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F0810
D

Failure to Ensure Resident Use of Adaptive Feeding Equipment

Pasadena, California Survey Completed on 05-23-2025

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 resident with diagnoses including dementia, osteoarthritis, and schizophrenia, who was dependent on staff for eating and had physician orders for adaptive feeding equipment, was not provided the opportunity to use a weighted spoon and plate guard for self-feeding during a meal. Instead, a Restorative Nursing Assistant used the specialized utensils to feed the resident directly, rather than allowing the resident to attempt self-feeding as ordered. The resident's care plan and physician orders specified the use of these assistive devices to promote independence in eating, and the occupational therapist confirmed that these devices were intended to support the resident's self-feeding abilities. Interviews with facility staff, including the MDS nurse, occupational therapist, and Director of Nursing, verified that the adaptive equipment was present but was not used by the resident as intended. The occupational therapist was unaware that the resident was being fed by staff instead of using the assistive devices, and the Director of Nursing confirmed that the devices were meant for resident use, not staff. Facility policy also indicated that assistive devices are to be provided and supervised for resident use to support independence.

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