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F0550
D

Failure to Provide Dignified Dining Experience for Dependent Resident

San Diego, California Survey Completed on 05-15-2025

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 a resident with amyotrophic lateral sclerosis (ALS), dysphagia, contractures, and muscle wasting, who was dependent on staff for eating, was not provided a dignified dining experience. The resident's meal tray was repeatedly delivered to their room and placed out of reach, leaving the resident unable to access their food. On multiple occasions, the resident had to wait for extended periods before being fed, while observing their roommate being fed first. The resident expressed dissatisfaction with having to wait and watching their meal sit out of reach. Staff interviews confirmed that the resident was typically fed by a restorative nursing assistant (RNA) after meal trays were delivered, but there was inconsistency in the timing of feeding. The facility's policies required that residents receive assistance with meals in a manner that meets their individual needs and promotes dignity. However, observations and staff statements revealed that the resident was not fed promptly after meal delivery, and both the Director of Nursing and Administrator acknowledged that residents should be fed at the same time for a dignified experience, which was not occurring in this case.

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