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Mike: Welcome back, everybody. It’s that time again. That’s right. It’s F-Tag Friday on Cosmic Soup, so thanks for joining us today as we continue on our mission to venture into the unknown and explore the unsolved mysteries of the fabled F-Tags.

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Mike: As always, with me here in the Cosmic F-Tag Soup is licensed nursing home administrator, registered dietitian, and VP of Health Services for 3rdPlus and Culinary Coach, Randi Saeter. Hey, Randi. Welcome back to the Soup. Honored to have you here as always.

Randi: Yeah, thank you. I’m glad to be here.

Mike: Yeah. Well, this F-Tag thing is going pretty dang well, if I do say so myself. What do we have on the show today? I think we’re going to talk about a few F-Tags, right?

Randi: We are. We’re going to talk about four of them today.

Mike: Oh, my gosh! Four?!

Randi: Yeah, it’s a lot, but they’re a little bit related, so I thought, “Well, let’s talk about all these at the same time.” It’s 804 through 807 today.

Mike: Okay.

Randi: Yeah.

Mike: Break these down for us. What exactly is the content of said F-Tags today?

Randi: Well, we’re going to talk a little bit about the nutritive value of what needs to be in your menus and the food that you serve in terms of those requirements. We’re going to talk a little bit about foods and the mechanically altered or special diets, then some allergies and things like that, and also hydration – today.

Mike: Okay. Yeah. Well, since there is so much of this, I’m just going to turn this over to you and let you run loose with this stuff.

Randi: Absolutely. In F804, the first area is concerned with the methods of storage and preparation used in the community to make sure that the food stays nutritive, that there’s no nutritive value lost during, again, the storage and preparation. The community has to then offer the resident food that is prepared using methods that conserve that nutritive value, flavor, and appearance, which is important, I think, because we don’t want to, again, serve substandard food that doesn’t look appetizing.

This means that the community has to ensure that, during cooking, that it’s not compromised or destroyed due to prolonged food storage or light and air exposure. That means having the food sit out for a long time before it gets served or cooking food.

You’ve probably seen this, Mike. When you cook food in large volumes of water, it reduces the flavor profile. That includes, too, holding food in a steamed table for a length of time.

Mike: [Loud exhale] Can I rant for a second, Randi?

Randi: Yes.

Mike: Can I?

Randi: Yes, please.

Mike: Okay. All right. Everybody, listen up because this just blows my mind.

I can’t tell you how many times I’ve walked into a kitchen and they have these really, really super (like $15,000, $20,000) combi ovens and somebody is cooking green beans at 8 o’clock in the morning that they’re going to serve at dinner. Because they’re so afraid they’re going to fall behind on their day, they’ve got to cook all their stuff in the morning. Stop it!

Randi: Yeah.

Mike: I don’t even understand the mentality behind it. For instance, somebody will put a chicken breast in there, and they’ll cook it for like 12 hours, or they’ll leave stuff out on the counter. In the restaurant business, we all know what heat lamp fries are or heat lamp bacon, right?

Randi: Mm-hmm.

Mike: Stuff just gets sometimes prepared far too far in advance, or it just sits around for so long. Yeah. Or some of these old-school institutional methods of, for instance, boiling green beans until they just turn into a pile of brown mush.

Randi: Yeah.

Mike: You are degrading not only the quality and esthetic taste of the foods, but you’re losing straight-up nutrients. As far as storage goes, yeah, I walk into a walk-in freezer and there are boxes that are just open and the contents are exposed. They’re dried out and they’re nasty, or they’re just not stored in the proper vessels. Things like fish will be left in their plastic bags and not put on ice. Just all kinds of stuff that I see. I can’t imagine not getting F-Tag violations on this stuff.

Randi: Yeah. That is so disappointing. It’s kind of like, if you think about it, if we don’t want to eat it, why would our residents want to eat that?

Mike: Yeah. I approach it, of course, as a chef from the esthetic value, but really, in terms of these particular F-Tags, there is a loss of nutrients that are associated with basically mishandling of product.

Randi: Mm-hmm. Absolutely. Oh, and let’s talk about the temperatures, too. We want to serve food that is at the right temperature. We don’t want to serve food that’s cold when it’s supposed to be hot, and vice versa. That also is part of that guidance is that you have to make sure the temperatures are up to par because otherwise, it’s not going to taste good, and then also it could be unsafe.

Mike: Yeah. Yeah, foodborne illness and all that kind of stuff.

Randi: Mm-hmm. Yeah.

Mike: [Laughter] I’m sorry. I just keep thinking about stuff on a steam table for like nine hours, turning colors, and otherwise delicious food is just bad. That’s again one of the things. Stuff will sit out in steam wells or in serving vessels, not at the proper temperature.

Randi: Yeah.

