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F0803
E

Failure to Follow Therapeutic Diet Menus and Portion Controls

Carmichael, California Survey Completed on 05-23-2025

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, the facility failed to follow the planned menu for therapeutic diets as prescribed. Six residents on small portion diets received three ounces of roast beef instead of the two ounces specified in the menu. Additionally, six residents on fortified diets did not receive the planned extra one ounce of melted butter or margarine on their mashed potatoes. These discrepancies were confirmed by kitchen staff and through review of the facility's menu spreadsheet, which outlined the correct portions and fortification requirements for each diet type. Furthermore, 57 out of 113 residents who received lunch meals did not receive the required parsley garnish, as indicated on the menu. Interviews with the Dietary Manager and Registered Dietitian confirmed that the menu was not followed as planned, and that the small portion and fortified diets were intended to address specific nutritional needs, such as weight loss or inadequate caloric intake. The facility's diet manual, menu planning policy, and job descriptions for dietary staff all required adherence to the planned menu and portion control, which was not observed during this meal service.

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