F0550

D

Failure to Maintain Dignified Mealtime Assistance for Dependent Residents

Milwaukee, Wisconsin Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to ensure residents were treated with dignity and respect during mealtimes, as required by facility policy and residents’ rights. Surveyor observations on 2/11/26 showed CNAs standing over residents while feeding them and one CNA feeding two residents interchangeably at the same time, contrary to the facility’s expectation that staff sit when feeding residents and provide a relaxing, enjoyable mealtime environment. The facility’s Meal Supervision and Assistance guideline, revised 10/29/24, states that residents will be prepared for a well-balanced meal in a calm environment with adequate supervision and assistance to assure an enjoyable event, but this was not followed during the observed meals.

One resident (R1) had significant functional and cognitive impairments, including spastic hemiplegia, paraplegia, aphasia, moderate protein-calorie malnutrition, colostomy status, and seizures. R1’s MDS dated 1/5/26 documented both short- and long-term memory impairment, severely impaired decision-making, and range of motion impairment in both upper and lower extremities, with dependence on staff for eating and other ADLs. R1’s care card and care plan directed that R1 receive maximum assist from one staff member for eating and noted that R1 does well with finger foods. Despite these needs and directives, surveyors observed CNAs standing while feeding R1 and one CNA alternating feeding between R1 and another resident during both breakfast and lunch.

Another resident (R2) had diagnoses including encephalopathy, CKD, type 2 DM, adult failure to thrive, Alzheimer’s disease, dementia, depression, and anxiety disorder. R2’s MDS dated 12/4/25 showed both short- and long-term memory impairment, severely impaired decision-making, no ROM impairment, and total dependence on staff for eating and other ADLs. R2’s care card and care plan documented total dependence on one staff member for eating. During breakfast, surveyors observed R2 appearing to be sleeping with a bowl of eggs in front of them while the CNA attempted to wake them, and later the same CNA stood between R1 and R2, feeding both residents interchangeably. Similar standing and alternating feeding behavior was observed at lunch. When interviewed, the CNAs stated they were standing because they did not see any seats, and the DON confirmed that CNAs are expected to follow the care cards and to sit when feeding residents, acknowledging the surveyor’s concerns about the observed practices.