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Based on observation, interview, and record review the facility failed to ensure:

1. The Registered Dietitian did not provide regularly scheduled oversight and guidance to the Food and Nutrition Services per State Title 22 licensure requirements. (Refer to A 619);

2. The Food Service Manager did not effectively monitor the dietetic service operations in accordance with the Food Service Manager job description and professional standards of practice. (Refer to A 620);

3. There was not an effective staff training and competency program in place, and Dietary staff did not safely and effectively carry out the functions of food and nutrition services per policy and professional standards of practice. (Refer to A 622);

4. There was not an effective system in place to meet the nutritional needs of patients with a longer length of stay. (Refer to A 629);

5. The facility failed to ensure the Food and Nutrition Services (FANS) Department used data to identify opportunities for improvement, plan and implement changes, and monitor for quantifiable improvement in the quality of care (Refer to A 283).

6. Equipment was not maintained to ensure and acceptable level of safety and quality.

These systemic problems resulted in failure to ensure food and dietetic services were provided in a safe and effective manner.

Based on staff interviews and record reviews, the facility failed to ensure the Food and Nutrition Services (FANS) Department used data to identify opportunities for improvement, plan and implement changes, and monitor for quantifiable improvement in in the quality of care.

This failure has the potential to leave patient care issues unaddressed, and to result in suboptimal nutrition care and food safety for all patients receiving care in the hospital.

Findings:

Review of the Food and Nutrition Services (FANS) contract with an outside vendor, titled Master Agreement for Patient and Retail Food Services, effective date 4/1/22, showed "Quality Assurance Program. If Supplier (contractor) is providing goods or services to Customer (Hospital) that are used in a licensed or accredited healthcare facility, Supplier shall participate in the KP (Kaiser Permanente) Quality Assurance Program."


A review of a facility document provided by the Director of Quality Management (DQM), titled "Hospital Quality and Patient Safety Program Description Annual Work Plan and Evaluation," dated 5/14/24 showed its purpose was to "provide the mechanism for improving hospital quality and safety ..."


During an interview with the Director of Quality Management (DQM) on 2/12/25 10:05 am, she stated the kitchen came and reported to the Quality Management Committee on a regularly scheduled basis to report quality issues/concerns, and they came once or twice a year or as needed. She stated the committee depended on the DFS to provide oversight of the kitchen/ FANS contract and to follow up with issues. The FANS QAPI report for May 2024 was later provided (see below). During follow-up interview with the DQM on 2/13/25 at 1:40 pm, she stated she did further research, and FANS also reported their QAPI efforts to the Quality Committee in October each year. The October 2024 report was not provided.


Review of a FANS policy and procedure titled Quality Management Committee, revised 5/24, showed "Policy: The Food and Nutrition Services (FANS) Quality Management (QM) Committee is responsible for ensuring that there is an integrated, continuous cycle of objective FANS systems evaluation and process improvement procedures (QAPI)." "Purpose: to define in writing the role and scope of the QM Committee in developing monitoring, overseeing, and assessing process improvement systems in alignment with Departmental and Medical Center goals and objectives." It further states the QM will meet monthly to analyze data collected through quality monitors, identify opportunities for system improvement, develop and implement strategies for system improvement and evaluate the effects of actions taken, develop the annual FANS Performance Improvement activities ..."


During an interview with the FSM on 2/12/25 at 10:20 am, he was asked what QAPI his department was working on. He replied, "I'd have to go look."


Patient Meal Test Trays -

During an interview with the Director of Food & Ancillary Services (DFS) on 2/11/25 at 9:05 am, he was asked what QAPI the FANS department was working on. In a concurrent record review, the DFS showed a binder with test tray (a sample meal tray that follows meal production, tray assembly, and delivery processes and is evaluated for timeliness, appearance, temperature, flavor and texture, with purpose to simulate the patient experience) documentation, which mostly showed issues with cold food. He stated the test trays were done by the kitchen supervisors. It was unknown to him how often the test trays were done or if there were any issues. The DFS stated he had no evidence that anything was done when a problem was identified. He further stated the kitchen was also doing QAPI with food delivery truck inspections to make sure delivery trucks were in good shape and there was no compromised food. When asked if the facility has had any problems with the delivery trucks, he replied, no.


During a follow up interview on 2/13/25 at 1:40 pm the DFS stated the facility had no specific policy about test-trays. He provided the Kaiser "Quality Management Committee FNS Policy." He stated test tray data was reported to the FANS contractor, but not to Kaiser.


During an interview with Patient #31 on 2/13/25 at 8:55 am, he stated his food was often cold and he couldn't eat it once it got cold. He stated staff did not reheat his food or request another tray of food item for him. He stated the cold food made him sad, especially when it was a food he really liked and would like to eat more of, but when it was cold he couldn't eat it (Cross Reference A-0629).


Patient Feedback -

During an interview with the DFS on 2/11/25 at 9:05 am, he stated FANS performance was no longer measured in the new (national) patient survey system. He explained that beginning 10/24, the FANS Department received "real time feedback from patients" through his rounding with patients regarding FNS and clinical nutrition care. He generally saw 3 to 10 patients each time he came to the facility, 3-4 times monthly. He asked patients about food temperature, food quality, food selection, patient identifiers, courtesy and respect. He stated he put that data on his dashboard. When asked about any trends he responded that (September/October 2024) patient meal ordering (room service menu) showed "there's no selection." When they investigated this, they found through diet office software reports that catering associates were not seeing patients and offering them food choices, and this was addressed/resolved.


Clinical Nutrition - During an interview with Registered Dietitian (RD) 1 on 2/11/25 at 3:11 pm, she stated the clinical dietitians monitored food/drug interactions (example Coumadin) and provided education as needed in person within 24 hours or by mail. Threshold ~95%. She stated they have had no events with patient diet-drug interaction events in the facility. RD 1 stated she had a couple of other QAPI projects but "I can't remember what they are." She stated she reported QAPI to the Pharmacy and Therapeutics Committee, to the clinical nutrition manager at Riverside, and to the clinical nutrition manager at the FANS contracted company. RD 1 added that she and RD 2 did monthly chart reviews that were reported to the FANS contract company and included: use of patient identifiers, fully completed nutrition assessments, recommendation were followed up/addressed, nutrition assessment/reassessment guidelines were followed. She stated the threshold was >90% and they did well with that.


Sanitation:

During the survey beginning 2/10/25, the FANS kitchen was found unsanitary (Cross Reference A-619, A-620).


During an interview with the Director of Food and Ancillary Services (DFS) on 2/10/25 at 2:30 pm, he stated he did not keep any records of his quarterly kitchen inspections.


During an interview with the Food Services Manager (FSM) on 2/10/25 at 3:00 pm, he stated he did a morning inspection of the kitchen daily but he didn't write it down. Deep cleaning of equipment and kitchen areas was assigned by managers/ supervisors based on need.


During an interview with the Registered Dietitian (RD) 1 on 2/11/25 at 3:11 pm, she stated the RDs were not involved in kitchen management, and did not provide oversight to the kitchen.


Review of a document provided by the DQM titled "MVMC Food and Nutrition Services County Health Inspection - Executive Summary," dated 5/2/24 showed a report of evidence of rodents in the FANS kitchen on 1/29/24, actions taken to intervene, subsequent county health inspections where "The County Health Inspector identified additional problems" and scheduled another site visit. Recommendations showed FANS continued to "complete (unnamed) log and clean and sanitize all contact food surface areas prior to opening the department each morning." They were approved by the county health inspector on 4/15/24, and they discontinued their log on 4/17/24 since no rodent activity had been seen in the kitchen since 4/8/24.


Review of an additional spreadsheet provided by the DQM titled "Department of Heath Inspection - Food Service - Moreno Valley, dated 3/14/24 listed health department citations with unknown citation dates, but with resolution dates spanning 3/14/24 to 3/16/24. Citations included but were not limited to inadequate 3-compartment sink incoming water temperature, steamers leaking on to the floor, rodents in the kitchen - all areas, storage of personal food, food stored on floor, food labeling and dating, tape in multiple locations (cross contamination), deteriorated gasket seals, frozen condensation in the walk-in freezer. Many of these issues continued to be observed during the survey beginning 2/10/25.


Review of an additional document provided by the DQM showed title page "Food & Nutrition Services (FANS) Moreno Valley QOC (Quality of Care) 2024" followed by a document titled "ABM (FANS contractor) Kaiser Moreno Valley Dashboard." It showed data points regarding:

*1. Patients receiving house/ non-select meals (versus room service selected meals), monthly dates ranging from 9/23 to 8/24, showed the average percentage of patients who received non-select (not room service patient-selected) meals rose from a low of 19% (desirable) in 11/23 to 49% in 8/24 (undesirable) at breakfast, desirable scores at lunch, and desirable scores at dinner.

