Kitchen Staff Failed to Follow Meal Ticket and Identify Fortified Food Substitutes
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills related to following meal tickets and identifying substitute fortified food items. During a concurrent observation and interview in the trayline for lunch, CK 1 placed shredded cheese and extra shredded cheese on Resident 67’s tray even though the meal ticket indicated the resident disliked cheese. CK 1 stated she failed to check the meal ticket and should have reviewed and followed it. Resident 67’s record showed diagnoses including COPD, major depressive disorder, and chronic kidney disease, and the resident’s care plan and order summary included a regular texture, thin liquids, fortified, lactose-free diet with extra gravy/sauce ordered. The report also found that CK 2 and the Dietary Supervisor could not verbalize substitute fortified food items for cheese. During interview, CK 2 stated she was not sure what substitute fortified items could be used if residents could not eat cheese and said she would use butter if residents were allergic to dairy products. The Dietary Supervisor stated he could not recall substitute food items for fortified diet instead of cheese and could not think of substitutes, although he acknowledged fortified diet was intended to add extra calories to prevent weight loss. Both staff members stated they should have known the substitutes because residents could be lactose intolerant or allergic to dairy products. Resident 67 stated she did not like cheese because it caused her stomach to hurt really bad and that she had received dairy products in the past and did not eat the meal. She also stated she could not understand why kitchen staff did not follow the meal ticket containing her likes and dislikes. The Registered Dietitian Nutritionist stated the meal ticket contained the resident’s preferences, allergies, diet order, and preferred dining location, and staff should have read and followed it to avoid giving food items that might cause adverse health effects or dishonoring the resident’s preference. The facility’s competency documentation for CK 1 and CK 2 did not specifically address follow-through of the meal ticket or the list of fortified food item substitutes.
Penalty
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Below are regulatory guidelines relevant to this citation:
Insufficient dietary staffing resulted in delayed supper service and improvised meal substitutions when the pm cook did not report. Residents reported late meals, sandwiches served before pizza arrived, and difficulty with the food provided. Staff interviews and labor records showed repeated pm cook coverage problems, with the DM, DON, and corporate staff involved in arranging emergency food service and alternate diet meals after the scheduled cook failed to work.
FNS staff were not shown to have the needed competencies to safely perform kitchen duties. A dietary aide gave incorrect manual dishwashing steps, a staff member did not follow the pureed pork recipe and added water and thickener without measuring, expired sanitizer test strips were used for chlorine and quat testing, and two staff failed to perform proper hand hygiene when entering the kitchen and after handling dirty items. The DM stated there was no documented kitchen-specific training or competency assessment for staff.
Inadequate Training and Competency for CNAs Assigned to Dietary Tasks: CNAs were pulled from nursing units to help in the kitchen when dietary staffing was short, and they performed food prep tasks such as making pudding, cottage cheese, fruit cups, sandwiches, tuna salad, and tray line service. One CNA also blended cottage cheese with milk for a pureed diet. The RD stated CNAs should only do simple tasks with a DA present and confirmed there were no formal training records or competency documents showing CNAs were trained or competent for dietary duties.
A dietary aide incorrectly removed pudding from a resident’s full liquid diet tray, stating it was not a liquid, even though the facility’s diet manual and kitchen cheat sheet listed pudding as an allowed item. The resident had dysphagia and other neurologic diagnoses, and the tray ticket and diet order both specified a full liquid diet.
Insufficient and Untrained Dietary Support Staff: The facility used nursing, administrative, and other non-dietary personnel to prepare meals, serve food, wash dishes, and sanitize the kitchen when dietary staff were unavailable. An LPN and a CNA reported performing kitchen duties without prior training in safe food handling or sanitization, and the Administrator stated staff were not trained before working in the kitchen. Temperature logs were missing for multiple meals, and the facility’s dietary orientation requirements were not reflected in the nursing skills checklists.
Dishwasher 2 was observed testing a pink sanitizing solution with an expired chlorine test strip that was not the correct strip for the QUAT sanitizer. He did not know how long to keep the strip in the solution and could not recall the last in-service on sanitizer testing. The DFN stated the facility was out of the correct QUAT test strips and had no skill check in place for verifying sanitizer strength.
