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F0805
D

Resident Served Incorrect Diet Despite Mechanical Soft Order

Jefferson, Wisconsin Survey Completed on 06-23-2025

Penalty

10 days payment denial
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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

A deficiency occurred when a resident with a physician order for a mechanical soft diet was served a regular diet meal instead of the prescribed mechanically altered meal. The facility's policy specifies that a mechanical soft diet is intended for individuals who have difficulty chewing, requiring certain foods to be modified for easier consumption. During a lunch observation, an aide prepared and served a regular diet plate to the resident who required a mechanical soft diet, while another mechanical soft meal was set aside and not served to the intended resident. The surveyor confirmed through interview and record review that two residents on the unit were prescribed mechanical soft diets, but only one received the correct meal. The error was identified when the aide removed the incorrectly served regular diet plate from the resident's table. The incident was discussed with the dietary director and reported to the nursing home administrator and director of nursing. No explanation was provided for why the wrong diet was served to the resident.

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