*2. Sanitation Audit Scores

*a. Kitchen Production Sanitation Audit Scores, with 25 dates ranging 2/8/23 to 9/20/24, showed a sanitation goal 90% or above, with average score of 93%. Issues/Barriers/Concerns - Kitchen Production general comments were mostly single line comments such as 3/10/24 "The door from the cafe needs to be clean," and 5/9/24 "The convenience cart will be cleaned on Saturday." Yet during survey beginning 2/10/25, surveyors found the kitchen unsanitary (Cross Reference A-0620).

*b. Retail Service (Cafeteria) Sanitation Audit Scores, with 25 dates ranging 2/12/23 to 9/20/24, showed an average score of 96%, with comments such as 1/6/24 "The hood needs to be cleaned;" and 9/20/24 "The hood vent is going to get clean on Saturday (9/21/2024)." Yet during survey beginning 2/10/25, surveyors found the cafeteria unsanitary (Cross Reference A-0620).

*c. Trayline/ Dishroom Audit Scores, with 25 dates ranging 2/8/23 to 9/20/24, showed an average score of 93%, with comments such as 1/6/24 "Ceiling vents need to be cleaned. And we need lids for trash cans," and 2/8/24 "Drains on the bottom of the steam table will be clean on 2/10/24."

*3. National Food Quality and Courtesy Scores - The "ABM Kaiser Moreno Valley Dashboard" also showed data points for NRC (National Research Corporation) healthcare quality patient surveys regarding food quality and food courtesy, dated monthly 9/23 to 8/24. Scores for patient satisfaction with food quality ranged 49-52%, with Average Quarterly Score for NRC Quality 55, and NRC Quality Ranking 32 percentile for 10/23. Scores for food courtesy ranged 88 to 93% with average quarterly score 92%, and NRC food courtesy goal 94%.

The source of the sanitation audit scores is unknown since the DFS, FSM stated they did not document their kitchen inspections and RD 1 stated she did not provide oversight to the kitchen.

Based on observations, interviews and record reviews, the facility failed to ensure the Registered Dietitian (RD) provided regularly scheduled oversight and guidance to the Food and Nutrition Services per California State Title 22 licensure requirements. This failure to provide oversight resulted in:

1. Ineffective systems and monitoring to ensure sanitation of the kitchen and professional standards of practice in staff's food handling.

2. Ineffective systems and monitoring to ensure staff training, competency, and professional standards of practice in the department.

3. Ineffective systems and monitoring to ensure Catering Associate staff training and competency on therapeutic diets.

4. Ineffective systems and monitoring to ensure menus provided food variety and met the nutritional needs of patients with longer lengths of stay, regardless of the diet order.

Findings:

Review of California Health and Safety Code 1265.4 showed " (a) A licensed health facility...shall employ a full-time, part-time or consulting dietitian...(b) to supervise dietetic service operations." It's the responsibility of the Registered Dietitian to provide guidance and oversight to the Food and Nutrition Services.

During an interview with the Director Food & Ancillary Service (DFS) on 2/11/25 at 9:07 a.m. he stated, "The Food Service Manager is the primary responsible for the Food and Nutrition Services". The DFS admitted the RDs did not oversight of the Food and Nutrition Services.

On 2/11/25 at 3:12 p.m., an interview was conducted with Registered Dietitian (RD) 1. RD 1 stated she aware of the California Title 22 regulations, that required her to provide oversight the Food and Nutrition Services. She stated her job description showed responsibility for oversight of the kitchen, however, she did not perform this oversight because she was directed by her contract company to only provide clinical nutrition care, and she was further directed not to be involved in any Food and Nutrition management services.

During an interview with the Food Service Manager (FSM) on 2/12/25 at 10:00 a.m., the FSM acknowledged the Registered Dietitian did not involve oversight of the Food and Nutrition Services, staff training, staff competency evaluation, and menu reviewed.

A review of the contract company job description titled, "Food and Nutrition Services - Lead Registered Dietitian", revision date 7/23, provided by the facility, showed "...RESPOSIBILITIES - ESSENTIAL FUNCTIONS: ...Develops menus with Chef/Operations Managers and signs off on nutritional adequacy...Ensures compliance with regulatory agencies. Develops and implements in-service programs according to procedure...Assists with hiring and training new nutrition services and call center staff...Periodically audits menu accuracy; use of standardized recipes; and safe food handling guidelines...Periodically evaluates (tastes) food products. Periodically checks that meal service is provided at designated times in patient areas. Conducts annual performance evaluation process for all call center staff...and ensuring reviews are completed per facility guidelines and time frames...Assists in department and annual facility training programs; conducts nutrition-related in-service training for patient service team..."

1. Kitchen Sanitation and Safe Food Handling Practices

During multiple observations, interviews and record reviews in the Food and Nutrition Services Department beginning 2/10/25 at 9:05 a.m., concerns were identified regarding kitchen sanitation systems, and staff work practices that did not meet professional standards for food safety (Cross Reference A620);

During the initial kitchen tour on 2/10/25, beginning at 9:43 a.m., observations and concurrent interviews were conducted with the Director of Food & Ancillary Services (DFS) and Food Service Manager (FSM) regarding overall kitchen sanitation and cleanliness. There were multiple areas and equipment in the kitchen that were not clean including but not limited to a) build-up of black/brown debris, resembling dust found on the dry storage door frame; food cart in walk-in refrigerator # 3; fan cover at walk-in refrigerator b) grime build up found on walk-in refrigerator number (#) 1 and 3 door's gasket; handles to cabinets in the cold food prep area; c) brown grime build-up found on ice scoop holder; d) black, white, grey substance build-up found on walk in refrigerator # 3 storage shelves; e) 5 cutting boards were marred (disfiguring damage) with brown and black stain on surface. f) the knife rack in the cook's area was not clean, and four out of nine knives in the rack were not clean; g) racks throughout the kitchen had an accumulation of dust and grime, including wire racks for storage of clean equipment, and drying racks in the dish room; h) in the dish room, soiled cloths (collected to be laundered) were not covered; i) two bins located near the three-compartment sink that held "clean" aprons and towels were soiled inside and out; j) unattended soiled rags were left on counters and equipment throughout the kitchen throughout the survey; r) unsanitary ice machine at kitchen; k) Chef 1 with facial hair not wearing beard guard was handling foods. In concurrent interview with the FSM, the FSM stated kitchen needed to be kept clean to prevent cross contamination (bacteria are unintentionally transferred from unsanitary equipment/working surface to another with harmful effect) and could lead to foodborne illnesses (illness that results from ingesting contaminated foods) to patients.

In addition to the sanitation concerns identified above, staff also did not follow safe food handling practices as following.

On 2/10/25, at 10:09 a.m., a concurrent observation and interview was conducted with the Food Service Manager (FSM) at the walk-in refrigerator # (number) 1. There was a food cart near entrance door holding several food items which were undated and unlabeled. In a concurrent interview with the FSM, the FSM stated this food cart was used to defrost food items. The FSM identified those foods items as three sliced beef stored in plastic container, weighing 4 pound each and an opened box of 15 pound pork chorizo bulk. The FSM was unable to demonstrate the date those food items began the thawing process. The FSM stated he need to throw away those meats for food safety.

During an interview, on 2/10/25, at 1:50 p.m., Cook (CK) 5 acknowledged he did not document monitoring the cooling process (refers to the process of cooling food quickly from 135°F to 41°F to minimize bacterial growth. Cooked food left out at room temperature, or not cooled quickly enough can become unsafe to eat in a matter of hours) for Tuna salad or any ambient temperature foods. CK 5 stated the kitchen did not have a log to record ambient food cooling temperatures.

2. Staff training, competency, and professional standards of practice in the department (Cross Reference A-0622)

During an interview on 2/11/25 at 9:05 am, the DFS stated the FANS Department had "Huddle Notes" showing communication with staff, but there was no other documentation of in-services for FANS at that facility.

During an interview with the FSM on 2/12/25 at 10:20 am, he stated in the past 12 months his department had had huddles. He explained did verbal training for staff, but did not document it, and did not document attendance. He stated he covered topics such as handwashing, preventing cross contamination, and safety.

On 2/12/25 at 3:00 pm, a binder of "Huddle" minutes with dates 2/20/24 and ending 10/9/24 were reviewed. They showed a few huddles around August 2024 (8/12/24, 8/16/24) included staff signatures on a sign in form, with minutes showing topics such as soiled equipment, food prep not completed by staff, weekend cleaning, dirty floors and direction to catering associates to please take all patient orders. A review of huddle minutes from March 2024 (3/18/24, 3/28/24) had no record of attendance and showed topics such as labeling and dating food, sink temperatures, cleaning schedules, handwashing, and direction to catering associates to use their script guide when working with patients.

On 2/13/25 at 10:05 am, seven Food and Nutrition Services employee files (CK1, CK3, CK5, FSW1, FSW4, FSW5, FSW9), were reviewed with the DFS. The files showed zero out of eight staff had been evaluated for competency since 2022. The file for FSW 5, hire date 9/23/24, showed she completed an undated "Probationary Competency Assessment" that stated "To successfully complete the probationary period, this test must be taken and passed with a minimum of 88%." There was no evidence the document had been reviewed or evaluated.

