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F0806
D

Failure to Honor Resident Food Preferences and Dietary Needs

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 provide food that accommodated resident preferences and dietary needs for three residents, as evidenced by direct observations, interviews, and record reviews. One resident with moderate cognitive impairment and a history of malnutrition and dysphagia was repeatedly served vegetables and tough meats, despite these being listed as disliked foods on his meal ticket and his inability to chew them. The resident had communicated these preferences to staff and the dietician, but the issue persisted, resulting in the resident refusing meals and expressing frustration over not being heard. Another resident with Crohn's disease and a low residue diet order was served mixed vegetables, including beans, which were specifically restricted on her meal ticket. The resident, who was cognitively intact, reported that she sometimes received foods incompatible with her medical condition, and this was confirmed by observation and staff interview. The care plan for this resident did not specify which foods to avoid or safe alternatives, contributing to the dietary errors. A third resident, who had a documented dislike of gravy and a preference for Cheerios at breakfast, continued to receive gravy on her meals and had to repeatedly request her preferred breakfast cereal. Despite her dislikes being clearly listed on her meal ticket, staff continued to serve her foods she did not want, leading to ongoing frustration. These incidents demonstrate a failure to honor resident food preferences and provide appealing alternatives as required by facility policy and resident rights.

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