Mike: Again, a very common thing that I am just shocked more places aren’t getting served F-Tag violations for because I know it happens.

Randi: Yeah.

Mike: I have seen it, and I have called it out more times than I want to admit.

Randi: Exactly. I have, too. You just want to say, “What are you doing?”

[Laughter]

Mike: What are you doing?!

Randi: Yes.

Mike: All right.

Randi: Yes. Another thing, too, that really bothers me, I know that (in the communities) we want to make sure that the residents are not spilling coffee, for example. This topic is related to temperature. We don’t want them to get burns because, if they spill hot coffee, we know they can get burned. But at the same time, we don’t want to serve them cold coffee either. We don’t want to do that.

A lot of communities have gone to that extent where they’re serving coffee at 150 degrees in order to make sure that the residents (just in case they spill) won’t get burned. I think that’s awful because if I’m drinking coffee, I mean, yes, I’ll have an iced coffee from time to time, but that’s different. I want to make sure that my coffee is hot.

Mike: Yeah.

Randi: That, too, has a lot to do with palatability. It may not be a foodborne illness issue, but again this is more the dignity, right? It’s dignity. Serve me a dignified cup of coffee that is hot.

Mike: Yes. Hey, guys. It’s not rocket science. It’s coffee.

Randi: Yeah.

Mike: Granted, I have seen people. We’ve all heard the infamous McDonald’s $8 million lawsuit coffee.

Randi: Yeah.

Mike: That coffee was at, like, 225 degrees or some absurd number. Don’t do that.

Randi: No.

Mike: But a hot cup of coffee, if you have concerns, serve it in a proper vessel.

Randi: Yes.

Mike: Maybe let it cool down a little bit before the resident gets their hands on it.

Randi: Right.

Mike: I get it. There is a legitimate fear of injury or there is a legitimate fear of legalities, but these are super basic skills—

Randi: They are.

Mike: –that should not require this level of attention.

Randi: Yeah.

Mike: Sadly, because there are violations, now we have these F-Tags.

Randi: Mm-hmm.

Mike: Let’s move on then to the next F-Tag.

Randi: Yes, so the F805 refers then to special diets, food, and the forum to meet individual needs (is how it’s worded). That just refers to then we need to make sure we serve food that is safe to chew and swallow for the residents. If they’re having a lesser ability to chew and swallow, then we need to make those modifications.

Basically, it also includes then surveyors coming in, and they will look at what you are serving. Is it safe? Has the resident been assessed for their abilities to chew and swallow? They’re making observations to make sure that they’re receiving the correct type of food in terms of the mechanically altered and even the therapeutic diets as well.

Mike: I would assume that, as a relative newb to this industry myself, the dysphagia, dysphasia diet, I assume, is specifically one that is a challenging one to make sure that you adhere to, correct?

Randi: It is. It can be very, very challenging. You’re right. A lot of the residents receive the modified diet textures based on dental issues, memory loss. They may have had a stroke. They may have had ear, nose, and throat cancers, so then they have an inability to swallow properly. Then they would get what we call dysphagia (which means difficulty swallowing) type of diet in order to make sure that then they can consume food in a safe manner.

Mike: Yes.

Randi: That’s what it means. Mm-hmm.

Mike: It still needs to be nutritious, delicious, and prepared to the best skill set possible.

Randi: It does. It has to still be eye-appealing and be tasty. I know that sometimes maybe dining staff don’t want to taste their own food when they’re making it, but I think it’s important, if not crucial, to taste your dysphasia diets to make sure they have the correct amount of spice – not hot spice, of course, but seasonings – and also the presentation that it looks attractive on the plate.

Mike: Man, the scoop and plop – it’s a thing.

[Laughter]

Mike: We need to make some more efforts to make the food look appealing, for sure.

Randi: We do.

Mike: Something that I think a lot of people don’t think about is those people that can’t chew or that they can’t swallow properly. That doesn’t mean that they’re not people, that they don’t have tastebuds, and that they don’t still want to get what enjoyment out of their food they could. This particular F-Tag really covers the fact that this needs to happen in the appropriate fashion.

Randi: It does, and also another area of it (when we talk about special diets) is finger foods.

Mike: Oh, yeah.

Randi: If someone has memory loss, and they have forgotten how to use a knife and a fork, then we need to accommodate that. Different stages of dementia, they do require different levels of assistance.

Finger foods would definitely be a way to go because then they can be on the go and eat at the same time. That’s perfectly okay in the senior living community. If your mom doesn’t want to sit down and finish a meal within 20 minutes – she wants to walk around and look at things at the same time – let’s accommodate that to make sure then that she gets the adequate nutrition that she needs.