Continued review of the staff files showed they variably contained quizzes on topics such as hand washing, dress code, basic food safety, customer service, kitchen safety, fire safety, most quizzes were undated, and many had no name on them. There was no evidence these quizzes had been reviewed by management for correct answers and actual staff competency.

The file for FSW 4 contained a Competency Skills Evaluation (topic IDDSI - dysphagia diets - diets for patients with difficulty swallowing) dated 3/3/22, which showed the staff did not pass the competency. The evaluator's signature was illegible. A note showed "Action Plan - Watch food texture video within one week. Retest in 2 week." There was no evidence this plan was followed up. In a concurrent interview with the DFS, he stated "She is only a dishwasher so she doesn't do this stuff. He was asked if maybe there should there be notes about that, or maybe a different validation form/process for the dishwasher position? The DFS replied "yes."

During continued interview, the DFS agreed that other than competency checklists, none of the staff's competency quizzes showed evidence they were reviewed by leadership for correct answers and actual competence in the subject matter, and annual competencies had not been completed since 2022. The DFS stated "They are supposed to be done every year."

Review of the facility Food and Nutrition Services policy and procedure titled Inservice Education, revision date 5/24, showed "In-service Programs for all employees are conducted each month. The In-service Program is an ongoing educational experience and is planned in advance for one year." Purpose showed to provide ongoing employee development of job skills and knowledge, and "To develop awareness of and compliance with the highest possible standards of nutritional care, food preparation, service and sanitation," The procedure showed the Director assigned responsibility for weekly huddle meetings, and the leader is responsible to determine the topic and agenda, include FANS Quality Management Committee's activities, ensuring all staff sign the attendance record (clinical and food related topics require 100% attendance), and documentation of the education program.

3. Catering Associate staff training and competency on therapeutic diets.

During an interview with RD 1 on 2/11/25 at 3:11 am she stated the RDs provided no oversight to the catering associates. She did not know what training they received. She did not know who educated them about therapeutic diets to help patients make appropriate selections for therapeutic diets. She stated the RDs answered staff questions about diets for patients.

During an interview with the FSM on 2/12/25 at 10:20 am he stated the Catering Associates who helped patients make menu choices were trained by other "seasoned" Catering Associates. He stated RD 1 was involved in training Catering Associates, but they learned about the therapeutic diets through what was available in CBORD (diet office software). If a food was not compliant for a physician-ordered diet order in CBORD, it would be red. Catering Associates had the ability to override CBORD and select non-compliant foods for patients, but they had to initial it when they did that. He stated staff were trained how to contact the RD with questions.

The FSM stated he didn't do any of the training on therapeutic diets with the Catering Associates. He stated "I have a CDM, but I don't think that qualifies me to do training on diets." He stated there was no system of formal staff training set up with the RD except for training on entering isolation rooms and utilizing PPE (Personal Protective Equipment). He stated the RD also provided the training on "Safety" trays, established for patients who might harm themselves or others if they received normal meal service-ware.

During an interview with Food Service Worker (FSW) 9 on 2/12/25 at 3:45 pm, he stated he started as a dishwasher and was promoted to be a Catering Associate. He stated another catering associate trained him, and that kitchen supervisors provided any other help needed, and answered questions about diets. He stated the catering associates trained him about therapeutic diets "They know everything already," and the RD only provided training about PPE and isolation rooms. FSW 9 stated the RD provided them with a list of food substitutions that could be made for patients, and that they were to tell the RDs when they used substitutions. The RDs also taught him about tube feedings and supplements.


4. Patient Menus, Nutrient Analysis, Patient Needs, Length of Stay

Review of a document provided by the facility titled MV 2024 ALOS (Average Length of Stay) showed an average of how long patients stayed admitted in the hospital. In 2024 the monthly ALOS ranged 3.1 to 3.6 days, with an annual average of ~3.4 days.

During an interview with the DFS on 2/11/25 at 9:05 am, he stated they had a two-day house menu cycle, Kaiser-wide (all Kaiser facilities), meaning the house menus were repeated every other day. House menus were the meals sent when the patient had not ordered food from the room service menu. The DFS stated their facility's average length of stay (ALOS) was 2-point something days. When asked what they did for patients who were in the hospital longer than the ALOS he replied "We are creative." He further explained the catering associates "push choice" from the room service menu, customized to the diet order, and they worked with the Registered Dietitians (RDs) to meet patient nutritional needs.

During an interview with the FSM on 2/12/25 at 9:07 a.m., he stated they recently revised their patient standard menus and patient tri-fold room service menu. He stated he and the DFS did the revision, and the facility RDs were not involved.

During an interview with RD 1 on 2/12/25 at 1:00 p.m., she stated she had never seen the three nutrient analysis binders that were provided to the surveyors by the DFM. In a concurrent review of the nutrient analysis for several diets, RD 1 was asked if the calories provided by the Diabetic CC 225 gm diet avg/day (1555 - 1541 Kcal/day), looked about right in relation to the patient nutrition needs she assessed. RD 1 stated the MD orders section in the electronic medical record showed that a Diabetic CC 225 gm diet order would provide approximately 1800 kcals/day and that did not match the nutrient analysis. During a follow-up interview with the DFS on 2/12/25 at 4:00 pm, he stated the facility's nutrient analysis was printed out the previous day from the corporation's nationwide data base. He stated the standard menu was a corporate-wide menu, with only a 2-day menu cycle and it was developed by a corporate-level RD.

During an interview with Registered Dietitian (RD) 1 on 2/11/25 at 3:11 pm she was asked about the two-day menu cycle and she replied, the variety of food for patients who had a longer length of stay (LOS) was "definitely a problem." "Most people don't want to eat the same thing every day." She stated the facility did their best to provide variety with the existing menu. When asked how she worked with these patients with longer LOS she stated the RDs reviewed the diet order, meal intakes, labs, medications, and did a quick mini assessment to evaluate if the patient could have a requested food one time. They adapted what could be provided based on clinical status. They did their best. Sometimes they had to say no.

During a record review and concurrent interview with RD 2 on 2/12/24 at 1:10 pm, the electronic medical record for Patient #31 was reviewed. It showed Patient #31 was admitted on 1/10/25 and had been in the hospital for approximately one month. He was admitted with a diagnosis of Sepsis (severe infection), with Clostridium Difficile (severe, potentially life-threatening diarrhea), a pressure wound, diabetes, Parkinson's disease and peripheral edema. A review of the Nutrition Initial Assessment conducted by RD 1 on 1/13/25 at 3:44 pm showed Patient #31 met the criteria for severe malnutrition with loss of 15% of his body weight in approximately three months, poor meal intakes for greater than seven days, and muscle loss over nine areas of his body per the Nutrition Focused Physical Exam. RD 1 estimated patient #31's energy needs were 1900 to 2800 kilocalories/day, and protein needs at 76 to 91 grams/day based on actual weight. It was noted the patient didn't have teeth, and stated he didn't wear his dentures due to poor fit, and he requested a liquid diet. Meal intakes ranged zero to 30% over six meals, with average intake 9% of food provided. RD 1 recommended pureed or full liquid diet per patient request; Cardiac Diet (low sodium, low cholesterol, no caffeine), "Diabetic Consistent Carbohydrate: 225 gm avg/day (about 1800 calories)," multivitamin and Vitamin C.

During an interview with RD 1 on 2/13/25 at 8:37 am, regarding Patient #31, she stated he had been at the facility for about one month. He requested pureed diet due to missing teeth, variable meal intakes, poor appetite. He received diabetic nutrition supplements three times daily, and he was now drinking it well. His diet order was diet order was Cardiac (low sodium, low cholesterol, no caffeine), Diabetic Consistent Carbohydrate 225 g (about 1800 calories), Pureed. When asked about pureed diet food options during an extended length of stay, RD 1 stated "I only know what I see in the Room Service Choice software program," and the kitchen purchased their pureed food from a vendor. They did not puree food in-house. "He's probably getting the two-day menu over and over again."

A document provided by the Food Service Manager (FSM) titled "Your Choice Room Service Menu," with (possibly) a date "ABM_0422" was reviewed. It showed a variety of breakfast, lunch and dinner food choices with symbols indicating if a food was compliant for heart healthy (cardiac) diets, renal diets, vegan (plant-based) diets and gluten-free diets. It also had numbers in parentheses next to food items, indicating the carbohydrate content of the food for diabetic diets. All foods were available for regular diets. It did not show any pureed food options.

A review of documents titled "Ticket History" dated 2/2/25 through 2/8/25 showed Patient #31 received:
Breakfast house menu 1, three out of seven breakfasts.
Breakfast house menu 2, four out of seven breakfasts.
He received lunch/dinner entrees - Chicken Enchilada 5/14 meals, Chicken with Rice 4/14 meals, Meatloaf 3/14 meals, Chicken with Vegetables 2/14 meals.
He received mashed potatoes with gravy 10/14 lunch/dinner meals.
He received applesauce 17 out of 21 meals.
He received cranberry juice 13/21 meals.
He received fruitable vegetable juice 7/21 meals.
He received a chocolate supplement 21 out of 21 meals.
He received his favorite, tomato soup, one out of 21 meals.


