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F0803
E

Failure to Follow Therapeutic Diet Menus and Portion Requirements

Carmichael, California Survey Completed on 04-24-2025

Penalty

Fine: $26,685
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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

The facility failed to follow prescribed therapeutic diets as outlined in their menu spreadsheets during lunch meal services. On two separate occasions, residents on Consistent Carbohydrate (CCHO) diets received incorrect desserts: three residents were served pineapple Bavarian cream square instead of pineapple tidbits, and another resident received pudding instead of the specified CCHO dessert. These discrepancies were confirmed by both the Certified Dietary Manager (CDM) and the Registered Dietitian (RD), who stated that the menu and spreadsheet should have been followed to ensure residents received the correct items for their dietary needs. Additionally, during another meal service, fifteen residents on fortified diets did not receive the required super soup, and two residents on large portion diets were served three ounces of meat instead of the prescribed four ounces. The facility's menu spreadsheets and diet manual specified the correct items and portion sizes for these diets. Both the CDM and RD acknowledged these failures during interviews, confirming that the meals provided did not match the ordered diets as required by facility policy and resident care plans.

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