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F0550
D

Failure to Provide Dignified, Safe Feeding Assistance at Eye-Level

Sunland, California Survey Completed on 08-07-2025

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 certified nursing assistant (CNA) was observed providing feeding assistance to a resident with severe cognitive impairment, hemiplegia, epilepsy, diabetes mellitus, and dysphagia. The resident was dependent on staff for eating and required a pureed, consistent carbohydrate, no added salt diet. During the lunch observation, the CNA was seated in front of the resident, who was in a Geri chair that was not in an upright position. The CNA and the resident were not at eye-level during feeding. The CNA stated the chair was reclined to prevent the resident from falling forward. A licensed vocational nurse (LVN) confirmed that the resident was lying back while eating and should have been positioned more upright to prevent aspiration. The director of nursing (DON) stated that residents should be positioned upright as much as tolerated to prevent aspiration and that CNAs should be at eye-level with residents during feeding to maintain dignity. Facility policies and the CNA job description require feeding to be provided with attention to safety, comfort, and dignity, including not standing over residents and treating them with respect at all times. The observed actions did not align with these requirements.

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