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F0806
D

Failure to Honor Resident Food Preferences for Portion Size and Flavor

Susanville, California Survey Completed on 09-12-2025

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 honor a resident's food preferences regarding portion size and flavor, despite documented assessments and repeated verbalizations from the resident. The resident, who had a history of major depression, fatigue, and a major neurocognitive disorder due to possible Alzheimer's Disease, was observed to consistently receive large food portions and multiple chocolate-flavored nutritional supplements, even after expressing dissatisfaction with both. Facility policy required that food preferences be assessed and communicated to dietary staff, and that staff confer with the physician if a resident was unhappy with their diet. Observations and interviews revealed that the resident repeatedly stated she was tired of chocolate and found the food portions too large, which discouraged her from eating. Despite these statements, the dietary department was not notified of her preferences, and her meal trays continued to include large portions and chocolate-flavored drinks. Staff interviews confirmed awareness of the resident's complaints, but no action was taken to update her dietary profile or consistently offer alternative flavors or smaller portions. Documentation showed that while small portions were previously ordered, this was discontinued after a noted weight loss, and the resident's ongoing preference for smaller portions was not reinstated or communicated. Multiple staff members, including CNAs, LNs, and dietary management, acknowledged the resident's dissatisfaction but did not ensure her preferences were reflected in her meal service. The resident's dietary profile still listed chocolate as a liked preference, and staff were unaware of the need to notify dietary or nursing when preferences changed. As a result, the resident continued to receive meals and supplements that did not align with her stated preferences, as evidenced by uneaten food and partially consumed supplements observed during multiple meals.

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