During a telephone interview on 2/14/25 at 10:35 am, RD 1, RD 3, and a facility corporate (national) nutrition manager were asked what the role of the RD should be at the facility. RD 3 stated the facility RDs should provide clinical nutrition care, act as liaison with the medical staff and facility staff, approve menus, provide patient education, staff in-services, and oversight of food services for sanitation, food safety, and ensure regulatory compliance. When asked if that was happening at this facility she replied "No, but it will be soon."

Based on observations, interviews and record reviews, the facility failed to ensure the Food Service Manager (FSM) effectively monitored the dietetic service operations in accordance with the Food Service Manager job description and professional standards of practice when

1. The kitchen was not sanitary.

2. Staff competency assessments were not in place after 2022, and staff food production and sanitation practices were not in accord with regulations or professional standards of practice.

3. Catering Associates did not receive formal training in therapeutic diets by a qualified person, yet had the ability to override the diet office software to provide food non-compliant to the diet order.

These failures had the potential to result in ineffective and inadequate directing of the day-to-day foodservice operations and to ensure the nutritional needs of patients were met in a safe and sanitary manner.

Findings:

During a review of the hospital-provided Job Description, undated, titled "Food and Nutrition Service Manager ", it indicated, " Job Summary: The Food and Nutrition Service Manager- (FNS Manager) is responsible for the management of all food service operations. The FNS Manager will provide leadership for the overall planning, control, financial, evaluation of program(s), service, and materials as they relate to the food service operations... POSITION RESPONSIBILITIES...Monitors training programs to ensure compliance and completion within given time frames; conducts in-service training as required. Follows Universal Precautions/Infection Control Procedures. ...Directs and monitors all patient and retail operations to ensure operations are consistent in each food service area. ...Facilitates the implementation of department policies and procedures to ensure program meet the goals within a clean and safe environment for all service areas...Monitors and inspects food service operations to ensure compliance with criteria for proper licensing and always maintaining regulatory compliance...Monitors service, food production, sanitation, and safety; identifies problems and directs staff as to corrective action to resolve and prevent occurrences. ..."

1. The kitchen was not sanitary.

During the initial kitchen tour on 2/10/25, beginning at 9:43 a.m., observations and concurrent interviews were conducted with the Director of Food & Ancillary Services (DFS) and Food Service Manager (FSM) regarding overall kitchen sanitation and cleanliness. There were multiple areas and equipment in the kitchen that were not clean including but not limited to a) build-up of black/brown debris, resembling dust found on the dry storage door frame; b) multiple beverages(water, juices) found on dry storage floor ; c) black grime found on walk-in refrigerator number (#) 3 door's gasket (a piece of rubber lined with refrigerator's door to prevent cool air sip out refrigerator) ; d) black, white, grey substance build-up found on walk in refrigerator # 3 storage shelves ; e) Dust/dirt found on food cart in walk-in refrigerator # 3; (d) brown grime build-up found on ice scoop holder; f) black grime found on walk-in refrigerator # 1 door's gasket; (g) dust/dirt found on fan cover at walk-in refrigerator #1, (h) a bottle of mustard with used by date: 7/21/24 found at the corner of walk-in refrigerator #1 floor; (i) 5 cutting boards were marred (disfiguring damage) with brown and black stain on surface; (j) two out of two floor drains near the cook prep area had an accumulation of grime; k) three out of three storage tubs in the cook's area were soiled and held soiled serving utensils; l) the knife rack in the cook's area was not clean, and four out of nine knives in the rack were not clean; m) handles to cabinets in the cold food prep area had accumulation of black grime; n) racks throughout the kitchen had an accumulation of dust and grime, including wire racks for storage of clean equipment, and drying racks in the dish room; o) in the dish room, soiled cloths (collected to be laundered) were not covered; p) two bins located near the three-compartment sink that held "clean" aprons and towels were soiled inside and out; q) unattended soiled rags were left on counters and equipment throughout the kitchen throughout the survey; r) unsanitary ice machine at kitchen; s) Chef 1 with facial hair not wearing beard guard was handling foods. In concurrent interview with the FSM, the FSM stated kitchen needed to be kept clean to prevent cross contamination (bacteria are unintentionally transferred from unsanitary equipment/working surface to another with harmful effect) and could lead to foodborne illnesses (illness that results from ingesting contaminated foods) to patients.

During the kitchen tour on 2/10/25, at 10:00 a.m., observations and concurrent interviews were conducted with the FSM regarding food storage in the walk-in refrigerator # (number) 1. There were multiple food items that were not stored properly including but not limited to a) several expired foods found on storage shelves. Those food items were Pizza: must use by 1/30/25; Sliced cheddar cheese: must use by: 2/7/25; Tomato paste: must use by: 2/8/25; Opened canned mandarin oranges stored inside a plastic container: must use by: 2/9/25; opened Shredded Cheddar Cheese stored inside zip lock bag: must use by: 2/5/25.; b) There was a food cart near entrance door holding several food items which were undated and unlabeled. In a concurrent interview with the FSM, the FSM stated this food cart was used to defrost food items. The FSM identified those foods items as three slice beef stored in plastic container, weighing 4 pound each and an opened box of 15-pound pork chorizo bulk. The FSM was unable to demonstrate the date those food items began the thawing process. The FSM stated he need to throw away those meats and expired foods for food safety.

2. Staff competency assessments were not in place after 2022, and staff food production and sanitation practices were not in accord with regulations or professional standards of practice.

During general food production observations throughout the survey, concerns were identified related to staff work practices and staff training and competency. In addition to the sanitation concerns identified above, staff also did not follow ambient food cooling processes to ensure food safety, and did not follow recipes and portion sizes to ensure diet order compliance and nutritional adequacy of diets.

During an interview, on 2/10/25, at 1:50 p.m., Cook (CK) 5 acknowledged he did not document monitoring the cooling process for Tuna salad or any ambient temperature foods. Ck 5 stated the kitchen did not have a log to record ambient food cooling temperatures.

During an observation, on 2/11/25, at 10:52 a.m., Food Service Worker (FSW) 1 did not measure the portion size of Tuna Salad when making Tuna sandwiches. During an additional interview, on 2/11/25, at 12:08 p.m., FSW 1 stated she served 3 slice of Turkey meats instead of 4 slices as directed by the recipe for Turkey sandwich. During an interview and observation, on 2/11/25, at 12:09 p.m., FSW 5 did not follow the recipe for Chef Salad and provided different ingredients than listed in the recipe.

On 2/13/25 at 10:05 a.m., a concurrent interview and record review of seven Food and Nutrition Services employee files (CK1, CK3, CK5, FSW1, FSW4, FSW5, FSW9) were reviewed with the DFS. The files showed zero out of seven staff had been evaluated for competency since 2022. The DFS acknowledged annual competencies had not been by the FSM completed since 2022. The DFS stated "They are supposed to be done every year by FSM."

3. Catering Associates did not receive formal training in therapeutic diets by a qualified person, yet had the ability to override the diet office software to provide food non-compliant to the diet order.

During an interview with the FSM on 2/12/25 at 10:20 am he stated the department had two job descriptions for kitchen staff: 1) Food Service Workers included the catering associates, dishwashers, and cashiers; and 2) Cooks (Hot/Cold food preparation). He stated the Catering Associates helped patients make menu choices and were trained by other "seasoned" Catering Associates. They generally trained for seven days since, unlike other positions in the kitchen, Catering Associates had to learn the diet office software. The FSM stated they learned about the therapeutic diets through what was available in the diet office software and from other catering associates. He stated Catering Associates had the ability to override the diet office software and select non-compliant foods for patients, but they had to initial it when they did that. He stated staff were trained how to contact the RD if they had questions. The FSM stated he didn't do any of the training on therapeutic diets with the Catering Associates. He explained "I have a CDM (Certified Dietary Manager training and certification), but I don't think that qualifies me to do training on diets." He stated there was no system set up for the Registered Dietitian (RD) to provide formal training on therapeutic diets to the catering associates.

During interviews with FSW 9 on 2/12/25 at 3:45 pm, and with FSW 8 on 2/13/25 at 1:00 pm, they stated they were Catering Associates, that other catering associates trained them, and that kitchen supervisors helped and answered their questions as needed. They stated the catering associates trained them about therapeutic diets. FSW 9 stated "They know everything already." FSW 8 and FSW 9 clarified the RD did not train them regarding therapeutic diets, but she did provide training about PPE (personal protective equipment) and isolation rooms.

A review of the Food Service Worker job description, date revised 6/15, did not include any "Responsibilities - Essential Functions" in relation to catering associate's knowledge of therapeutic diets, assisting patients with menu choices, or knowledge of diet office software that was essential to provision of diet order-compliant meals to patients. The "Responsibilities - Essential Functions" does show "Prepares, serves, and delivers food to patients of all ages; Orders daily food and supplies as needed; Utilizes excellent customer service skills at all times; (and) Complies with Federal and State Law..."

