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F0550
D

Failure to Maintain Resident Dignity During Mealtime Assistance

Orlando, Florida Survey Completed on 06-20-2025

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

Staff failed to ensure that two residents with severe cognitive impairment and total dependence for eating were afforded dignity during mealtimes. Both residents had care plans indicating total dependence on staff for eating and other activities of daily living. During meal observations, staff members, including a CNA and a physical therapist, were seen standing while assisting these residents with their meals rather than sitting at eye level. One CNA acknowledged she was supposed to sit while feeding but did not do so because a chair was unavailable, and the physical therapist was unaware of the requirement to sit while assisting with meals. Both staff members later confirmed their understanding that sitting was necessary to maintain resident dignity, but did not follow this practice during the observed meals. The facility's policy required nursing staff to assist residents in need during mealtimes, and the Assistant Director of Nursing confirmed that CNAs were trained on the importance of sitting while assisting with meals. Despite this, staff did not consistently follow the policy, and in at least two instances, residents were assisted with eating while staff stood over them, rather than sitting at their level. This failure to follow established protocols resulted in a lack of dignity for the residents during mealtime assistance.

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