These 4 F-Tags are grouped together as they relate to Food and Drink, which each resident receives and the community is responsible for providing.

F-804: What is required?

There are two areas covered in this regulation.
The first area is concerned with the methods of storage and preparation used in the facility to ensure there is a minimal loss of nutrients.

• The community must provide each resident with food that is prepared via methods that conserve the food’s nutritive value, flavor and appearance. This means the facility must ensure that the nutritive value of food items is not compromised or destroyed due to prolonged food storage, light and air exposure, or cooking foods in large volumes of water, or holding foods on a steam table.

The second area requires providers to ensure that food is appetizing to residents, palatable and served at appropriate temperatures for residents to enjoy. Per the Centers for Medicare and Medicaid Interpretive Guidance (IG), ensuring that food items are tasty helps to improve residents’ nutrition and hydration status, which in turn provides the benefits of preventing illness or injury, and helping to heal issues the resident may be experiencing.

• The facility must provide residents with food and drinks that are palatable, attractive and at a safe and appetizing temperature. The IG emphasizes the need for a balance to be struck between ensuring the food is served at a temperature that is appetizing to residents, but also minimizes the risk for scalding and burns.

It is important to recognize that if a facility serves a hot beverage to a resident that results in a risk or an actual burn, there is a likelihood of a negative outcome not only for the resident but possibly the community as well. There are an increasing number of citations under F804 for issues related to hot beverages and spills. We know these types of incidents can also be cited under F689, Free of Accident Hazards/ Supervision/ Devices, so it is important to monitor hot beverage temperatures when offering them to residents, and provide the necessary monitoring or assistance to prevent a burn or other negative outcome. If a resident insists on consuming very hot coffee, it is the community’s responsibility to let the resident know of the risk involved and to provide a cup that decreases the risk of spills. Just serving lukewarm coffee to the resident does not solve the problem. Rather, it may upset the resident.
There are many opportunities during an annual inspection or survey for issues in these areas to be identified by surveyors. These include:

• Resident interviews
• Group interviews, such as the Resident Council Meeting
• Review of the Resident Council Meeting Minutes that could indicate complaints about food temperatures, food palatability, etc. that have not been resolved
• Surveyor observations in the kitchen and interviews with staff
• Surveyor observation that food served is not being eaten
• Surveyor observation that there is a delay in meals being served to the residents in a timely manner

For example, during meal service, the surveyor observed staff take temperatures of food prior to serving, but not after the last meal was served, so there was no documentation of end of service temperatures. The surveyor interviewed the resident who received the last tray during meal service and asked how the food was. The resident replied that the food could be warmer. Other residents were interviewed and stated that the food is often not warm and alternatives are not offered.

As you can see from these citations, it is relatively easy to identify when there are issues with food temperatures or palatability in a community. If a surveyor can find all of these issues in only a few days, then communities should also be able to identify any issues and implement corrective actions to provide a dining experience where residents enjoy their food and drinks.

So, Food Committee meetings and other feedback from residents must be addressed timely manner in order to maintain a high standard of service. Conducting internal audits utilizing the actual forms that surveyors use, such as the CMS Dining Observation audit tool and the Kitchen/Food Services Observation tool, can help you maintain compliance with regulations, but more importantly, provide meals to the residents that meet all expectations.

F-805: What is required?

This tag is about serving meals that meet residents’ needs according to their assessed ability to chew and swallow foods. More specifically, this tag focuses on ensuring residents receive food that is safe for them to eat.

F-805 specifically states, “Each resident receives, and the facility provides food prepared in a form designed to meet individual needs.” The requirement further states that surveyors need to:

• 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?

While some residents may not have difficulty eating the typical meals you serve, others with various conditions could have issues chewing or swallowing certain foods. Your dining team needs to ensure that those residents have meals that they can eat safely while reducing the risk of choking or aspiration.

Special diets:

Residents may require texture modification for a variety of reasons; dental issues, memory loss, stroke, and ear, nose and throat cancers can all lead to chewing and swallowing challenges.

Modified-texture diets are used when an individual suffers from dysphagia, which is when someone has difficulty chewing or swallowing. These difficulties may be common in senior living communities, so your dining team must know how to properly prepare modified-texture meals. Studies* have found that a modified-texture diet with fortified foods improves dietary intake, nutritional status and quality of life for elderly residents with dysphagia.

There are many types of modified-texture diets. Texture modification ranges from softening and chopping into bite-sized pieces and progresses towards a full puree. Texture modification can be done to almost any food as long as the person preparing the food knows how to soften, enhance flavor, and create consistent textures using a variety of juices, broths, gravies and thickening agents added to the modified food.

The IDDSI* (International Dysphagia Diet Standardization Initiative) initiated an effort to create a “new global standardized terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures.” The Academy of Nutrition and Dietetics has removed all other texture modified diets from its Nutrition Care Manual in favor of the IDDSI texture standards, so IDDSI should be referenced when training new staff.

Modified foods can look eye-appealing and be tasty. Different spices and combining colorful foods and paying attention to presentation (e.g. piping techniques) can make these foods appetizing to the residents.

Finger foods that are well-thought out and prepared can also help residents with dementia at meal time. Often, residents in different stages of dementia face mealtime challenges, like getting food, being distracted, having trouble using utensils, refusing to sit and refusing food. Finger foods that don’t require a fork and knife may encourage residents with dementia to eat more often. The dining team is responsible for producing finger foods that are appropriate, safe and appetizing for these residents.

https://pubmed.ncbi.nlm.nih.gov/19266119/https://iddsi.org/Framework