Apr 9, 2020
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Questions we frequently receive

Our team answers many questions from facilities and consumers, and we’ve included some of the most common questions here. Don’t see your question? Ask us here.

Questions from Healthcare Professionals


Q: Our menus are prepared by our food vendor. They include many items that our residents do not like and the vendor refuses to make individual facility changes. My administrator has instructed me to go ahead and make changes. May I do this?

A: The menus served in long-term care must meet federal regulation (and any state regulations that may be more strict), along with the U.S. RDA for the population in the facility. They must also be appropriate for the resident population, prepared in advance, and followed. Review the F363 Menus and Nutritional Adequacy requirement, your state regulation for menu requirements, and discuss any proposed menu changes with the dietitian. The dietitian needs to approve any menus or proposed menu changes to ensure they are nutritionally equivalent to the original items and that therapeutic diet menus are appropriately completed.


Q: When should foodservice workers wear disposable gloves?

A: Gloves must be worn whenever a worker is directly handling a food item. Workers must wash their hands before putting gloves on. Gloves are not a substitute for appropriate and thorough handwashing. Hands must be washed when changing gloves. Replace gloves at least hourly or when changing food preparation tasks, after sneezing, coughing, or touching hair, face, and any other contaminated surfaces.

Q: When using the two-stage cooling process, what if we can’t get the temperature of the food to 70° F within the first two hours?

A: The two-stage cooling process is the rapid cooling of a food product through the temperature danger zone. (Check with your state health department to verify the temperature danger zone for your state). You must cool a food item from 135° F to 70° F within two hours and from 70° F to 41° F within four hours. If the temperature of 70° F or below has not been reached within the first two hours, you may reheat the food one time only and try cooling by a different method, or you must discard the product.

Q: We recently had a resident suffer a second-degree burn on his inner thighs after spilling 150° coffee into his lap. Is there any regulation as to how hot a hot beverage or other hot food should be or a maximum temperature?

A: To the best of our knowledge, there is no regulation stipulating an upper level for hot foods or beverages. Coupled with the requirement to keep hot foods and beverages at both safe and palatable levels of 135° or greater, there can be a concern of how hot is “too hot.” While many people like their coffee or other hot beverage in the 170° to 200° range, this can present a risk to residents who are cognitively impaired, have weakness or are fatigued, have difficulty with motor skills or simply require assistance to eat and drink. These residents need to be monitored closely by staff at meals — perhaps including this risk in the resident’s individual care plan and conducting a staff training program on how to safely serve hot beverages or soups. Many facilities have adopted a policy of hot beverages leaving the kitchen between 130° to 135°. We suggest you discuss developing a policy that is appropriate to your facility residents, as well as a training program for staff with your administrator, Director of Nursing and Dietitian.

Q: We recently received an F371 tag for a resident who requests her food “lukewarm.” We prepare her tray anywhere from 30 to 60 minutes ahead of her receiving it. Hot foods are usually between 100° and 120° by this time and cold foods are usually 55° to 70°. She is then served the tray and — since she prefers to eat very slowly (and without assistance from staff) — we leave the tray with her as long as she wants, which is sometimes up to 2 hours after being served. The survey cited F371 and that all hot foods had to be 135° or greater, but this was done at the resident’s request. Doesn’t the resident have a choice in this matter?

A: F371 does stipulate that foods (both hot and cold) are served at safe and palatable temperatures. According to the Federal Food Code, this is 135° or greater for hot foods (especially potentially hazardous hot foods, or PHF) and 41° or less for cold foods. However, it is the resident’s right to have foods served to her at a temperature that she prefers. This should be clearly addressed in her care plan with regular reviews to see that the goals and approaches continue to be appropriate and meeting her needs. Also, chart notes should clearly indicate this preference and how you are handling it. We would suggest a limit of 2 hours on food that is left in the danger zone of between 41° and 135° — as this is the upper limits of safety for preventing pathogen growth in PHF. This may have been the surveyor’s primary concern. It’s always good to ask questions and fully understand the surveyor’s concerns before the exit conference.


Q: Our facility was recently cited for not addressing weight gain in an overweight resident. The resident did not have any of the “significant” weight gains that we look for monthly (e.g. 5 percent or greater in 1 month, 7.5 percent or greater in 3 months, and 10% or greater in 6 months). She went from 155 to 173 pounds in a nine-month period. The resident is on a general diet and enjoys her meals thoroughly, as well as the foods provided at activities and that her family brings in. Is this appropriate?

