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F0656
D

Failure to Develop and Implement Person-Centered Care Plan for Dietary Preferences

Torrance, California Survey Completed on 12-15-2025

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 develop and implement a person-centered care plan that honored a resident's food preferences, resulting in the resident expressing dissatisfaction with meals that did not align with his dietary requests. The resident, who had diagnoses including COPD, anxiety disorder, and PTSD, was cognitively intact and able to independently manage most activities of daily living. Despite having a physician order specifying a vegetarian diet with certain allowable foods and completing dietary request forms, the resident did not consistently receive meals according to his preferences. On multiple occasions, the resident was served items not permitted by his diet, such as shredded chicken and meat patties, and was told by kitchen staff that requested items were unavailable. Interviews and record reviews revealed that while the resident's food preferences were assessed upon admission and communicated verbally to the kitchen, there was no documentation of updates to the resident's Nutrition/Dietary Food Preference since admission. The Dietary Technician acknowledged the importance of documenting changes but confirmed that updates were not made, leading to confusion and unmet meal requests. The resident's care plan did not include goals or interventions addressing changes in food preferences, and the facility's policy required care plans to be dynamic and person-centered, incorporating resident choices and preferences. The lack of documentation and care plan updates resulted in inconsistent care and unmet resident needs.

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