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F0806
D

Failure to Accommodate Resident Meal Preferences and Dietary Needs

Conroe, Texas Survey Completed on 11-25-2025

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 a resident consistently received meals that accommodated her stated food preferences, specifically regarding the exclusion of sausage and gravy from her meals. Despite the resident's repeated requests and documentation on her meal tickets to avoid these items, kitchen staff continued to serve her sausage for breakfast and meals covered in gravy. The resident reported that her preferences were not being honored, and she frequently had to remind staff about her dislikes, which were also communicated to dietary management and administration. Record reviews revealed that the resident had multiple medical diagnoses, including Type 2 Diabetes, GERD, hypertension, gout, and anxiety disorder, and was on a therapeutic diet as ordered by her physician. The care plan included interventions to offer alternatives if the resident did not like the meal and to document any issues with meal consumption. Nutrition progress notes and resident council meeting minutes documented ongoing complaints about the failure to follow meal preferences, as well as issues with food temperature and quality. The facility's grievance logs showed a significant number of complaints directed toward the dietary department over several months, many of which were related to meal preferences and food quality. Interviews with dietary managers and administrative staff confirmed that staff were not consistently reading or following the meal tickets, resulting in the resident receiving unwanted food items. The previous dietary manager acknowledged receiving valid grievances from the resident and attributed the ongoing issues to staff not taking the time to check meal tickets. The facility also had issues with dietary staff lacking proper food handler certifications and a high volume of grievances related to the dietary department, as confirmed by both staff and administrative records.

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