow the menu, sometimes not.” During a kitchen tour observation on 8/30/2023 at 10:45 a.m., there were no fresh fruits and vegetables observed in the refrigerators. During an interview with the DS on 8/30/2023 at 3:44 p.m., DS stated, frozen fruits and vegetables are served to the patients. DS stated, "We do not serve fresh fruits and vegetables." During an interview with the Kitchen District Manager 2 (DM2) on 8/30/2023 at 4:19 p.m., DM 2 stated she does not know why fresh fruits and vegetables were not served or included in the menu. 3. A review of Patient 3 ' s Admission Record indicated the facility initially admitted the patient on 9/29/2022 and was re-admitted on 4/26/2023 with diagnoses that included type 2 diabetes mellitus (DM2, increase of blood sugar levels), mixed hyperlipidemia, and essential HTN. A review of Patient 3 ' s MDS dated 8/3/2023, indicated the patient was cognitively intact. The MDS indicated Patient 3 was assessed needing supervision and set up only when eating. A review of Patient 3 ' s Physician diet order, dated 4/26/2023, indicated an order for Patient 3 to receive a regular texture consistency diet. During an interview with Patient 3 on 8/30/2023 at 10:40 a.m., Patient 3 stated there was no variety of food and there were inadequate amounts of breakfast food served from the kitchen. Patient 3 stated the food served for breakfast were mostly beans, once sliced of wheat bread, 2 scrambled eggs and juice. Patient 3 stated food has no flavor and the kitchen mostly served chopped up beans and carrots with no seasonings. During a kitchen tour observation in the storage areas on 8/30/2023 at 10:45 a.m., the storage shelves were observed with the following: a. Walk-in Refrigerator 2 contained: 1 tub of shredded American cheese, 2 packet of American cheese, 1 tub of shredded Mexican cheese, 1 tub of sliced single served cheese, 1 carton of liquid whole egg, few pieces of butter, 1 tub of mustard, ¼ tub of canned sliced peaches, ¼ tub canned pineapple, and 1 tub of yellow cake mix. b. Reach-in Freezer contained: 5 plastic of frozen corn, 2 boxes of opened frozen dinner roll, 1 box of opened turkey patties, 1 plastic of tater tots, 1 box of opened cinnamon sweet roll frozen dough, and 1 box of frozen southern style biscuit dough. c. Refrigerator 3 contained: 2 boxes of honey thick juice, 1 bottle of orange juice, 23 cups of portioned orange juices, 1 tray of orange and apple juice portioned in cups. d. Refrigerator 4 contained: 4 pieces of peach puree, 2 oz of prepared juices. e. Dry storage area contained: 12 boxes of toasted oats, 5 cans of diced tomatoes, 4 cans of tropical fruit salad, 3 cans of tomato ketchup, 1 can beef stew, pouches o lemon drink, 1 pouch of lime gelatin, 1 pc mustard, 2 cans grape jelly, 2 plastic of elbow macaroni, 8 boxes of lasagna noodles, and corn starch boxes. During an interview with Cook 1 on 8/30/2023 at 11:03 a.m., Cook 1 stated the storage areas including dry storage (storeroom of canned and dry goods/food), freezer and refrigerator were empty. Cook 1 stated the staff has been dealing with this insufficient food supplies such as lack of garlic powder and onion powder since the new District Manager 1 (DM1) took over the kitchen for 2-3 months. During an interview with the DS on 8/30/2023 at 11:09 a.m., DS stated he is the person responsible for ordering food and paper supplies and was overseen by DM2 and DM1. DS stated that last food delivery was on Monday (8/28/2023). DS stated the schedule for ordering was bi-weekly (2 times a week). DS stated he ordered every Friday for Monday delivery for four days ' worth of food, then Wednesday for Thursday delivery for three days ' worth of food. DS stated he has 1 day worth of food supply at hand for tomorrow ' s use. DS stated the policy for ordering food was 3-4 days food supply, however, DS stated he was uncertain of the exact policy and would check with the DM1. During a concurrent kitchen tour observation and interview with the DS on 8/30/2023 at 11:29 p.m., corn bread, sausage patty, chicken, pumpkin pie, Philly cheese steak were not available in the kitchen. DS stated corn bread will be substituted with dinner roll, kernel corn will