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F0810
D

Failure to Consistently Provide Required Adaptive Eating Equipment

Hales Corners, Wisconsin Survey Completed on 06-18-2025

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 was identified when a resident with diagnoses including Parkinson's disease, osteoarthritis, osteoporosis, and unspecified lack of coordination did not consistently receive the adaptive eating equipment specified in their care plan and meal tray tickets. The resident's care plan and occupational therapy notes indicated the need for built-up silverware, a divided plate, and a small nosey cup to support independent eating and drinking. Despite these documented needs, multiple observations by the surveyor revealed that the resident's meal trays frequently lacked one or more of the required adaptive devices, such as the divided plate and nosey cup, even though these items were listed on the tray tickets. Interviews with facility staff, including dietary aides, certified nursing assistants, and the food service director, confirmed that the process for ensuring adaptive equipment was collaborative, with occupational therapy communicating needs and dietary staff responsible for assembling trays accordingly. However, staff acknowledged inconsistencies in the provision of adaptive equipment, and it was noted that the facility had a limited supply of certain items, such as only one 4-ounce nosey cup, which was not always available for the resident. The surveyor's review of the facility's policy on meal supervision and assistance further highlighted the expectation that trays be checked for correct diet, food consistency, and necessary adaptive devices before serving. Despite this policy, the resident did not consistently receive the adaptive equipment required for independent eating, as evidenced by repeated mismatches between the meal tray tickets and the items actually provided on the trays.

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