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F0806
D

Failure to Honor Resident Food Preferences

Pasadena, California Survey Completed on 06-05-2025

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 meals that accommodated the food preferences of a resident who was admitted with severe protein calorie malnutrition and muscle wasting. The resident's admission record and subsequent medical documentation did not include an updated Nutritional Quarterly Progress Evaluation reflecting her food preferences after she was started on an oral diet. Despite the resident expressing her dissatisfaction with the meals and specifically requesting certain breakfast items, there was no evidence that her preferences were assessed or honored by the dietary staff. The dietary director confirmed that no updated evaluation had been completed, and the facility's policy required the use of a dietary questionnaire to determine food preferences for residents on oral diets. Interviews with the resident, the dietary director, the DON, and an LVN revealed that staff were aware of the importance of honoring food preferences to prevent weight loss and ensure resident satisfaction. However, the staff did not communicate the resident's preferences to the dietician, speech therapist, or physician, nor did they take steps to ensure her choices were incorporated into her meal plan. The facility's policy and procedure required the dietary department to provide meals consistent with resident preferences, but this was not followed in the case of this resident.

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