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F0810
E

Failure to Provide Ordered Assistive Eating Devices During Meals

Big Bear Lake, California Survey Completed on 05-08-2025

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

The facility failed to provide required special assistive eating devices to three residents during mealtimes, as observed and confirmed by staff. Two residents with orders for a plate guard and anti-spill cup (KCup) were not given these devices during lunch, despite their meal tickets indicating the need for them. Both residents had medical conditions such as hemiplegia, hemiparesis, COPD, and dementia, which necessitated the use of these assistive devices. A Certified Nursing Assistant (CNA) confirmed that the devices were not provided during the entire meal, and the Director of Nutrition Services acknowledged that facility policy requiring such support was not followed. Another resident with diagnoses including dementia, depression, anemia, anxiety, osteoporosis, and Parkinson's disease was also not provided with a KCup as ordered, despite this being indicated on the meal ticket. The resident was observed drinking with a straw instead, and the assisting CNA confirmed the absence of the KCup. The Director of Nursing reviewed the facility's policy and confirmed that the resident should have received the KCup with meals, and that the policy was not followed by the staff involved.

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