Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated complaint survey completed on June 22, 2022, it was determined that Glen Brook Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Based on observation, test tray results, resident and staff interview and a review of minutes from the facility's food committee meetings it was determined that the facility failed to provide food and beverage that are palatable, and at a safe and appetizing temperature and appearance.

Findings include:

According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of "Danger Zone", found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness.

During individual interviews with residents conducted on June 22, 2022, with residents (Residents 1, 2, and 3) the residents reported that the food served in the facility was often served at unpalatable temperatures, and was visually unappetizing, and was tasteless.

A review of the minutes from the facility's food committee meeting that was conducted on April 11, 2022, revealed that Resident 1 reported that the vegetables were under seasoned and overcooked.

The first East Hall cart left the kitchen at 12:00 PM, arrived on the unit at 12:03 PM, and the staff began tray pass at 12:04 PM. The final resident tray was passed at 12:21 PM and the test tray was pulled to obtain food temperatures.

A test tray was conducted, on June 22, 2022, on East Hall, at 12:31 PM, at the time the last resident began eating, revealed the following:

The lunch meal consisted of roast turkey with gravy, mashed potatoes, Capri blend vegetables, pumpkin cheesecake, milk, apple juice, and coffee. The food temperatures that were obtained at the start of tray-line, at 12:00 PM, in the kitchen, were as follows: roast turkey with gravy was 178 degrees Fahrenheit, mashed potatoes were at 178 degrees Fahrenheit, Carpi blend vegetables were at 185 degrees Fahrenheit, and pumpkin cheesecake was at 45 degrees Fahrenheit (acceptable temperature for cold foods should be less than 41 degrees Fahrenheit).

The facility's food service manager accompanied and confirmed the test tray temperatures were as follows: roasted turkey with gravy was at 137 degrees Fahrenheit, mashed potatoes were at 135 degrees Fahrenheit, Capri blend vegetables were at 137 degrees Fahrenheit, pumpkin cheesecake was at 66 degrees Fahrenheit (acceptable temperature for cold foods should be less than 41 degrees Fahrenheit), milk was at 48 degrees Fahrenheit, apple juice was at 46 degrees Fahrenheit, and coffee was at 137 degrees Fahrenheit.

Observation revealed that the overall appearance of the meal was not visually appealing. . When tasted, the roasted turkey with gravy and mashed potatoes were bland. Observed that the pumpkin cheesecake dessert was not covered on the tray, which had the potential to introduce contaminants, and appeared to be melted, and served at an unpalatable temperature.

Interview with the food service manager on June 22, 2022, at 12:30 PM, confirmed that the lunch meal lacked visual appeal and items were not appetizing to taste, and that some of the items served at the lunch meal were not served at palatable temperatures.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 211.6(c) Dietary services.

 Plan of Correction - To be completed: 07/19/2022

Residents 1,2, and 3 shall be visited by the Registered Dietician and offered food and beverage that was palatable, safe and appetizing temperature and appearance.

The Dietician/designee will visit residents with a BIMS of >13 to identify if there are any concerns with food and beverage served related to palatability and whether it is appetizing in appearance and temperature.

The Regional Dietary Manager/ Designee will in-service the dietary staff on the guidelines to serve food and beverage that is palatable, safe and appetizing temperatures and appearance.

Monthly Food Committee Meetings will be held with residents and staff to address any consistent concerns related to palatability and whether it is appetizing in appearance and temperature.

Dietician/Guest Service Representative/designee will complete random audits and observations of resident meals to verify that the food and beverage served is palatable, safe with appetizing temperature and appearance. Audits shall be done daily x4 days, weekly x4, monthly x3 or until consistent substantial compliance has been achieved.

FSD/Designee will obtain food temps on random test trays daily x 4 days ,then weekly x4 weeks then monthly x3 to verify compliance. Findings of these audits shall be sent to the QAPI Committee and discussed at the monthly resident council meeting.

Target date 7/19/2022

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