Based on observation, interview, and record review the hospital failed to ensure Food and Nutrition Services staff were trained to carry out the functions of department safely and effectively when:


1. Multiple food service workers did not follow professional standards of practice using three separate steps (wash, rinse and sanitize) to clean and sanitize work surfaces. Failure to properly clean work surfaces may result in growth of microorganisms on equipment and could cross-contaminate food.

2. One staff (Food Service Worker 4) did not know that wash water in three-compartment sink had to be maintained at greater than 110°F (degrees Fahrenheit - a measure of temperature), and did not fully submerge washed kitchen equipment in sanitizer;

3. One staff (Food Service Worker 2) did not change soiled gloves and apron or wash his hands before handling clean dishes;


4. One staff (Food Service Worker 3) did not know the correct concentration for sanitizer (a solution used to reduce the number of germs on food contact surfaces to acceptable levels);


5. The facility did not train staff to safely and effectively use vegetable wash according to manufacturer's instructions.


6. Catering Associates did not receive formal training in therapeutic diets by a qualified person, yet had the ability to override the diet office software to provide food that was non-compliant to the diet order.


7. An effective in-service, education and competency program was not in place for the Food and Nutrition Services Department (FANS).


These failures had the potential to result in poor quality food, to cause patients to receive food and portions non-compliant with the diet order, and to cause foodborne illness for patients, staff and visitors who received food from the kitchen, cafeteria, or catering services.


Findings:

Review of the facility contract with an outside vendor for Food and Nutrition Services (FANS), titled Master Agreement for Patient Meal Service and Retail Food Services, effective date 4/1/22, showed "3. Training. If supplier (contracted service) provides services at a Customer facility on a regular basis, Supplier agrees that its personnel performing services at Customer facilities shall undergo the same training that Customer imposes on its own employees and supervisor in similar positions to ensure full compliance with all applicable laws, regulations and KP (Kaiser Permanente) policies."


1. During an interview with Food Service Worker (FSW) 4 in the dish room on 2/10/25 at 10:51 am, she cleaned the patient breakfast meal cart after unloading it. When asked what the process was to clean the cart, she stated she used the red sanitizer bucket (solution and rag) to clean. When asked if she ever used anything else in her cleaning process, she stated "No, just sanitizer." When asked if they ever used soap to clean the carts, FSW 4 stated they only deep clean the carts on the weekends. The process was to remove the racks, clean with soap, then water, then sanitizer. Then dry with a towel to keep them shiny.


On 2/11/25 at 11:02 a.m., FSW 1 was observed using only sanitizer to clean the food preparation counter after preparing Tuna sandwiches. In a concurrent interview, FSW 1 confirmed she only used sanitizer to clean the prep counter.


During an interview in the kitchen with Cook (CK) 4 on 2/10/25 at 2:13 pm he was asked how he cleaned the equipment in the cafeteria. He stated he wiped down equipment with sanitizer. He stated he worked 6:00 am to 2:00 pm (the cafeteria open hours), so when he closed after lunch there was no time to do any cleaning other than to wipe things down with sanitizer. "I only have 15 minutes" (before he was off shift).


During an interview in the kitchen on 2/10/25 at 2:13 pm, FSW 3 stated that at the end of her pm shift, she sanitized all the counters in the whole kitchen using a sanitizer bucket and rags. She stated there were no other steps to the cleaning process. When asked how long the sanitizer needed to stay wet she stated it had to stay wet "for a long time." She allowed the counters to air dry.


During an interview in the cafeteria on 2/10/25 at 2:30 pm, the DFS stated the quat sanitizer wet time was 1 minute.


During an observation in the cook's area on 2/11/25 at 12:18 p.m., Cook (CK) 2 was observed using sanitizer to clean a soiled food preparation counter. In a concurrent interview, CK 2 stated it was her usual practice to only use sanitizer to clean food preparation counters.


During an interview with CK 1 in the cafeteria on 2/10/25 at 2:30 pm, she stated that to clean fixed equipment they checked the sanitizer concentration. She thought the concentration should be "seven." She stated she wiped down the equipment with the sanitizer. When asked if the sanitizer needed to stay wet, she replied it didn't need to stay wet "for any time" that she knew of.


On 2/11/25 at 1:00 p.m., an interview was conducted with the DFS. He stated the standard of practice to clean and sanitize kitchen work surfaces was wash (with detergent), rinse (with clean water), and sanitize (with sanitizer).


During a review of the hospital's policy and procedure (P&P) titled, "Sanitizing Work Surfaces - Use of Sanitizing Pails and Towels", reviewed date 5/24, showed "All work area surfaces will be cleaned with a green bucket (soap for wash), then sanitized utilizing a red bucket (sanitizer). ... Containers of chemical sanitizing solutions in which wet wiping cloths are held between uses shall be stored ...and used in a manner that prevents contamination of food, equipment, utensils, linen and single-serve or single-use articles". "Procedure: ...4. Clean surface before using sanitizing solution. Allow sanitizing solution to dwell on surface, per manufacturer's guideline. Do not rinse off sanitizer. Allow to air dry."


A review of the instructions on the Diversey J-512 Sanitizer container directed that after cleaning equipment, to apply the sanitizer and "Allow surfaces to remain wet for at least 60 seconds."


2. On 2/10/25 at 1:50 p.m., a concurrent observation and interview was conducted with FSW 4 in front of three compartment sinks (three sinks used for cleaning kitchen wares, one for washing, one for rinsing and one for sanitizing) in the kitchen. The sanitizer sink was approximately half full with sanitizer solution, and the washed kitchen wares were only partially submerged in the sanitizer. FSW 4 stated the washed kitchen wares needed to be fully submerged in sanitizer for it to be properly sanitized. When asked about the temperatures of the solutions in the three sink compartments, FSW 4 stated "We don't temp the soap (sink), we temp the rinse water." She stated the sanitizer should be at 57-61 degrees.


A review of the hospital's policy and procedure (P&P) titled, "Manual Ware Washing," revision date 5/24, showed, "2.b.) Fill wash compartment with hot, soapy water from the dispenser (min 110°F). Fill rinse compartment with hot water (min 110°F). Fill sanitizing compartment using quat sanitizer dispenser. Ensure sanitizing solution is not >70 degrees F." "2.k.) Place into sanitizing sink, ...items need to be submerged. ..."


Review of a poster on the wall above the three-compartment sink, provided by the manufacturer, was titled Quaternary Sanitizer, dated 2022 showed "2. Testing must be done in sanitizer solution that is clean fresh and at room temperature 65° - 85°F." The poster directed the process to test the sanitizer concentration including "9. The correct reading (for the test strip) must be 200-400 ppm. If the solution does not meet the 200-400 ppm requirements, test again. Take corrective action if the reading remains out of range."


3. During an observation in the kitchen dish washing area on 2/11/25 at: 12:34 p.m., FSW 2 performed dish washing wearing gloves and a disposable plastic apron. FSW 2 loaded dirty dishes in racks; then he did not change his dirty gloves or soiled apron, and did not wash his hands before putting away clean dishes. In a concurrent interview, the DFS confirmed his observation of FSW 2's actions and instructed FSW 2 that after loading dirty dishes he needed to remove his dirty gloves, his disposable plastic apron, wash his hands, and then put on clean gloves and apron before proceeding to handle clean dishes.


During a review of the hospital's policy and procedure (P&P) titled, "Handwashing Procedures," revision date 5/24, the P&P indicated, " ...Handwashing is performed routinely under conditions of: ...1.2 Between handling soiled utensils or equipment and handling clean food or utensils. ...


4. On 2/10/25 at 10:02 a.m., an interview was conducted with the Food Service Manager (FSM) and FSW 3 in front of the three-compartment sink. FSW 3 was asked to demonstrate checking the concentration of sanitizer in sanitizing sink. FSW stated the sanitizer needed to be above 200 - 500 parts per million (ppm - a unit of measurement) and 500 ppm was the best concentration for sanitizing dish ware. The FSM stated sanitizer concentration should be in the range of 200 -400 ppm. The FSM explained 500 ppm was too strong with sanitizer which could contaminate the kitchen wares.


During a review of the manufacturer poster titled, "Sanitizer" posted above three compartment sinks, the poster indicated, " ...The correct reading must be 200 -400 ppm. ..."


5. The facility did not train staff to safely and effectively use vegetable wash according to manufacturer's instructions.


During an observation in the cook's cold food preparation area on 2/10/25 at 9:30 am, a two-compartment sink with sign posted "Antimicrobial Wash Only" had a build-up of grime and food debris.


During an observation and concurrent interview on 2/10/25 at 10:05 am, the Director of Food and Ancillary Services (DFS) stated staff cleaned and sanitized the sinks prior to each use, and they washed produce with the vegetable wash product daily. He agreed the sinks were not clean.