be substituted with peas, sausage patty will be substituted with eggs, chicken will be substituted with ground meat, pumpkin pie will be substituted with yellow cake and Philly cheese steak will be substituted with smothered steak hamburger patty as the delivery did not come in. DS stated that the reason why there were a lot of substitution was there were times the food were damaged and had to be returned. During an interview with the DS on 8/30/2023 at 11:49 a.m., DS stated that 1 day food supply at hand was acceptable as there was an order coming in the next day. DS stated if the food item was not available, he would get it from the sister facilities. During an interview with Cook 1 on 8/30/2023 at 1:05 p.m., Cook 1 stated that there were budget cuts which was the reason why DS was just ordering the exact amount of food per order. Cook 1 stated shelves were always empty and oil, bread, butter, seasonings were always out of stock because DS does not order enough. Cook 1 stated the kitchen would run out of milk and would use powdered milk. Cook 1 stated she told the DM2 that patients were complaining they were served chicken four times a week. Cook 1 stated, "We do not go by the books anymore for standardized recipes. We have not been following the menu books anymore because we have been substituting everything." Cook 1 stated the kitchen run out of food and offer what is available to the patients. Cook 1 stated they run out of spices to use as indicated in the standardized recipe and ended up using spices that were available on the shelves to flavor the food. Cook 1 stated the possible outcome of not following a standardized recipe was a change in flavor resulting to patient not liking and not eating the food. Cook 1 stated patients could lose weight and get sick due to the change of food flavor resulting to patient not liking and not eating the food During an interview with the Licensed Vocational Nurse 1 (LVN1) on 8/30/2023 at 1:15 p.m., LVN stated the facility has current limitations when it comes to low stocks of food as there had been budget cuts. LVN 1 stated the Director of Nursing (DON) was aware that the kitchen run out of food and there were missing food items. During an interview with Cook 2 on 8/30/2023 at 1:31 p.m., Cook 2 stated, "The kitchen run out of food items and were mostly tomatoes and condiments such as garlic powder, onion powder and paprika". Cook 2 stated she adds dill or black pepper to flavor the food, so patients would not complain. Cook 2 stated there were no garlic powder and fresh onions for the beef Mexican casserole preparation for (8/30/2023) dinnertime. During an interview with Certified Nursing Assistant 1 (CNA1) on 8/30/2023 at 1:59 p.m., CNA1 stated there were 2 patients(unnamed) complaining they did not like the food. CNA1 stated she offered alternative foods and went to the kitchen to request it. CNA1 stated there were times the kitchen staff would ask to come back at a certain time. CNA1 stated, "Sometimes they do not have the food." CNA1 also stated there were times when patients would get annoyed because they are served eggs during breakfast. CNA1 stated she went to the kitchen and the kitchen staff would not replace the food item and was told "That is all we have." CNA1 stated the kitchen run out of food such as milk, juices, and sugar quite often. CNA1 stated patients can starve, lose weight and get weaker as the immune system goes down as a possible outcome of not eating food. During a review of facility corporate undated recipe titled, "Beef, Mexican Casserole," not dated indicated ingredients included, "onion yellow, fresh and spice, garlic powder." A review of facility invoices from dairy vendor invoice number WEB153220, dated 8/28/2023, indicated fresh yellow onions were not ordered. A review of the facility invoices from food vendor invoice number 645792484, dated 8/28/2023, indicated there were no spice garlic powder ordered. During a concurrent kitchen tour observation and interview with DON and Assistant Administrator (AADM) on 8/30/2023 at 3:13 p.m., the DON stated that the food supply at hand was not meeting the regulatory requirement based on State regulations AADM stated ther