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F0804
E

Failure to Provide Palatable and Properly Tempered Food and Drink

Brookfield, Wisconsin Survey Completed on 06-25-2025

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 food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures, as required by facility policy. Multiple residents reported that their meals, particularly meat dishes, were too tough to chew and often served cold or lukewarm, especially when meals were delivered to resident rooms. Surveyors observed that food temperatures on test trays were below the required threshold for hot foods, with mixed vegetables at 122°F and beef with gravy at 130°F, both below the facility's policy of holding hot foods at 135°F or greater. Cold items, such as milk and cranberry juice, were also served above the required cold holding temperature, with milk at 52.1°F and juice at 51°F, exceeding the policy limit of 41°F or below. Residents with varying cognitive abilities, including those with moderate cognitive impairment and diagnoses such as protein-calorie malnutrition and dementia, voiced concerns about the palatability and temperature of their meals. Several residents indicated that the meat was too tough to chew or swallow, and that hot foods were often served cold, particularly for those eating in their rooms. Surveyors directly observed residents struggling to eat the provided meat, and noted that some residents resorted to bringing in outside food due to dissatisfaction with the facility's meals. Staff interviews revealed that there were operational issues contributing to the deficiency, such as a shortage of heat-retaining cambrio tops and bottoms, resulting in inadequate temperature maintenance during meal delivery. The dietary staff acknowledged that the beef was overcooked and dry due to being cooked in two separate stages, contrary to the recipe instructions. The facility's failure to maintain appropriate food temperatures and palatability affected all sampled and supplemental residents reviewed for food quality, as confirmed by both resident interviews and direct surveyor observations.

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