During an observation and concurrent interview at the vegetable wash sink on 2/11/25 at 1:12 pm, Cook (CK) 1 used a cutting board and knife to cut the stems off two heads of leaf lettuce. She threw the leaves into the bottom of the empty sink and used her hand to direct the vegetable wash solution from the black dispenser tube over the lettuce leaves. She picked up the leaves from the bottom of the sink and put them into a metal pan. Sam her process for using the vegetable wash was correct, and included to cut the stems off the lettuce, put the leaves in the bottom of the sink. "I just rinse them off" with the solution. When asked when the sink was normally cleaned and who did it, she replied "I have no idea."


During an interview on 2/11/25 at 1:15 pm, the DFS stated he didn't know what the vegetable wash process was.


During an interview on 2/12/25 at 10:20 am, the Food Service Manager (FSM) stated the vegetable washing solution was a Diversey product. They had difficulty testing the vegetable wash concentration because they have had difficulty getting the test strips. They have not logged the concentration since they started using the product last year. He described the process for correct us of the vegetable wash product was: the sink had to have enough vegetables wash in it for the produce to be completely submerged for one minute. He stated he had found staff using the vegetable prep sink for other activities such as thawing meat, and told them not to do that.


During an observation with the FSM on 2/13/25 at 11:15 am, the manufacturer's label for Diversey Suma Eden Antimicrobial Fruit and Vegetable Wash was reviewed. It showed two processes for use:

1. Faucet Method: Press the button on the J-fill dispenser ...for continuous use. Rinse processed fruit and vegetables for 60 seconds under a continuous flow of proper strength of Eden Wash solution. Scrub or agitate processed produce as necessary to remove visible soil.
2. Soak Tank Method: Fill soak tank to the desired level using the J-Fill dispenser ...Submerge prepared produce for a minimum of 60 seconds. Scrub or agitate processed produce as necessary to remove visible soil. Drain and refill soak tank with fresh solution at least every 8 hours or when soil becomes excessive. Periodically check pH using pH paper and if the pH rises above 3.5, the solution must be changed. Consult your Diversey Representative to establish an appropriate schedule for your facility.


During and interview with the DFS on 2/13/25 at 11:05 am, he stated there was no policy for the use of vegetable wash. There was only a policy that directed use of water to wash vegetables. He provided an "update" on the vegetable wash station: they received test strips from the vendor yesterday; the vegetable wash product concentration was out of range; they took the vegetable wash out of service and directed staff to only use water; the vendor was to come that day to recalibrate the dilution, and they have started in-servicing staff on the correct use of vegetable wash.


6. Catering Associates did not receive formal training in therapeutic diets by a qualified person, yet had the ability to override the diet office software to provide food that was non-compliant to the diet order.


During an interview with Registered Dietitian (RD) 1 on 2/11/25 at 3:11 am she stated the RDs provided no oversight to the catering associates. She did not know what training they received. She did not know who educated them about therapeutic diets to help patients make appropriate selections for therapeutic diets (Cross Reference A 619).


During an interview with the FSM on 2/12/25 at 10:20 am he stated the department had two job descriptions for kitchen staff: 1) Food Service Workers included the catering associates, dishwashers, and cashiers; and 2) Cooks (Hot/Cold food preparation). He stated the Catering Associates helped patients make menu choices and were trained by other "seasoned" Catering Associates. He stated unlike other positions in the kitchen, Catering Associates had to learn the diet office software. New staff generally trained for seven days, and the seasoned Catering Associates evaluated the their knowledge and understanding of training. The FSM stated they learned about the therapeutic diets through what was available in the diet office software and from other catering associates. He stated Catering Associates had the ability to override the diet office software and select foods non-compliant to the diet order for patients, but they had to initial it when they did that. He stated staff were trained how to contact the RD if they had questions. The FSM stated he didn't do any of the training on therapeutic diets with the Catering Associates. He explained "I have a CDM (Certified Dietary Manager training and certification), but I don't think that qualifies me to do training on diets." He there was no system set up for the RD to provide formal training on therapeutic diets to the catering associates.


During interviews with FSW 9 on 2/12/25 at 3:45 pm, and with FSW 8 on 2/13/25 at 1:00 pm, they stated they were Catering Associates, that other catering associates trained them, and that kitchen supervisors helped and answered their questions as needed. They stated the catering associates trained them about therapeutic diets. FSW 9 stated "They know everything already." FSW 8 and FSW 9 clarified the RD did not train them regarding therapeutic diets, but she did provide training about PPE (personal protective equipment) and isolation rooms.


A review of the Food Service Worker job description, date revised 6/15, did not include any "Responsibilities - Essential Functions" in relation to catering associate's knowledge of therapeutic diets, assisting patients with menu choices, or knowledge of diet office software that was essential to provision of diet order-compliant meals to patients. The "Responsibilities - Essential Functions" does show "Prepares, serves, and delivers food to patients of all ages; Orders daily food and supplies as needed; Utilizes excellent customer service skills at all times; (and) Complies with Federal and State Law..."
During a review of seven Food and Nutrition Services employee files (CK1, CK3, CK5, FSW1, FSW4, FSW5, FSW9) and with the DFS on 2/13/25 at 10:05 am, zero out of eight files had any evidence of training, competencies or quizzes regarding therapeutic diets.



7. An effective in-service, education and competency program was not in place for the Food and Nutrition Services Department (FANS).

During an interview on 2/11/25 at 9:05 am, the DFS stated the FANS Department had "Huddle Notes" showing communication with staff, but there was no other documentation of in-services for FANS at that facility.


During an interview with the FSM on 2/12/25 at 10:20 am, he stated in the past 12 months his department had had huddles. He explained did verbal training for staff, but did not document it, and did not document attendance. He stated he covered topics such as handwashing, preventing cross contamination, and safety.


On 2/12/25 at 3:00 pm, a binder of "Huddle" minutes with dates 2/20/24 and ending 10/9/24 were reviewed. They showed a few huddles around August 2024 (8/12/24, 8/16/24) included staff signatures on a sign in form, with minutes showing topics such as soiled equipment, food prep not completed by staff, weekend cleaning, dirty floors and direction to catering associates to please take all patient orders. A review of huddle minutes from March 2024 (3/18/24, 3/28/24) had no record of attendance and showed topics such as labeling and dating food, sink temperatures, cleaning schedules, handwashing, and direction to catering associates to use their script guide when working with patients.


On 2/13/25 at 10:05 am, seven Food and Nutrition Services employee files (CK1, CK3, CK5, FSW1, FSW4, FSW5, FSW9), were reviewed with the DFS. The files showed zero out of eight staff had been evaluated for competency since 2022. The file for FSW 5, hire date 9/23/24, showed she completed an undated "Probationary Competency Assessment" that stated "To successfully complete the probationary period, this test must be taken and passed with a minimum of 88%." There was no evidence the document had been reviewed or evaluated.


Continued review of the staff files showed they variably contained quizzes on topics such as hand washing, dress code, basic food safety, customer service, kitchen safety, fire safety, most quizzes were undated, and many had no name on them. There was no evidence these quizzes had been reviewed by management for correct answers and actual staff competency.


The file for FSW 4 contained a Competency Skills Evaluation (topic IDDSI - dysphagia diets - diets for patients with difficulty swallowing) dated 3/3/22, which showed the staff did not pass the competency. The evaluator's signature was illegible. A note showed "Action Plan - Watch food texture video within one week. Retest in 2 week." There was no evidence this plan was followed up. In a concurrent interview with the DFS, he stated "She is only a dishwasher so she doesn't do this stuff. He was asked if maybe there should there be notes about that, or maybe a different validation form/process for the dishwasher position? The DFS replied "yes."


During continued interview, the DFS agreed that other than competency checklists, none of the staff's competency quizzes showed evidence they were reviewed by leadership for correct answers and actual competence in the subject matter, and annual competencies had not been completed since 2022. The DFS stated "They are supposed to be done every year."


Review of the facility Food and Nutrition Services policy and procedure titled Inservice Education, revision date 5/24, showed "In-servie Programs for all employees are conducted each month. The In-service Program is an ongoing educational experience and is planned in advance for one year." Purpose showed to provide ongoing employee development of job skills and knowledge, and "To develop awareness of and compliance with the highest possible standards of nutritional care, food preparation, service and sanitation," The procedure showed the Director assigned responsibility for weekly huddle meetings, and the leader is responsible to determine the topic and agenda, include FANS Quality Management Committee's activities, ensuring all staff sign the attendance record (clinical and food related topics require 100% attendance), and documentation of the education program.

Based on observation, interview and record review, the facility failed to meet the nutrition needs of one patient (patient #31) in accordance with the diet prescription when:

1. The facility did not have an effective menu or plan in place to provide food variety and to meet the nutritional needs of patients with longer lengths of stay.

2. The facility did not have an effective system for collecting and honoring patient food preferences.

3. The calorie (a unit of energy) values described in the facility-approved diet manual and its nutrient analysis for the Diabetic CC (consistent carbohydrate) 225 gram diet did not match the calorie values described in the physician's orders section in the electronic medical record.

