F812 Food Procurement, Store/Prepare/Serve-Sanitary is ranked as the most frequently cited deficiency in Standard Surveys so far for the 2023 fiscal year (CASPER 5/7/23). F812 has been cited in 39% of these surveys.

No other dietary tags rank in the top 25, although some have resulted in immediate jeopardy citations.

Understanding the Regulatory Requirements and Avoiding Citation

There are 15 F-tags included in the Food and Nutrition Services category of federal regulations. The purposes or intent of these regulations are to ensure:

      • Facility staff support the nutritional well-being of the residents while respecting an individual’s right to make choices about his/her diet;
      • There is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services;
      • Menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines;
      • Nutritive value of food is not compromised and destroyed because of prolonged: (1) Food storage, light, and air exposure; or (2) Cooking of foods in a large volume of water; or (3) Holding on steam table;
      • Residents receive and consume foods in the appropriate form, and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident’s treatment, plan of care, in accordance with his/her goals and preferences;
      • Residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised; and
      • The facility: (1) Obtains food for resident consumption from sources approved or considered satisfactory by Federal, State or local authorities; (2) Follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility’s food handling processes; and, (3) Ensures food safety is maintained when implementing various culture change initiatives, such as when serving buffet style from a portable steam table, or during a potluck.

F812 – Food Safety Requirements

The facility must:

  1. Procure food from sources approved or considered satisfactory by federal, state or local authorities.
    1. This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
    2. This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
    3. This provision does not preclude residents from consuming foods not procured by the facility.
  2. Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

To cite F812, the surveyor’s investigation will generally show the facility failed to do any one or more of the following:

      • Procure, store, handle, prepare, distribute, and serve food in accordance with the standards summarized in this guidance; or
      • Maintain ‘potentially hazardous foods’ (PHF) and ‘time/temperature controlled for safety’ (TCS) foods at safe temperatures, at or below 41 degrees F (for cold foods) or at or above 135 degrees F (for hot foods) except during preparation, cooking, or cooling, and ensure that PHF/TCS food plated for transport was not out of temperature control for more than four hours from the time it is plated; or
      • Store raw foods (e.g., meats, fish) in a manner to reduce the risk of contamination of cooked or ready-to-eat foods; or
      • Cook food to the appropriate temperature to kill pathogenic microorganisms that may cause foodborne illness; or
      • Cool food in a manner that prevents the growth of pathogenic microorganisms; or
      • Utilize proper personal hygiene practices (e.g., proper hand washing and the appropriate use of gloves) to prevent contamination of food; and
      • Use and maintain equipment and food contact surfaces (e.g., cutting boards, dishes, and utensils) to prevent cross-contamination.

Example of F812 Immediate Jeopardy (L) – Dish Sanitation

Based on observation, review of facility policy, review of manufacturer’s guidelines, review of professional reference, and staff interview, the facility failed failure to ensure sanitization of dishware (utensils, dishes, pots/pan) used to serve residents, staff, and visitors in 1 of 1 kitchen. Failure to ensure the mechanical dishwashing machine maintains the correct hot water temperature required by manufacturer’s directions to destroy pathogens may result in the spread of illness and/or foodborne illness to residents, visitors, or staff During the on-site recertification survey, the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from observation of the dishwashing machine temperatures not being maintained at the manufacturer’s recommendations. This finding placed residents in immediate danger due to the potential of spread of illness and/or foodborne illnesses from improper sanitization.

Appendix PP Guidance in F812 regarding dish sanitation:

Machine Washing and Sanitizing – Dishwashing machines use either heat or chemical sanitization methods. Manufacturer’s instructions must always be followed. The following are general recommendations according to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code for each method.

      • High Temperature Dishwasher (heat sanitization):
        • Wash – 150-165 degrees F;
        • Final Rinse – 180 degrees F;

(160 degrees F at the rack level/dish surface reflects 180 degrees F at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured); or 165 degrees F for a stationary rack, single temperature machine.

      • Low Temperature Dishwasher (chemical sanitization):
        • Wash 120 degrees F; and
        • Final Rinse – 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse.

The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer’s guidelines.

F803 Menus and Nutritional Adequacy

Menus must:

  1. Meet the nutritional needs of residents in accordance with established
  2. national guidelines;
  3. Be prepared in advance;
  4. Be followed;
  5. Reflect, based on a facility’s reasonable efforts, the religious, cultural
  6. and ethnic needs of the resident population, as well as input received from residents
  7. and resident groups;
  8. Be updated periodically;
  9. Be reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy; and
  10. Nothing in this paragraph should be construed to limit the resident’s right to make personal dietary choices.

