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F0806
E

Failure to Accommodate Resident Food Preferences and Choices

Bonham, Texas Survey Completed on 07-23-2025

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 accommodate the food preferences and choices of three residents, as evidenced by observations, interviews, and record reviews. One resident, who was cognitively intact and at risk for malnutrition, repeatedly requested milk with her supper meals but was consistently served tea instead. Staff interviews revealed that milk was not provided on certain days, with conflicting explanations regarding whether the facility had run out of milk. The Director of Food and Nutrition and the Administrator both confirmed that the resident should have received milk as requested, and that it was her right to have her beverage of choice at meals. Another resident, also cognitively intact and at risk for malnutrition, had documented preferences and physician orders for bacon and oatmeal for breakfast, and a dislike for sausage and eggs. Despite this, she was served sausage and a biscuit instead of her preferred bacon and toast. The resident reported this issue during both an interview and a resident council meeting, and her tray card indicated her correct preferences, which were not honored by the dietary staff. A third resident, with a history of anxiety, bipolar disorder, and depression, reported not receiving bread, butter, or jelly with her meals, and noted that potatoes were served without butter or cheese. Staff interviews confirmed that the facility had run out of these items and was awaiting a delivery. The Director of Food and Nutrition acknowledged being aware of the shortage but did not inform the Administrator or Dietitian, and did not take steps to procure the missing items in the interim. A group interview with residents corroborated that shortages of condiments and food were a recurring issue. The facility's policy states that residents have the right to reasonable accommodation of their needs and preferences, which was not upheld in these instances.

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