Health inspection·May 21, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interviews, and record reviews, the facility failed to ensure the menu approved by the Registered Dietitian (RD) was followed for 131 of 131 residents when the meatloaf portion served to residents was less than 4 ounces (oz-unit of measurements). This failure had the potential for residents to receive the wrong caloric intake and not meet the nutritional needs of the residents which could compromise their medical status. Findings: During a review of the Detailed Census Report, (census), dated 5/21/24, the census indicated there were 134 residents in the facility. During an observation on 5/21/24, at 11:40 AM, in the facility kitchen, [NAME] 1 was cutting a cooked meatloaf into slices for lunch. During a concurrent interview and record review on 5/21/24, at 11:42 AM, with the Dietary Manager (DM), the recipe for the meatloaf titled Meatloaf 3 OZ SCR - Recipe #138 (recipe) was reviewed. The DM stated the recipe calls for the portions served to weigh 3 ounces (OZ). During a concurrent observation and interview on 5/21/24, at 11:44 AM, in the facility kitchen, with [NAME] 1 and the DM, [NAME] 1 weighed several of the meatloaf slices using a facility digital scale. [NAME] 1 stated the slices from the ends of the meatloaf were smaller, so we serve two of those pieces. [NAME] 1 weighed two of the meatloaf end pieces and measured 4.9 ounces. [NAME] 1 weighed the meatloaf center pieces and they averaged about 3.5 ounces each. The DM confirmed the meatloaf weights. [NAME] 1 stated all the other slices from the meatloaf were served one per resident's tray. During a concurrent interview and record review on 5/21/24, at 11:45 AM, with [NAME] 2, the recipe for the meatloaf titled Meatloaf 3 OZ SCR - Recipe #138 (recipe) was reviewed. [NAME] 2 stated, I made the meatloaf this morning. I'm cooking for 140 people. I used 30 pounds of ground turkey for the meatloaf. That's all we had. The meatloaf recipe indicated that for 150 people, 37.5 pounds of ground beef is to be used. [NAME] 2 stated, Oh, that's right. During a concurrent interview and record review on 5/21/24, at 11:52 AM, with the DM, and the Registered Dietician (RD), the recipe for the meatloaf titled Meatloaf 3 OZ SCR - Recipe #138 (recipe) was reviewed. The DM stated the meatloaf was 7.5 pounds of ground beef short of the recipe. The RD confirmed the meatloaf recipe was not followed correctly. Page 1 of 2 555240 555240 05/21/2024 Turlock Nursing & Rehabilitation Center 1111 E Tuolumne Road Turlock, CA 95380

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 5/21/24, at 12:06 PM, with [NAME] 3, [NAME] 3 stated, whoever the cook was this morning, they should have informed a manager that we were going to be short [on the meatloaf]. During an interview on 5/21/24, at 12:55 PM, with the DM, the DM stated I do the buying of the food for the facility, and we follow the recipe for 150 people. The DM stated we have a total of 134 residents and three residents are NPO (nothing by mouth) and getting their nourishments by way of Gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach). The DM stated, This is my fault. I was incorrectly passing along to the cooks the incorrect size package of food. The DM stated she had not been reading the recipe spreadsheets correctly. During a concurrent interview and record review on 5/23/24, at 10:42 AM, with the RD, the recipe for the meatloaf titled Meatloaf 3 OZ SCR - Recipe #138 (recipe) was reviewed. The recipe indicated Portion Size: 4 OZ and Use scales to serve 4 OZ portions. The RD stated residents should have been served 4 oz of meatloaf. The RD was unable to explain why the title of the recipe indicated Meatloaf 3 OZ but indicated portion sizes of 4 OZ. The RD stated, That may just be the title of the recipe. The cook should be serving 4-ounce portions. The RD stated serving portion sizes smaller than 4 ounces would result in residents not getting the calories they are supposed to. During a review of the facility policy and procedure (P&P) titled, Meal Production, dated 2/09, the P&P indicated, in part, Purpose- Utilized tools to assist in accurate meal production. The Food and Dining Services Manager/designee maintains meal service systems in the food and dining department to assist food and dining services staff to correctly forecast and produce sufficient products for meal service, according to resident preference and physician's diet orders. 555240 Page 2 of 2