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F0806
D

Failure to Honor Resident Food Preferences and Update Dietary Profile

Sunland, California Survey Completed on 09-11-2025

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

The facility failed to provide meals that accommodated a resident's food preferences and did not implement its own food preference policy by neglecting to update the resident's dietary profile during the required quarterly review. The resident, who had diagnoses including end stage renal disease, type 2 diabetes mellitus with hyperglycemia, mild protein-calorie malnutrition, and was dependent on renal dialysis, was admitted with specific dietary needs, including a renal/no added salt/consistent carbohydrate diet and a stated dislike for carbohydrates. Despite these documented preferences and dietary orders, the resident was repeatedly served meals containing carbohydrates such as rice, pasta, bread, and cake. The resident reported to staff that these items were consistently provided despite his expressed dislike and concern for their impact on his blood sugar. Observations and interviews confirmed that the kitchen staff did not honor the resident's preferences, and the Director of Dietary Services acknowledged that the resident's dietary profile had not been updated as required during the last quarterly review. The facility's policy required food preferences to be updated at least quarterly or as the resident's needs changed, but this was not done for the resident in question. As a result, the resident's food preferences were not honored, and the facility did not follow its own procedures for updating and documenting dietary preferences.

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