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F0550
D

Undignified Meal Assistance Provided by Standing Staff Member

Castro Valley, California 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

During a meal observation, a resident with diagnoses including dysphagia, hemiplegia, and dementia was assisted with eating by an occupational therapist (OT) who stood while spoon-feeding the resident. The resident was seated in a wheelchair in the dining room at the time. The OT stated that she sometimes stood and sometimes sat while feeding residents, depending on the cues she needed to provide. The resident had a physician's order for 1:1 feeding, indicating the need for dedicated, personalized support during meals. Interviews with the Director of Nursing (DON) and the Director of Rehabilitation (DOR) confirmed that staff are expected to be seated at eye level with residents when providing meal assistance to preserve dignity and ensure safety. The facility's policy on meal assistance also specifies that residents who cannot feed themselves should be assisted with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents while feeding them. The observed action of standing while feeding the resident was inconsistent with both facility policy and staff expectations, resulting in undignified and disrespectful treatment.

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