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F0806
D

Failure to Honor Resident Food Preferences for Breakfast

West Bend, Wisconsin Survey Completed on 04-23-2025

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 the food preferences of two residents by not providing their preferred breakfast item of fried eggs, despite these preferences being documented and communicated to dietary staff. One resident, who was cognitively intact and had a history of chronic medical conditions, regularly requested fried eggs for breakfast but was repeatedly told by the dietary manager that shelled eggs could not be provided due to vendor supply issues and facility budget constraints. The resident expressed dissatisfaction with the alternative options, such as liquid eggs, and stated that discussions with the dietary manager had not resulted in their preference being met. Observations in the kitchen revealed that shelled eggs were present but reserved for specialty items, and not used to fulfill resident breakfast preferences. Another resident, with moderately impaired cognition and multiple chronic diagnoses, also had a documented preference for fried eggs at breakfast but did not receive them. This resident reported that requests for fried eggs were denied due to cost and availability, and expressed dissatisfaction with the alternative scrambled eggs provided. Interviews with dietary staff confirmed that while shelled eggs were ordered, they were not served to residents as requested due to budget limitations, vendor supply issues, and staffing constraints. Meal tickets for residents who preferred fried eggs were changed to "if available," but the facility did not provide the preferred item, resulting in unmet resident preferences.

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