Mike: That’s not necessarily saying—I incorrectly assumed at one point that when we’re talking about finger foods or things that have been basically manipulated into a different sense. You don’t have to create an entirely different menu item out of it. You can just modify an existing kind of a thing.

Let’s say that you have a chicken breast, for instance, that can’t be cut up with a knife and fork.

Randi: Yeah.

Mike: You can cut that chicken breast into strips that can be held by hand.

Randi: Yes.

Mike: Or have variants of those foods so that, from a dignity standpoint, they’re still getting the same food as everyone else. It’s just in a different form for them.

Randi: Exactly. Exactly.

Mike: Awesome.

Randi: Yeah.

Mike: Moving on—

Randi: Yeah.

Mike: 806, is that? See, guys. We’re cruising through these F-Tags.

Randi: [Laughter]

Mike: Settle down. It’s okay.

Randi: Yes, absolutely. 806 talks about resident allergies, preferences, and substitutes. We, of course, need to make sure that nobody receives something they’re not supposed to have, right?

Mike: Right.

Randi: It talks about that, even intolerances, and then the preferences, as well as the allergies. We are responsible, in a community, of being aware of what they’re allergic to, for example, and then providing appropriate alternatives. The food alternative then also has to be consistent with usual food items provided by the community. Again, they should not be receiving something completely different from what the rest of the residents are receiving.

If a resident doesn’t like or is allergic to orange juice, for example, then they can substitute another type of juice that contains Vitamin C and that is perfectly okay then because that’s an appropriate substitute. Whatever you need to do in order to accommodate is what’s important.

Mike: I think that one of the things that I’ve run into, even in the standard restaurant industry, is when we talk about allergies, for instance. Not just likes or dislikes, but legitimate reasons why people wouldn’t want to eat certain foods, whether or not it’s a cultural issue, a political issue, an allergy issue, or a nutrient issue.

Randi: Mm-hmm.

Mike: Sometimes employees get really irritated. “Oh, my god. I have another allergy request,” or “Oh, my god. I have this or that.”

In a skilled nursing environment, this is crucial.

Randi: Yeah.

Mike: It’s always crucial, but even more so in these particular instances. Not only should you because it’s the right thing to do, but you are legally obligated to make sure that you go above and beyond to ensure the safety of the residents. At the bare minimum, it’s a safety issue sometimes.

Randi: It definitely is. Can you only imagine if someone gets served something that they’re highly allergic to and they have an allergic reaction? God forbid they end up almost being close to dying. That’s the worst-case scenario, but I want to bring it up because it’s real.

Mike: Yeah.

Randi: That’s why it’s so important to pay attention to these allergies. What is recommended in the senior living communities is that they have stickers, typically, in their electronic charts. When I say stickers, I mean like an alert. Not only does it say they’re allergic to, for example, fish, but it also will have to include what type of reaction is it that they would get and then what is the intervention.

If you need to have an EpiPen on your med cart or Benadryl, even, then you need to know. The staff needs to know what they’re supposed to do just in case there is an allergic reaction. That can happen at any time. That can happen in the dining room. Again, God forbid that happens, but again it’s a possibility anywhere you go.

Mike: It really is. What’s scary about it is sometimes people develop allergies later on that they didn’t previously have. As a foodservice worker myself for years, you have to start tuning yourself to really be aware of the ingredients that are in the products you buy.

If you make something from scratch, you have way more control over what’s going out on a plate. But if you buy a bunch of prefab food, if you’re not familiar with every element that’s in that prefab food, that can be a whole can of worms.

I think having staff that understands certain elements of food is crucial. If you have people on board that aren’t aware of what allergens may be present in certain foods, you need to make sure that you have that addressed.

Randi: Yeah. Absolutely. Also, too, when we talk about preferences, there are so many vegetarians now and even vegans.

Mike: Yeah.

Randi: You have to accommodate that as much as you can. Also, in some communities, they require Kosher food. Are you capable of providing that? That’s something you have to ask before you admit that resident as well. You have to be prepared at all times to accommodate.

Mike: Yeah.

Randi: A multitude of things, for sure.

Mike: I assume that because of the critical implementation standards of this particular F-Tag, this is probably not something you see a ton of violations on, I hope.

Randi: Not a ton, but I have seen some at times.

Mike: Oh!

Randi: And I’ve seen people with allergic reactions as well because it starts from the kitchen, right? They need to know what this person is allergic to.

Mike: Right.

Randi: On the meal card it needs to say, “Absolutely no mushrooms,” for example, but I have seen people with allergic reactions because they did receive that allergen. It’s devastating when it’s going on. Thankfully, I’ve never seen anyone pass away because of an allergic reaction, but it’s been pretty upsetting to observe that.

Mike: Yeah.

Randi: You do not want that.

Mike: Yeah, and I always tell my kitchen staff. For instance, let’s say that you make a dish and it’s not supposed to have an ingredient in it, right?