Insufficient dietary staffing led to delayed and improvised supper service
Penalty
Summary
The facility failed to ensure sufficient dietary staff were available to prepare and serve meals in accordance with the planned menu and residents’ physician-ordered diets. The deficiency involved 5 of 5 residents interviewed about food service, including residents on regular, renal, minced and moist, and consistent carbohydrate diets. The facility’s diet type report showed these residents had ordered diets that required different textures and/or restrictions, but the events described showed the evening meal was not reliably prepared or served as planned when the pm cook was absent. Residents reported that supper was delayed or not provided as expected when there was no pm cook. One resident stated supper arrived after 8:00 p.m. and that the facility ordered pizza late in the evening. Another resident stated supper was late and that the pizza soup provided was not good and could not be eaten. A third resident stated residents were given either one-half of a ham and cheese sandwich or a peanut butter and jelly sandwich around 7:00 p.m., then pizza was ordered later, with the meal not served until about 9:00 p.m. Another resident stated residents did not receive supper until an hour or more after it was due and that one-half of a sandwich was distributed before pizza arrived. One resident stated there had been a similar incident shortly after admission when there had not been a cook for the evening shift. Staff interviews and records showed repeated problems with pm cook coverage. A cook stated there had been no pm cook on the affected day, that she left when her shift ended, and that another scheduled cook had told her he could not work. The dietary aide stated he prepared sandwiches and fruit for residents, and the dietary regional director later came to the facility and brought pizza. The dietary manager stated he completed the schedules, used corporate float staff when available, and that nursing staff could contact him or the administrator if dietary staff did not report. He also stated the day had been a bad situation because neither he nor the administrator was available when both scheduled pm cooks did not report. Timecards and labor reports reviewed by surveyors showed instances where the pm cook was scheduled but worked only briefly, arrived late, or was not scheduled at all. The dietary regional director stated she was contacted about the lack of pm cook coverage, ordered and brought pizza, and prepared alternate diet meals, including pureed pizza with applesauce and pudding or a sandwich with diced peaches for residents requiring alternate diets. The dietitian stated the facility should have followed the planned menus and had a written plan of action for when a pm cook did not report.
FNS Staff Lacked Competency in Dishwashing, Recipe Use, Sanitizer Testing, and Hand Hygiene
Penalty
Summary
Food and Nutrition Services staff were not shown to have the competencies and skill sets needed to safely and effectively carry out department functions. The Dietary Manager stated he had nine kitchen staff, six of whom were new and less than a month on the job, and he did not have documented inservices or competency assessments for kitchen staff. He also stated he relied on on-the-job training because he was too busy to provide documented training, and the Director of Staff Development stated onboarding training did not include kitchen-specific training. The facility’s personal file checklist did not include kitchen-specific competencies. During observations and interviews, two staff demonstrated incorrect manual dishwashing procedures. One dietary aide described manual dishwashing as sanitizing in the first sink, rinsing in the second sink, and air drying, and stated she would not use soap. The Dietary Manager described a different process and confirmed the posted directions for the two-sink method showed wash, rinse, and sanitize. The manager also stated the directions were normally posted above the sink but had been removed. In addition, one staff member prepared pureed pork by adding water and thickening agent without measuring either ingredient, and the Dietary Manager stated this did not follow the recipe for pureed pot roast and likely resulted in bland food because too much water was added. The survey also found sanitizer testing was performed with expired test strips. One dietary aide used chlorine test papers with an expiration date of 10/1/25, and the Dietary Manager stated he did not know the strips had an expiration date. On another observation, quat test strips with an expiration date of 5/2026 were also confirmed to be expired. Finally, two staff did not follow hand hygiene procedures: one touched dirty items and then clean food service and food preparation items without washing hands, and another entered the kitchen, touched hair to put on a hair net, and touched a food preparation surface and recipe binder without washing hands. The facility policy required handwashing when entering or re-entering the kitchen, before contact with food surfaces, and after handling soiled equipment or utensils.
Inadequate Training and Competency for CNAs Assigned to Dietary Tasks
Penalty
Summary
The facility failed to ensure staff assigned to perform food and nutrition services possessed the competencies and skill sets necessary to carry out those functions. Certified Nursing Assistants (CNAs) were reassigned from the nursing units to assist in the kitchen with food preparation tasks when the dietary department was short staffed, including during periods when a dietary employee was absent and when the department had been short staffed for several weeks. The CNA job description identified direct resident care duties, while the Dietary Aide job description included preparing food, assembling trays, checking tray accuracy, preparing snacks, maintaining safe food temperatures, and kitchen cleaning tasks. During interviews, dietary staff stated CNAs were pulled into the kitchen to help with tasks such as preparing pudding, cottage cheese, fruit cups, sandwiches, tuna salad, and tray line service, and one CNA reported blending cottage cheese with milk to make the correct consistency for a pureed diet. The Registered Dietician stated CNAs could complete simple tasks if a Dietary Aide was present, but also stated CNAs should not be blending cottage cheese or modifying food textures. The RD further acknowledged the facility did not have formal written training records or competency documentation for CNAs assigned to dietary tasks, and that no supporting documentation was present in CNA personnel files to show they had been trained or deemed competent for those duties.
