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F0561
D

Failure to Honor Resident's Beverage Preference During Meals

Los Angeles, California Survey Completed on 04-13-2025

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

A deficiency occurred when the facility failed to provide a resident with warm water to make tea during meals, despite the resident's documented preference for tea at breakfast, lunch, and dinner. The resident, who had muscle weakness, lack of coordination, and chronic kidney disease, required substantial assistance with daily activities and was able to communicate her needs. The Food Preference Interview and dietary records clearly indicated the resident's desire for tea with each meal. However, during an observation, the resident's breakfast tray did not include a tea bag or hot water, and the resident expressed frustration at having to repeatedly request hot water for tea, despite staff being aware of her preference. A Certified Nursing Assistant (CNA) confirmed that she did not provide hot water because the tea bag was missing from the tray, even though she knew the resident regularly wanted tea. The Dietary Manager also acknowledged the resident's preference for tea and stated that CNAs were responsible for providing hot water when trays arrived. Facility policy required that residents' food preferences be honored and reflected on their tray cards, but this was not followed in this instance, resulting in the resident's preference not being honored and causing her frustration.

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