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F0806
D

Failure to Accommodate Resident Food Preferences and Intolerances

Los Angeles, California Survey Completed on 06-19-2025

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 food that accommodated the documented allergies, intolerances, and preferences of two residents. One resident with lactose intolerance and a dislike for sweets was served chocolate ice cream, despite these restrictions being listed on the resident's meal ticket. Observations showed that dietary staff prepared and served the incorrect dessert, and the resident expressed frustration, stating that such mistakes occurred frequently and that desserts were often returned to the kitchen. Staff interviews revealed a lack of clarity and consistency in checking meal tickets and ensuring diet accuracy before tray delivery. Another resident, who had documented cultural and religious preferences to avoid pork and ham, was served pork sausage for breakfast. The resident, who identified as Muslim, had these preferences noted in multiple records, including the nutritional screening, dietary slip, and care plan. Despite these clear indications, the resident reported being served pork on at least one occasion, and the dietary supervisor acknowledged the error, attributing it to new staff. Facility policies required that resident preferences and intolerances be accommodated and that food trays be inspected for accuracy. However, observations and interviews indicated that these procedures were not consistently followed, resulting in residents receiving food items contrary to their documented needs and preferences.

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