These failures had the potential to result in weight loss, nutrition compromise, extended length of stay, and poor outcomes for patients with longer lengths of stay.

Findings:

Review of the facility policy and procedure titled Scope of Service, revision date 9/24, showed Nutritional Services "C. Plans menus to meet inpatient nutritional and therapeutic needs by providing meals adapted to age, food preference, and ethnic or religious custom ...D. Provides nutritional and therapeutic support for the patient in accordance with the physician orders."

During a record review and concurrent interview with RD 2 on 2/12/24 at 1:10 pm, the electronic medical record for Patient #31 was reviewed. It showed Patient #31 was admitted on 1/10/25 and had been in the hospital for approximately one month. He was admitted with a diagnosis of Sepsis (severe infection), with Clostridium Difficile (severe, potentially life-threatening diarrhea), a pressure wound, diabetes, Parkinson's disease and peripheral edema. A review of the Nutrition Initial Assessment conducted by RD 1 on 1/13/25 at 3:44 pm showed Patient #31 met the criteria for severe malnutrition with loss of 15% of his body weight in approximately three months, poor meal intakes for greater than seven days, and muscle loss over nine areas of his body per the Nutrition Focused Physical Exam.

Upon further review, the weight history showed resident #31's normal weight was approximately 200 pounds with six weights documented 10/3/24 to 12/9/24. His weight on 1/13/25 was 167 pounds, with no edema (fluid retention) per RD assessment. RD 1 estimated patient #31's energy needs were 1900 to 2800 calories/day, and protein needs at 76 to 91 grams/day based on actual weight. It was noted the patient didn't have teeth, and stated he didn't wear his dentures due to poor fit, and he requested a liquid diet. Meal intakes ranged zero to 30% over six meals, with average intake 9% of food provided. RD 1 recommended pureed or full liquid diet per patient request; Cardiac Diet (low sodium, low cholesterol, no caffeine), "Diabetic Consistent Carbohydrate: 225 gm avg/day (about 1800 calories)," multivitamin and Vitamin C. There was no indication in the RD charting that Patient #31 was receiving any between-meal snacks.

Further review of Patient #31's medical record showed RD 1 provided an additional ten reassessments or consults, with the most recent on 2/10/25. The RD noted on 1/17/25 his intake was slowly improving, and he drank "some" of the nutrition supplement ordered, but intakes were still inadequate to meet his nutrition needs. 1/25/25 Pt disliked and refused the supplement so it was changed to a different one. 1/25/25 nutrition intake improved to adequate, drinking supplement. 2/10/25 intake had declined, no longer adequate, recommendations in place (same as 1/13/25), plus zinc sulfate and Arginine for wound healing, daily weights, and diabetic supplement drink three times daily. Patient #31's weight increased from 167 on admission to 179 pounds, but he also had edema (fluid retention) generalized (all over), right arm, left arm and other edema.


During an interview with Patient #31 on 2/13/25 at 8:55 am, he was in an isolation room due to Clostridium Difficile, personal protective equipment was required for persons to enter, and he was attended by two other staff. Resident #31 was alert and answered appropriately. He stated he appreciated the food and especially liked the tomato soup. He wished he could have more of it. He stated he was "sick of apple juice and applesauce" and would like to stop receiving it as it came on almost every tray. He stated no one came into the room to ask what he would like to eat. He needed to be fed by staff due to inability to use his hands. He stated his food was often cold and he couldn't eat it once it got cold. He stated staff did not reheat his food or request another tray of food item for him. He stated the cold food made him sad, especially when it was a food he really liked and would like to eat more of, but when it was cold he couldn't eat it.


1. The facility did not have an effective menu or plan in place to provide food variety and to meet the nutritional needs of patients with longer lengths of stay.


Review of a document provided by the facility titled MV 2024 ALOS (Average Length of Stay) showed an average of how long patients stayed admitted in the hospital. In 2024 the monthly ALOS ranged 3.1 to 3.6 days, with an annual average of ~3.4 days.


During an interview with the Director of Food and Ancillary Services (DFS) on 2/11/25 at 9:05 am, he stated they had a Kaiser-wide (all Kaiser facilities) two-day house menu cycle, meaning the same meals/menus were repeated every other day. The House "non-select" menus were the meals sent when the patient had not ordered food from the room service menu. The DFS stated their facility's average length of stay (ALOS) was "2-point something" days. When asked what they did for patients who were in the hospital longer than the ALOS he replied, "We are creative." He further explained the catering associates "push choice" from the room service menu, customized to the diet order, and they worked with the Registered Dietitians (RDs) to meet patient nutritional needs.


During an interview with Registered Dietitian (RD) 1 on 2/11/25 at 3:11 pm she was asked about the two-day menu cycle and she replied, the variety of food for patients who had a longer length of stay (LOS) was "definitely a problem." "Most people don't want to eat the same thing every day." She stated the facility did their best to provide variety with the existing menu. When asked how she worked with these patients with longer LOS she stated the RDs reviewed the diet order, meal intakes, labs, medications, and did a quick mini assessment to evaluate if the patient could have a requested food one time. They adapted what could be provided based on clinical status. They did their best. Sometimes they had to say no.


During an interview with the FSM on 2/12/25 at 9:07 a.m., he stated they recently revised their patient standard menus and patient tri-fold room service menu. He stated he and the DFS did the revision, and the facility RDs were not involved.


During an interview with RD 1 on 2/13/25 at 8:37 am, regarding Patient #31, she stated he had been at the facility for about one month. He requested pureed diet due to missing teeth, variable meal intakes, poor appetite. They added nutrition supplements, and he was now drinking it well. His diet order was diet order was Cardiac (low sodium, low cholesterol, no caffeine), Diabetic Consistent Carbohydrate 225 g (about 1800 calories), Pureed. When asked about pureed diet food options, RD 1 stated "I only know what I see in the Room Service Choice software program," and the kitchen used only purchased pureed food from a vendor. They did not puree food in-house. "He's probably getting the two-day menu over and over again."


A document provided by the Food Service Manager (FSM) titled "Your Choice Room Service Menu," with (possibly) a date "ABM_0422" was reviewed. It showed a variety of breakfast, lunch and dinner food choices with symbols indicating if a food was compliant for heart healthy (cardiac) diets, renal diets, vegan (plant-based) diets and gluten-free diets. It also had numbers in parentheses next to food items, indicating the carbohydrate content of the food for diabetic diets. All foods were available for regular diets. It did not show any pureed food options.


A review of documents titled "Ticket History" dated 2/2/25 through 2/8/25 showed the content of the meals Patient #31 received over the past week:
Breakfast: He received house menu 1, three out of the seven breakfasts. He received house menu 2, four out of the seven breakfasts
Lunch/dinner entrees - He received Chicken Enchilada 5/14 meals, Chicken with Rice 4/14 meals, Meatloaf 3/14 meals, Chicken with Vegetables 2/14 meals.
He received mashed potatoes with gravy 10/14 lunch/dinner meals.
He received applesauce 17 out of 21 meals.
He received cranberry juice 13/21 meals.
He received fruitable vegetable juice 7/21 meals.
He received a chocolate flavored supplement 21 out of 21 meals.
He received his favorite, tomato soup, one out of 21 meals.


During a telephone interview with RD 1, RD 3 and a Kaiser national level RD on 2/14/25 10:35 am, RD 1 was asked if she had ever considered requesting to liberalize Patient #31's diet to give him more food choices and improve his meal intakes since he was 83 years old, was malnourished, and had been eating poorly. She replied that it wasn't appropriate to liberalize the diet order because of the need to tightly control his blood sugars so he would heal as fast as possible, and because he had a history of a heart attack.


2. The facility did not have an effective system for collecting and honoring patient food preferences.


During an interview with RD 1 on 2/13/25 at 8:37 am She stated the RDs had never been taught to put food preferences into the CBORD software, and even when they tried to enter food preferences, CBORD did not implement it.


During an interview with Food Service Worker (FSW) 8 on 2/13/25 at 1:00 pm, she reported she had been a Catering Associate since 2020. When asked how they worked with patient food preferences, she stated they put patient preferences in "Service Notes" in the diet office software. She explained the only time they put a preference into the system was for patient-requested sauces served at the Riverside facility. She stated the catering associates let patients know what foods were available from room service, and the diet office software told her what foods patients could and could not have in their diets.
A concurrent record review with FSW 8 of the "service note" for Patient #31 showed "patient sleeping" and similar notes in long list of notes, with an occasional food comment. If the patient didn't like applesauce and it was only entered in a service note, he could continue to receive applesauce daily if staff did not catch that manually. FSW 8 stated the service notes only showed when the tally was printed out, but the catering associates communicated to each other verbally about patient needs. There was no other system for tracking patient food preferences or communication about patient care.


