PEACHTREE CITY, GA-SOUTHLAND HEALTH AND REHABILITATION

A review of the Resident Council Meetings Minutes from January 2021 to December 2021 noted the following:

On 4/07/21 residents had concerns about food presentation. Residents stated sometimes they could not tell what the meal was supposed to be by looking at the food presented on the tray.

Residents reported that soups and drinks were watered down, and breaded food with breakfast was soggy.

On 4/13/21 residents stated the above concerns, but additionally stated that the eggs served during
breakfast were watery. It was noted that Dietician discussed food concerns with group members.

On 4/21/21 residents discussed food concerns to include meat being too tough to cut at times, food
presentation, eggs, and watery juice. Food Service Manager made a visit to the meeting and discussed food preferences and food portions. On 5/20/21 residents discussed food quality.

On 6/10/21 residents discussed food presentation. On 7/08/21 residents requested baked potatoes to be placed on the menu and how they disliked diced potatoes served on the menu.

On 9/15/21, residents discussed that breads were soggy when served on places and requested that breads served at breakfast time be placed in plastic bags.

On 10/07/21 residents discussed that grits and oatmeal were served cold and hard, and portion sizes were too small. Residents requested cabbage greens to be served more often and staff was forgetting to serve condiments. Food Service Manager was noted to have attended the meeting to respond to food service requests.

On 11/04/21 residents discussed that potatoes were not fully cooked. Residents stated that they understood that kitchen did not have some foods but requested that if kitchen staff could do better with the foods that they did have it would be appreciated. Residents also discussed that pizza was a blob of dough and did not resemble pizza at all. Rice did not resemble rice. Chili was cold as if it had been refrigerated.

Residents further discussed that they had not had soup in a while, there were no tops or straws for cups, and the food was awful at best. Residents also stated that they would like cereal to be added to regular breakfast and portion sizes of meats are too small or too difficult to eat.

On 12/09/21 residents discussed that grits and oatmeal was inedible and they would like cereal instead since the breakfast was always cold. Residents approved to begin to request department managers into the resident council meetings. Administrator discussed convenience menu to residents. Residents also discussed that the grill cheese was always burned as well as pizza. Residents further discussed not receiving soups or vegetables. Residents also discussed that weekend meals are terrible. 

A test tray observation was started on 1/06/22 at 1:00 p.m. During this observation the meal was placed on the cart at 1:00 p.m. After all trays on the cart were passed to residents, the test tray was removed and sampled by anonymous staff at 1:28 p.m. They stated that the sweet potato was a little under cooked, the corn was dry and cooked too long. Staff stated that the chicken was okay but missing something. Staff reported that food was better than it had been in the past but that residents still complained about the food all the time.

During an interview on 1/06/22 at 4:36 p.m., Food Service Manager (FSM) AA stated that she attended the Resident Council Meetings and the few complaints that she was aware of had been addressed. FSM AA stated that she would provide documentation showing concerns were addressed. The information was requested twice, but no documentation was provided.

During an interview on 1/07/22 at 9:48 a.m., Registered Dietitian (RD) EE stated the expectation was the food should be warm and palatable when served to residents. RD EE stated that if foods were not warm when served, then the nursing staff was expected to warm the food in the microwave in the nurse pantry and take the temperature of the food prior to service. RD EE stated in regard to food that was not served tender enough to cut with plastic knife, from this point forward, the dietary department would monitor residents who needed more assistance.

During an interview on 1/07/22 at 2:05 p.m., the Administrator stated that it was her expectation that staff would document grievances that were voiced by residents. The grievances were to be delegated to the appropriate department, the grievance would be investigated, a correction plan would be completed, and the resolution would be reported to the person who filed the grievance.

The Administrator further stated that it was the expectation that the dietary manager was to review the grievances filed for the dietary department and respond appropriately to the grievances filed.

Resident Review: 

Findings include:
1. Record review revealed that R#48 was admitted to the facility on [DATE].

A review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R#48 revealed a Brief Interview for Mental Status (BIMS) score of 15, meaning that R#48 is cognitively intact.

During an interview on 01/04/22 12:28 p.m., R#48 stated that the Resident Council had a meeting last month. R#48 stated that the biggest complaint in the past meetings was about the food. R#48 stated that the residents have requested to have cereal and milk in the mornings for breakfast, but it has not happened.

2. Record review revealed that R#32 was admitted to the facility on [DATE].
A review of the Annual MDS dated [DATE] for R#32 revealed a BIMS score of 13, indicating mild cognitive impairment.

On 1/04/22 at 1:29 p.m. R#32 was observed eating her lunch. She stated that food was not good; the food was cold and that the meat was tough. She stated that the taste overall was just not good.

On 1/05/22 at 2:35 p.m. R#32 stated that she had chicken for lunch and that it was tough and dry, and the potato was not cooked well.

3. Record review revealed that R#296 was readmitted to the facility on [DATE].
A review of the Annual MDS dated [DATE] for R#296 revealed a BIMS score of 13, indicating mild cognitive impairment.
Review of R#296’s medical record revealed no evidence of her likes and/or dislikes.
Review of the meal ticket for R#296 dated 1/7/22 revealed NAS diet with no evidence of dislikes or
preferences listed.

During an interview with R#296 on 1/4/22 at 10:10 a.m., she stated that the food was cold (all meals), she was served items that she cannot eat (bacon, ham), and that the meals were served on Styrofoam-like take out trays with plastic silverware for all meals. She said that she did not like this, and that she did not even go to restaurants that serve on Styrofoam-like containers.