A: The F325 Guidelines for Surveyors are in the process of being rewritten and finalized to more fully address a “continuous, progressive or insidious weight gain or loss” — in addition to the “significant weight change parameters” we are accustomed to and that you have referred to. There are many factors that can impact a resident’s weight, including medication side effects, resident’s own wishes and plan, medical diagnoses and any chronic conditions, and any current functional or psychological considerations. These should be fully evaluated by the dietetics professional, with specific goals and plan, and indicating what can be anticipated for the resident weight in the future. We do need to be looking for these UWLs and UWGs on a regular basis. Our staff routinely looks for any weight “trends” occurring over the past year, as well as any of the “significant weight changes” in 1, 3, and 6 months. There is no set standard for “trends;” however, your resident would fit into this category. Some dietitians look for a continuous 1 to 3 pound gain every month for 6 months or so.

Q: Our medical director states he wants the menus in our facility to have between 1400 to 1700 calories. He feels the current menus (the general menus contain between 2000 and 2300 calories) are too much for his geriatric residents and is concerned it will lead to obesity, worsening coronary diseases, more Type II Diabetes, etc. However, our state regulations specify a minimum of various types of foods be served to our residents daily and the residents like our menus the way they are. What can I do?

A: You do have to follow regulatory guidelines for the menus, based on federal guidelines as well as any state guidelines. You might use the Limited Concentrated Sweets or Consistent Carbohydrate diet with skim milk and limited fats to help limit calories for those whose excess weight is a health concern. This would bring calories down to possibly 1600 to 1900 calories a day. It’s important to remember that residents have the right to have a diet and menu that they prefer and may also eat a variety of snacks at activities or other social events as well as foods brought in by visitors. Appropriate lower-calorie snacks should be available for residents at activities with counseling by nurses or other professional staff of the possible problems associated with eating foods not on their diet or too many calories. And, of course, the care plan needs to address non-compliance to diet or concern for weight gains. We suggest you explain these options to the Administrator as well as the medical director and see what plans can be put in place that will meet the state and federal regulations as well as address the physician’s concerns.

Questions from Consumers

Q: If we forget to thaw a frozen turkey in the refrigerator, are there any other safe methods for proper thawing?

A: There are three other methods you may use to safely thaw the frozen turkey. First, you may thaw under drinkable running water at a temperature of 70° F or below with sufficient water pressure to agitate and float off loose food particles into overflow. Just remember, if the temperature exceeds 70° F, the food item may begin to cook. Second, you may thaw in a microwave when the food will be immediately transferred to conventional cooking facilities as part of a continuous cooking process or when the entire uninterrupted cooking process takes place in the microwave oven. Lastly, you may thaw as part of the conventional cooking process. Never thaw at room temperature. Bacteria multiply and grow rapidly when exposed to warm temperatures.

Q: I’m confused when I go shopping with some of the terminology I see. One package says “Sell-By” another says “Best Before” or “Use By.” What does it all mean?

A: “Sell-By” date tells the store how long to display the product for sale. You should buy the product before the date expires. A “Best if Used By (or before)” date is recommended for best flavor or quality. It is not a purchase or safety date. A “Use-By” date is the last date recommended for the use of the product while at peak quality. The manufacturers of the product have determined the date. “Closed or coded dates” are packing numbers for use by the manufacturer. This type of dating might appear on shelf-stable products such as cans and boxes of food.

Q: My 86-year-old mother has been in a nursing home for 6 months now. She is diabetic, not on insulin and can be a rather picky eater. She is on an 1800-calorie Diabetic diet and is told by the dietitian that she can’t have some of her favorite foods because “she is diabetic.” She weighs 160 pounds and is a little overweight, but likes to have a donut every morning with her breakfast. I have talked to the dietary manager about this, but am not getting anywhere with our concern.

A: In long-term care facilities, the accepted and preferred standard is to use what is called “a liberalized diet approach.” Where “ADA” diets were once the gold standard for diabetic care, now there are so many more resources available to help control blood sugar levels in diabetes mellitus — such as, being able to monitor closely and address blood sugar levels with accuchecks as well as there now being many more medications that can help improve blood sugar levels. We find that the majority of residents with diabetes in long-term care facilities do well with a liberal diet such as Low Concentrated Sweets or Consistent Carbohydrate diets. Many factors need to be considered with a therapeutic diet for diabetes or any medical condition—including, but not limited to quality of life concerns, resident food preferences, religious or cultural customs, appetite and food intake, and concerns for pressure ulcers or other nutrition risks, as well as Resident’s Rights. We suggest you talk with the administrator regarding your concerns and ask if it’s possible to liberalize the diet your mother is on and allow her some of the foods she is accustomed to eating if she were home.