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F0692
D

Failure to Provide Adequate Mealtime Assistance for Resident Requiring Moderate Support

Montrose, California Survey Completed on 07-03-2025

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 certified nurse assistant (CNA) failed to provide adequate nutritional care and services to a resident who required moderate assistance with eating. The resident, admitted with diagnoses including dysphagia, severe protein-calorie malnutrition, and dementia, was assessed as having severely impaired cognition and needing moderate assistance for activities of daily living, including eating. The care plan and physician orders specified a mechanical soft diet and interventions such as monitoring and anticipating the resident's needs. Despite these documented requirements, observations showed that the resident's breakfast tray was placed in front of her without necessary assistance, such as cutting bread into smaller pieces or ensuring all items were within reach. The resident was seen struggling to cut her food and unable to access her snack and water without help. Interviews with staff confirmed that the CNA did not provide the required assistance, such as cutting food and setting up the tray appropriately, as outlined in the resident's care plan and facility policy. The facility's policy required nursing staff to provide assistance to residents who have difficulty feeding themselves, but this was not followed in the case of this resident. The failure to provide the necessary support was directly observed and corroborated by staff interviews and record reviews.

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