Randi: Yeah.

Mike: You throw mushrooms in there or throw tomatoes on there. Guys, you can’t just pick that stuff out and call it good. If it’s an allergy issue, it’s not a matter of just not wanting to eat it. It can’t touch stuff.

Randi: Yes, exactly.

Mike: Especially things like shellfish and things like peanut or tree nut allergies are highly toxic to people. Even being in proximity to those elements can create a reaction. If for some reason you make a little tiny boo-boo – well, actually it’s not a little tiny boo-boo. It’s a potentially a big boo-boo.

Randi: Yeah.

Mike: Start over. Start over.

Randi: Yes.

Mike: That’s the best thing you can do is start over because it’s not worth somebody’s life, or it’s not worth your livelihood because of just a simple mistake that happen. Mistakes do happen. You just have to correct them in the proper fashion.

Randi: Absolutely. Then also it’s so important to meet with the residents as soon as they admit to your community because then you can discover these types of things that you need to be made aware of from day one.

Mike: Yes.

Randi: The nursing staff, you need to let them know, “Please, please communicate these allergies to the kitchen staff right away so we can be on high alert and make sure that they don’t receive those food items.”

Mike: Enough said there.

Randi: Yes.

Mike: Closing it out, number 807, what do we got?

Randi: Yes, so we have drinks available to meet the needs, the preferences, and hydration needs of the residents. This just quickly talks about providing enough water and other liquids consistent with the resident needs and preferences in order then to sufficiently maintain their hydration status. Yeah, I mean that makes sense, right?

You want to make sure that people have enough to drink. If they’re on a food restriction, they don’t get too much to drink, right? But yeah, we want to make sure that they’re offered fluids that can help them not develop urinary tract infections, pneumonias, or skin breakdown.

We know that hydration status is so important when they’re already compromised coming into a skilled nursing community. We want to just do prevention from the get-go, so that’s why it’s so important to offer, offer, offer fluids in any shape or form you can imagine. It doesn’t just have to be water. It doesn’t just have to be juices and things like that. It could be broths, popsicles, or ice cream.

Mike: How about margaritas?

Randi: [Laughter] Maybe mock-margaritas.

Mike: [Laughter] Sorry, guys. I tried. Hey, what am I going to do?

Randi: Yes. Alcohol too, from time to time, is okay in the senior living community with a doctor’s order. A little side note there.

Mike: Disclaimer.

Randi: Yeah, disclaimer. But yeah, just in different forms, even ice cream, so whatever they like. Again, this is why it’s so important to meet with the resident or the families to make sure you get a history. Make sure you even get their preferences from the get-go so they don’t get several days without getting what they like and then they could potentially end up in a more compromised position if they don’t get that. That’s what this one is all about.

Mike: Moral of the story: Keep them hydrated. I would think of probably the ones that are the easier ones to maintain. That would be one that you shouldn’t have a whole ton of problem with.

Randi: You shouldn’t, but there are a lot of residents that come in and, when you get older, you don’t have the sense of thirst like you did when you were younger.

Mike: Right.

Randi: A lot of elderly do not drink enough. Sometimes, it presents to be a challenge.

Mike: Okay.

Randi: It’s the community’s responsibility to go in and offer on a frequent basis. We usually say when you visit the resident in their room, bring a glass of water with you (or whatever that they prefer), so you always have those checkpoints where you offer. That way you can help prevent then dehydration, which again, as we know, can lead to so many other issues.

Mike: If Mr. Parker doesn’t ask for something to drink, that doesn’t mean he doesn’t need something to drink.

Randi: That’s exactly right. That is exactly right. Offer enough fluids on the tray. Offer fluids between meals and with medication pass. Make sure you stand there and wait for them to drink it before you leave their bedside. Just different little tricks to make sure they get enough.

Mike: There you go, guys. Proactive versus reactive.

Randi: Mm-hmm.

Mike: Thanks, Randi.

Randi: Mm-hmm. Yeah.

Mike: That was four F-Tags in a relatively short amount of time, but they did all tie in together.

Randi: Yes.

Mike: I’m glad that you presented them in a fashion that we could bang a few of these out and let people know how they relate to each other.

Looking forward to the next F-Tag Friday. Thanks, again. We’ll talk to you again real soon.

Randi: Thank you so much. Have a good day.

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Mike: Well, that was a whole lot of stuff to throw at you all at the end of your week, but I’ve got faith that you took it all in and now it’s all second nature, right? Let’s be honest. It probably already was because you’re that awesome.

We appreciate you taking the time to hang out with us. We’ve got so much more in store for you in our future installments of F-Tag Friday. For now, relax, go enjoy your weekend, and we’ll talk to you soon on Cosmic Soup.

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