During lunch observation on 1/4/22 at 1:15 p.m., R#296 was served chili, peas and a baked potato. Resident said she did not like chili (gives her heartburn). Reviewed R#296’s lunch meal ticket which only listed her name, room number with diet ordered; however, no likes and/or dislikes listed.

During breakfast observation on 1/5/22 at 9:13 a.m., R#296’s meal ticket was observed to be blank other than diet listed. She was served on Styrofoam-like carry out tray. She was served grits, which appeared to be thick and pasty white colored. During interview with R#296 on 1/5/22 at 9:18 a.m., she said that she did not like grits and that nobody from dietary had spoken with her about her dislikes.

During observation and interview with R#296 on 1/5/22 at 1:32 p.m., her lunch tray observed with one roll, unknown substance of ground meat which appeared hard on top with gravy, mashed potatoes with gravy, and a dark gray colored unknown type of beans serving. The resident said that the tea was kind of sweet but that she liked unsweet tea. She said, What does not kill you, makes you stronger. Resident stated, while pointing to the unknown substance of ground meat, that it looked very hard.

During observation of breakfast on 1/6/22 at 9:30 a.m., R#296 was sitting up in her bed, eating
approximately her meal. The tray had grits on it which the resident did not touch. Her meal ticket remained without preferences.

During observation of lunch on 1/6/22 at 1:30 p.m., R #296 was sitting up in her wheelchair, served her lunch tray which contained sweet tea, a small corn on the cob, half of sweet potato, and a small piece of chicken breast. She said that the food was lukewarm and that the sweet tea would have to be diluted with water.

4. Record review revealed that R#67 was readmitted to the facility on [DATE].

Review of R#67’s Admission MDS assessment dated [DATE] revealed a BIMS score of 15, meaning that R#67 is cognitively intact.

Review of the meal ticket for R#67 dated 1/7/22 revealed regular diet with dislikes for eggs and grits.

During initial tour of the facility on 1/4/22 between 10:00 a.m.-11:00 a.m., R#67 stated that the facility food was not good (cold food).

During observation and resident interview on 1/4/22 at 1:30 p.m., R#67 said that she ate only the vegetable and bake potatoes for lunch due to the chili giving her heartburn.

During lunch observation on 1/6/22 at 1:15 p.m., revealed R#67 sitting up in her recliner, finishing her lunch, in which she was served a small corn on the cob, half of a sweet potato, red velvet cake, yogurt, and chicken. The resident stated that she did not enjoy the chicken, that it was hard to cut, so she did not eat it. The chicken was observed and appeared to be dry.

5. Record review revealed that R#85 was admitted to the facility on [DATE] with a diagnosis of diabetes, and below the knee amputation (BKA).

Review of the Quarterly MDS assessment dated [DATE] revealed that R#85 had a BIMS of 15, meaning that R#85 is cognitively intact.

Review of the January 2022 Physician Orders revealed that R#85 was to receive large portions of
vegetables with her meals. (Originally ordered 11/5/21.)

Review of the tray ticket dated 1/7/22 revealed that R#85 was to receive large portions of vegetables, and that R#85 disliked peas and carrots.

During lunch observation on 1/4/22 at 1:13 p.m., R#85 was sitting in her room eating her lunch off a Styrofoam-like take out tray. She stated that the food was not good, had no flavor and was cold.

During observation, she said that she loved vegetables and that she did not get any vegetables on her tray. No vegetables were observed on her lunch tray. She stated that she does not eat chili, which was served for lunch, due to it giving her heartburn. She said that when she asks for an alternate vegetable, she received a sandwich.

During lunch observation and resident interview on 1/5/22 at 1:22 p.m., R#85 sitting in her wheelchair in her room eating lunch from a Styrofoam-type take out tray. The tray contained a small amount of chopped meat, and mash potatoes with brown gravy; however, no other vegetables were noted on R#85’s tray. During observation, R#85’s tray ticket was reviewed, and revealed large portions of vegetables were to be served. R#85 said that she did not like eating off Styrofoam and was unsure how long she had been eating with plastic silverware. R#85 said that she did not get large portions of vegetables, but she loved them. She further stated that the meat was a mystery meat, that it does not look like meat loaf.

During lunch observation on 1/6/22 at 1:20 p.m., R#85 was sitting in her room eating lunch from a
Styrofoam-like take out tray. The tray contained a small ear of corn, half of a sweet potato, red velvet cake, a roll, and a small piece of chicken breast, which appeared to be dry and hard. The resident said that the chicken looked so tough. R#85’s tray ticket review revealed large portions of vegetables.

6. Record review revealed that R#44 was admitted to the facility on [DATE].
Review of the Quarterly MDS assessment dated [DATE] revealed that R#44 had a BIMS of 15, meaning that R#44 is cognitively intact.

On 1/4/22 at 11:27 a.m. in an interview with R#44, he stated the food wasn’t consistent. He stated that he was on a diet and was told he can’t have fried chicken, but he receives fried fish some days. He stated the kitchen is constantly saying they don’t have some items.

During an observation and interview with R#44 on 1/4/22 at 12:29 p.m. he was served chili and half of a baked potato for lunch. He stated that he doesn’t really eat chili, so he requested a second baked potato. He was served an additional baked potato but was told by staff that he couldn’t get any extra butter because there wasn’t any left.

Review of facility policy titled Menus with copyright date of 2020 revealed that it was the intent of the facility to provide meals based on a menu following established national guidelines. Further review revealed that menu items will be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature, and within cost or budget projections. The menu alternates of similar nutritive value will be offered to patients daily and as needed.