In a concurrent interview with the DFS and the Food Service Manager from the Riverside facility (their diet office software expert), they stated they had not taught anyone to use the preference window in the diet office software. They only used the service notes. They stated the dietitians should be putting preferences into the system. There was no response when it was shared the dietitians stated they had never been taught to enter preferences into the system, and their efforts to do that had not resulted in the desired changes for the patient.


When asked about how Catering Associates worked with isolation patients, FSW 8 stated "We only go into the contact isolation rooms, but usually the nurses will just ask the patient what they want."


3. The caloric (energy) values described in the facility-approved diet manual and its nutrient analysis did not match the caloric values described in the electronic medical record physician's orders section for the Diabetic Consistent Carbohydrate (CC) 225 gm average/day diet.


During a review of the facility diet manual and concurrent interview with RD 1 on 2/11/25 at 3:11 pm, the approval page showed it was approved by the Pharmacy and Therapeutics Committee on 3/22/24, the Medical Director on 4/2/24, a Clinical Dietitian (RD 1) on 4/3/24, and an additional unknown Clinical Dietitian on 4/8/24.


Further review of the diet manual showed the Diabetic Consistent Carbohydrate Diets section explained "A consistent carbohydrate diet provides approximately the same amount of total carbohydrate daily, distributed across meals and snacks" and was used to assist patients and providers manage the patient's blood glucose (sugar) levels. The section titled Nutritional Adequacy of Non-Select Menu showed "Based on the non-select diet the diet is adequate in all nutrients according to the Recommended Dietary Allowances" ...except for ...it was inadequate in "calories for males and females greater than nine years of age."


Review of the "Carbohydrate Diet Spread (meal patterns)" section showed "Snacks are available in the unit pantry to provide based on the patient's diet order, blood glucose levels, and preference. The combined total of carbohydrate from snacks (0-30g) and meals are intended to meet the diet order." The chart showing the meal patterns of various level carbohydrate diets did not include snacks, except the Diabetic CC 350 gm Avg/d diet had an afternoon snack. All CC diet levels had and asterisk in the bedtime snack column. The asterisk explanation showed "The bedtime snacks are provided outside of the diet office software. The snacks are provided to the nursing unit pantries for the provider to select the items and timing desired and as ordered by the physician. The carbohydrate meal allowances within the diet office software program are adjusted to account for this number of grams of carbohydrate that may (bolded) be provided to the patient, as needed."


A review of the nutrient analysis of facility menus, provided by the Director of Food & Ancillary Services (DFS), showed Recommended Daily Dietary Allowance (RDA) adult nutritional goal for energy was for 2000 calories daily. It showed he facility's two day menu cycle for the Diabetic Consistent Carbohydrate (CC) 225 gm average/day diet provided 1541 to 1555 calories daily.


During an interview with RD 1 on 2/12/25 at 2:00 pm, she was asked about the Diabetic CC 225 gm diet, and if the average 1555 - 1541 calories it provided daily sounded about right in relation to the energy needs she calculated for patients on that diet. RD 1 informed us the physician's orders section in the electronic medical record (EMR) showed that the Diabetic CC 225 gm diet order would provide approximately 1800 kcals/day. She agreed the diet manual and EMR should match but they didn't.


A review of 93 lunch meal tray tickets, dated 12/12/25, showed 32 out of 93 of patients with meal tray tickets had a Diabetic, Consistent Carbohydrate (CC) 225-gram average/day diet order.


During a telephone interview with RD 1, RD 3 and a Kaiser national level RD on 2/14/25 10:35 am, and subsequent email exchange, they were asked about the facility's Consistent Carbohydrate (CC) diet meal patterns as shown in the diet manual. RD 3 stated the diet manual allowed and planned for three (0 to 30 grams carbohydrate each) snacks each day for patients on CC diets. She stated nursing offered and provided snacks from floor stock. She stated their computer system would show the snacks. The surveyor requested copies for one week of the snacks provided for Patient #31. The facility provided one screenshot from what appeared to be Patient #31's cardfile meal ticket entry in the diet office software, showing a diabetic supplement was provided with a meal. No evidence was provided to show Patient #31 received any snacks from nursing. When asked again if Patient #31 received any snacks, RD 3 replied the nutrition supplement was the snack.


A review of a Boost Glucose Control nutrition facts label showed one serving (237 ml) provided 190 calories and 16 grams of protein. The RD 1 interviews during survey, and the nutrition assessment and reassessment notes showed Patient 31's intake of the nutrition supplement was variable.

Based on general kitchen/cafeteria observations, foodservice and departmental staff interview, and document review, the facility failed to ensure timely maintenance or replacement of multiple pieces of essential equipment. Failure to maintain essential equipment had the potential to result in compromise of food safety, food quality, and patient satisfaction for all patients, staff and visitors consuming food from the facility.

Findings:

1. Convection Steamer


During an observation in the Cook's area on 2/10/24 at 9:30 am, the steamer had a "Stop, Do Not Use" (out of service) tag on it. The back of the tag provided no dates or other information regarding the status of the equipment. In a concurrent interview, Cook (CK) 2 stated the kitchen's steamer had been out of service for at least two to three weeks. She stated it just stopped working, was old, and needed to be replaced.


During an additional interview with the Director of Food and Ancillary Services (DFS) on 2/10/25 at 9:55 am, he stated the steamer had been out for 2 weeks, and a new steamer should arrive next week.


Review of an email between the DFS and Facilities Coordinator (Capital Equipment Committee) dated 1/16/25, provided by the DFS, showed a request had been submitted to replace the steamer on July 10, 2024.


A review of the County of Riverside Department of Environmental Health, Food Establishment Inspection Form, dated 4/15/24, showed "At time of inspection, observed the steam kettles to be dripping water onto a container on the floor under the equipment. Per person in charge, the work order was in progress, and it takes time given the repairs to the equipment."


2. Walk-in Refrigerator number (#) 3


On 2/10/25 at 9:04 a.m., a concurrent observation and interview was conducted with the Food Service Manager (FSM) in the walk-in refrigerator number #3. Condensation was observed on the walk-in refrigerator's ceiling. The FSM stated this issue had been occurring on and off for roughly three months. The FSM was unable to locate the Engineering Department work order communication for this issue.


On 2/12/25 at 10:32 a.m., an interview was conducted with the Senior Manager of Facilities Engineering (SMF). The SMF stated the reasons the walk-in refrigerator had condensation could be due to the refrigerator itself was too cold; or the refrigerator did not have good air circulation; or the chilled water pipes were not insulated properly. The SMF stated Food Service workers needed to report this issue to Engineering. Otherwise, this condition could affect the quality of foods stored in the refrigerator.


3. Induction Charger - Tray Line (meal assembly process) Plate Base Activator (warmer)


An induction charger is equipment that magnetically charges a base, upon which warmed food plates are placed, then dished with a food, and then covered with an insulated dome. A properly charged base may keep a plate of food hot for up to 1 ½ hours.


During an observation of the kitchen on 2/10/25 at 9:14 am, the top surface of the induction charger had multiple large cracks.


During an observation of lunch tray line on 2/11/25 at 12:05 pm, Cook 3 placed her hand on the cracked top surface of the induction charger and stated, "It's not working."


During an interview with Cook 3 on 12/11/25 at 12:41 pm, she stated the induction charger was working, but it took a long time, and it shut itself off if you used it a lot.


A review of the County of Riverside Department of Environmental Health, Food Establishment Inspection Form, dated 4/15/24, showed "Violation Description: All utensils and equipment shall be approved and in good repair." "Cracked top component for the Dinex plate warmer. Facility stated they will replace the unit. Replace with an approved type so it is smooth and easily cleanable."


Review of an email between the DFS and Facilities Coordinator (Capital Equipment Committee) dated 2/11/25, provided by the DFS, showed the Capital Equipment Committee approved the purchase of an induction charger 1/15/25, approximately nine months after the lack of regulatory compliance was cited by the county.


4. Cafeteria Reach-in Refrigerator


On 2/10/25 at 2:30 p.m., a concurrent observation and interview was conducted with the FSM in the cafeteria. The reach-in refrigerator's gasket (rubber piece that lined at the door of refrigerator to prevent cool air from slipping out) was observed torn. The FSM stated the torn gasket needed to be replaced; Otherwise, the torn gasket would not properly seal the refrigerator's door which could result in the refrigerator being unable to maintain at the correct temperature.


During a review of the hospital's policy and procedure (P&P) titled, "Preventive Maintenance and Equipment Repair", revision date 5/24, the P&P indicated, "The Engineering Department performs a regular preventive maintenance check on major equipment in the Food and Nutrition Department. Additionally, all equipment problems occurring during normal operations are immediately reported to Plant Operations, so that they may be corrected promptly. PURPOSE: To minimize occurrence of breakdowns and to maximize life span of equipment, and reduce safety hazards, by ensuring prompt repair of damaged equipment. PROCEDURE: A. Equipment Repairs 1. All personnel are instructed to report any equipment problems to management. 2. Management is responsible for notifying Engineering either via the ServiceNow system, or by telephone in an emergency situation. ..."