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F0803
D

Failure to Honor and Document Resident Food 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 ensure that a resident's food preferences were honored, resulting in the resident not consistently receiving meals in accordance with his dietary plan. The resident, who had diagnoses including COPD, anxiety disorder, and PTSD, was assessed as having intact cognition and was independent in eating. Despite having a physician order specifying a vegetarian diet with certain allowed breakfast items, the resident reported receiving meals inconsistent with his preferences on multiple occasions. He completed dietary request forms, but on at least two occasions, his requests were not fulfilled due to unavailability of requested items, and he subsequently stopped submitting requests. The resident also reported receiving meals containing meat, which was not in line with his dietary restrictions, even after discussing his meal plan with facility staff. Interviews with dietary staff revealed that while food preferences were assessed upon admission and intended to be updated as needed, there was no documentation of updates to the resident's food preferences since admission. Staff acknowledged the importance of documenting changes to ensure all team members were informed and to maintain consistency in meal preparation. The facility's policy required honoring and documenting individual food preferences, but the lack of documentation and communication led to the resident not receiving his preferred meals.

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