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F0550
D

Failure to Honor Resident's Dining Location Preference

Mount Horeb, Wisconsin Survey Completed on 09-15-2025

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 the facility failed to honor a resident's stated preference to eat meals in the dining room, as required by both facility policy and federal regulations regarding resident rights. The resident, who has a history of multiple sclerosis, cerebral infarction, major depressive disorder, muscle weakness, and heart failure, expressed her desire to eat in the dining room for social interaction and because she had no suitable place to eat in her room. Despite her care plan and meal tickets indicating her preference for dining room meals, staff did not consistently facilitate this choice. On the morning in question, the resident was not taken to the dining room for breakfast due to a delay in her scheduled shower, resulting in her receiving her meal in her room instead. Interviews with facility staff, including the CNA, Dietary Manager, and DON, confirmed that the resident's preference to eat in the dining room was known and documented. The DON acknowledged that it is the resident's right to choose where to eat and that staff should honor this choice. However, the failure to coordinate care and ensure the resident was clean and dressed in time for breakfast led to her not being able to exercise her right to dine in the dining room as she wished.

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