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F0658
D

Untrained Staff Provided Feeding Assistance to Dependent Resident

Los Angeles, California Survey Completed on 07-14-2025

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 facility failed to ensure that only trained staff provided feeding assistance to a resident who required a pureed diet and one-on-one feeding. During an observation, a Receptionist, who had not received training on feeding residents, was seen feeding a resident with a pureed, honey-thick diet in the front lobby. The resident's records indicated dependence on staff for eating, oral hygiene, and personal hygiene, and physician orders specified the need for one-on-one feeding with a teaspoon only, as well as monitoring for swallowing difficulties and behaviors. The Receptionist confirmed in an interview that she had not been trained to feed residents and that the DON and other nursing staff expected her to assist with feeding and behavior monitoring. Facility policy required that all employees assisting with meals be trained and demonstrate competency in safe feeding practices. The failure to follow these policies resulted in an untrained staff member feeding a resident with significant dietary and behavioral needs.

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