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F0803
E

Failure to Follow Prescribed Diet Menus and Portion Sizes

Sacramento, California Survey Completed on 05-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a lunch meal service, five residents on mechanical soft (MS) texture diets received a smaller portion of meatballs than specified in the facility's menu guidelines. The cook used a #16 scoop (two ounces) instead of the required #10 scoop (three ounces) for these residents, as indicated in the facility's Spring Cycle Menus spreadsheet. Additionally, one resident on a fortified diet did not receive the prescribed extra one ounce of gravy on the meatballs and an extra half ounce of melted margarine on the vegetables, as required for fortified meals. These discrepancies were confirmed through interviews with the cook and the registered dietitian, as well as a review of the facility's menu documentation. The registered dietitian acknowledged that the correct portion sizes and fortification procedures were not followed during the meal distribution. Facility policies and job descriptions for dietary staff require adherence to prescribed menus, portion control, and physician's orders for therapeutic and regular diets. The failure to follow these established procedures resulted in six residents not receiving meals that met their prescribed dietary needs during the observed lunch service.

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