Dietary Aide Misunderstood Full Liquid Diet Requirements
Penalty
Summary
The facility failed to ensure competency of dietary aides regarding what constitutes a full liquid diet for one of two sampled residents. During a concurrent observation and interview in the kitchen during lunch trayline, a dietary aide removed pudding from a meal tray and replaced it with apple juice, stating she checked the tray against the ticket and removed the pudding because it was not a liquid, even though the tray was for a full liquid diet and included two bowls of soup. The registered dietitian later stated that pudding is okay to place on the tray for a full liquid diet. Resident 39 was admitted with diagnoses of dysphagia, weakness, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side. The resident had a diet order for a full liquid diet, and the meal tray ticket also indicated full liquid for breakfast, lunch, and dinner. The facility’s diet manual listed pudding as part of the full liquid diet, and a facility document used as a cheat sheet for dietary aides also listed pudding as a full liquid diet menu option. The dietary aide’s action showed a misunderstanding of the diet order and the facility’s own guidance.
Insufficient and Untrained Dietary Support Staff
Penalty
Summary
The facility failed to ensure sufficient dietary support staff were employed and trained to carry out safe food and nutrition services for the kitchen. Nursing staff and other facility leadership staff without dietary training completed meal preparation, meal service, dishwashing, and end-of-meal sanitization when dietary staff were not available. An anonymous interview stated that nursing staff were cooking for residents and that meals were cold, not edible, and not served on time. Record review showed the evening cook was not scheduled for the first two days reviewed, and the Kitchen Manager stated she began working at the facility after a period when nursing staff were cooking because of a lack of dietary staff. Food temperature logs for multiple days in May and June did not document final cooked temperatures or holding temperatures for numerous breakfast, lunch, and dinner meals. The Administrator stated that all facility staff picked up kitchen shifts for about two weeks, that an emergency menu was used, and that nursing staff cooked the meals, but she was not sure whether those staff knew proper food handling protocols or whether someone with a food service certificate was always present. Interviews with an LPN and a CNA showed they washed dishes and performed kitchen duties on several occasions without prior training in general kitchen duties, safe food handling, or sanitization rules. The Administrator later stated that all but two dietary staff were fired, department heads worked in the kitchen, and nursing staff covered kitchen duties until full dietary staffing was hired. A review of the dietary coverage schedule showed multiple meal services were prepared, served, and sanitized by staff such as the SDC, ADON, BOM, MDS Coordinator, SSD, DON, Admissions, housekeeper, medical records staff, CNAs, QMAs, and other non-dietary personnel. The facility’s dietary orientation requirements included sanitization rules, tray setup, food preparation principles, therapeutic diets, proper storage, equipment use, and kitchen shutdown procedures, but the nursing skills checklists provided did not include those dietary skills.
Dishwasher Not Competent to Verify QUAT Sanitizer Strength
Penalty
Summary
The facility failed to ensure that one of ten dishwashers was competent in food and nutrition service duties when Dishwasher 2 did not know the proper sanitizer test strip to use for the quaternary ammonium (QUAT) sanitizer and did not know the procedure for testing the sanitizer strength. During a kitchen tour and interview, two sink areas were observed: one three-compartment sink area used to clean and sanitize cooking pots and pans by hand, and a separate area used to clean and sanitize residents’ dishes and utensils with the dishwasher. During observation in the three-compartment sink area, Dishwasher 2 demonstrated how he normally tested the pink chemical sanitizing solution by removing a paper test strip from a bottle labeled Ecolab Chlorine Test Strip and dipping it into the solution. The strip did not change color, and Dishwasher 2 stated it was supposed to turn purple immediately and that he did not know how long to keep it in the solution. He also stated he could not remember the last time he received in-service training on testing the sanitizing solution. The Director of Food and Nutrition Services stated the test strip used was not the correct strip, that the bottle had expired in 2019, and that the facility was out of the correct QUAT sanitizer test strips. The Director also stated there was no skill check in place for verifying the QUAT sanitizing solution and that the dishwasher was required to be competent in checking the solution to ensure it remained in the critical 150-400 PPM range.
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