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F0550
D

Failure to Honor Resident's Right to Communicate Dietary Preferences

Sonora, 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

Resident 5's right to a dignified existence and self-determination was not honored when her repeated requests to speak with the dietician regarding her dietary preferences were not addressed. Documentation from Resident Council meetings on three separate occasions showed that Resident 5 asked to see the dietician, but the requests were either referred to other staff or noted as sent to a supervisor, with no evidence that the resident was actually able to communicate with the dietician. During an interview, Resident 5 expressed dissatisfaction with her meals, specifically noting that the meats were very dry and that she preferred to have gravy served separately with each meal, a preference that was not accommodated or discussed with her. Record review indicated that Resident 5 had a history of chewing and swallowing difficulties, requiring a mechanical soft, gluten-free diet, and that her preference for gluten-free gravy was documented. The dietician acknowledged being aware of the request and attempting to find a suitable gravy option, but admitted to not following up or communicating directly with Resident 5 after the initial documentation. This lack of follow-up and communication resulted in Resident 5's dietary preferences not being addressed and her requests not being honored.

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