Surveyor probes for citing F803

Through interviews, observations and record reviews determine if:

      • Residents are receiving food in the amount, type, consistency and frequency to maintain normal body weight and acceptable nutritional values.
      • Resident preferences and needs are incorporated into the development of the individual food plan?
      • A resident chooses not to consume certain foods or food groups such as the resident is a vegetarian or does not eat dairy, how does the facility ensure the resident’s menu and/or the individual resident’s food plan meets his or her nutritional needs?
      • Menus meet basic nutritional needs by providing meals based on individual nutritional assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue?

Example #1 of F803 Immediate Jeopardy (K)

Based on observation, interview, and record review the facility failed to ensure food was prepared according to the required menu for modified food textures and thickened liquid consistencies and as ordered by the physician for 3 of 3 residents. This failure placed 27 total residents assessed to require altered food textures and/or thickened liquid consistencies, for safe swallowing, at risk for choking while eating, aspiration (inhalation of food/fluids into the lungs), pneumonia, and/or death.

Example #2 of F803 Immediate Jeopardy (J)

The facility failed to provide a mechanical soft diet, causing a resident to choke, become unresponsive, and require hospitalization. The resident had a physician’s order for a mechanical soft/chopped diet. The resident was served coleslaw which had not been properly prepared per the physician order. The facility failed to provide a mechanical diet for texture according to the facility policy for therapeutic diets. The resident choked for approximately five minutes prior to becoming unresponsive and emergency medical services (EMS) documented suffocation/asphyxia. The resident was hospitalized for six days. The hospital discharge summary record documented a diagnosis of acute encephalopathy (damage that affects the brain) present upon arrival to the hospital, likely secondary to suspected aspiration pneumonia versus dysphagia with choking.

F805 Food and drink

Each resident receives and the facility provides food prepared in a form designed to meet individual needs.

 Surveyor probes for citing F805

      • Observe meals and food preparation to assure the food is prepared and appropriate to meet resident’s needs and according to their assessment and care plan.
      • Are there any observations of residents having difficulty chewing or swallowing their food?
      • Is the food cut, chopped, ground, or pureed for individual resident’s needs?

 Example of F805 Immediate Jeopardy (J)

Based on observation, interview, and record review, the facility failed to provide fluids in the prescribed texture/consistency for 1 of 2 residents reviewed for food/beverages served in proper form. This deficient practice resulted in the delivery of fluid of inappropriate consistency which resulted in episodes of choking and aspiration (accidental breathing of food/fluid into the lungs, which can cause pneumonia), and the likelihood of aspiration pneumonia and potential for death.

How to Avoid These Citations

      • Survey Pathways: CMS provides copies of the tools used by surveyors to complete the required tasks. These pathways consist of observations and interviews that follow the guidelines of multiple regulations and indicate which F-tag(s) should be cited if criteria is not met. Facilities should consider using the survey pathways as their own audit tools to determine compliance and prevention of citation. Survey Pathway – Kitchen Observation Form CMS-20055
      • SOM Appendix PP Access: Ensure your dietary manager has access to the Food and Nutrition section of the SOM Appendix PP and shares/educates the dietary department team members accordingly.
      • SOM Appendix PP web links: Within the Food and Nutrition regulations there are web links containing additional information and resources. Ensure dietary manager accesses these as indicated. Here are a couple of them: http://www.FoodSafety.gov and https://www.fda.gov/food/fda-food-code/food-code-2017.
      • Manufacturer’s Recommendations: Throughout the SOM Appendix PP you find ‘according to manufacturer’s recommendations’ referenced. Be sure that dietary staff have access to equipment manuals and are following the proper recommendations/instructions.
      • Ongoing Education/Training: Consider annual skills competency review and testing for dietary staff, including equipment use, key policies and meal prep/service.
      • Routine Preventive Maintenance: Ensure that dietary equipment receives routine preventive maintenance in accordance with manufacturer’s recommendations and facility policy.
      • Policies: Review policies annually and as needed (change in equipment, vendors, etc.)

Join us May 23 2023 for the webinar “Designs for Well Rounded Dietary Departments” as part of the Mission Possible department head series. Access past sessions in this series. Contact Proactive for survey readiness assistance including policy and procedure review, competency based training, mock survey and plan of correction support.

Written By: Angie Hamer, RN, RAC-CT
Clinical Consultant

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