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F0806
D

Failure to Honor Resident Beverage Preferences During Meals

Sanger, California Survey Completed on 05-01-2025

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 diabetes mellitus and kidney failure, who was cognitively intact, did not receive food in accordance with his documented preferences. Despite clear documentation in the resident's admission record, meal ticket, and progress notes indicating a preference for no milk except with breakfast and a request for alternative beverages at other meals, the resident was repeatedly served milk with his meals. The resident expressed frustration and upset at receiving milk for all scheduled meals, stating that staff were not listening to his requests. Interviews with facility staff, including a Licensed Vocational Nurse, Certified Dietary Manager, Registered Dietician, and Director of Nursing, confirmed that the resident's preferences were known and should have been honored. The facility's policy required staff to document and follow resident food preferences, but this was not done in this case. The failure to provide the requested beverage alternatives resulted in the resident being upset and had the potential to impact his nutritional intake.

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