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F0803
D

Failure to Update and Honor Resident Food Preferences

Mayfield Heights, Ohio Survey Completed on 05-29-2025

Penalty

Fine: $173,90029 days payment denial
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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 ensure that a resident's food preferences were honored and updated as required. The resident, who had diagnoses including adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia, and depression, was cognitively intact and required set up for meals. Despite a physician order specifying a regular diet with no oatmeal, a preference for cold cereal, and a request for chef's salad, the resident reported that her preferences were not being followed. She stated that she continued to receive oatmeal, which she disliked, and her dietary tray ticket did not list any preferences or dislikes. Observation confirmed that her tray ticket did not reflect her stated preferences. Interviews with facility staff revealed that the Registered Dietitian completed nutrition assessments but did not update resident preferences, which was the responsibility of the Dietary Manager. The Regional Dietary Manager acknowledged that there had been several changes in the Dietary Manager position and that she had not been visiting residents to obtain or update preferences since starting in her role. It was also unclear if previous dietary managers had fulfilled this responsibility. Facility policy required that food preferences be assessed upon admission and documented in the care plan, but this was not done for the resident in question.

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