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F0689
D

Failure to Provide Required Dining Supervision and Assistance

Beaver Dam, Wisconsin Survey Completed on 07-21-2025

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

A deficiency occurred when a resident with significant medical needs, including Parkinson's disease with dyskinesia, dementia, dysphagia, and essential tremor, was not provided with the required level of supervision and assistance during mealtime. The resident's care plan specified the need for feeding assistance, direct supervision, and cuing due to worsening tremors and difficulty feeding independently. Despite these documented needs, the resident was observed eating alone in the dining room without staff seated at the table to provide supervision or assistance. Staff present in the dining area were either assisting other residents or unaware of the specific supervision requirements for this resident. Interviews with CNAs revealed a lack of clarity regarding which residents required meal assistance, with one CNA stating that such information would be found in computer charting, but not specifically in the CNA charting for this resident. The Assistant Director of Nursing confirmed that direct supervision meant a staff member should be seated at the table with the resident to assist with eating. The facility did not have a separate dining supervision policy and relied on care plans and general regulatory guidance, which led to inadequate supervision for the resident during meals.

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