Failure to Adhere to Dietary Restrictions for Resident
Summary
The facility failed to adhere to dietary restrictions for a resident, specifically regarding the use of straws, which were prohibited due to the resident's risk of choking and aspiration. During an observation, it was noted that the resident's lunch tray included drinks with straws, despite a clear order against their use. The resident's meal ticket and physician's order both specified 'no straws' due to the resident's facial weakness and poor dentition, which increased the risk of choking when using straws. The Speech Language Pathologist had recommended against the use of straws as a precautionary measure following a clinical evaluation and swallow study. Staff interviews revealed a lack of awareness and adherence to the dietary restrictions. A Registered Nurse admitted to not checking the meal ticket for straw restrictions and acknowledged the expectation for CNAs to read meal tickets. The Director of Nursing explained that therapy communications are supposed to be updated in the care plan by the unit manager, and serious orders are highlighted in the electronic medical record for CNAs. However, despite these protocols, the order for no straws was not followed, leading to the deficiency.
Penalty
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A resident with dysphagia and a hx of stroke was ordered a slow-flow adaptive drinking cup with fluids, and the care plan and meal ticket also identified the need for the device. During a meal observation, a CNA served cranberry juice in a regular cup instead, and the resident drank from it and immediately coughed. The CNA, an LVN, the SLP, and the DON all acknowledged the resident should have received the ordered adaptive cup.
Failure to provide ordered drinking equipment: A resident with severe cognitive impairment and staff-assisted feeding was supposed to use a nose out cup per the care plan, but a regular cup was served instead. During feeding, the cup hit the resident’s nose as it became less than half full. The NA said the cup was not sent from the kitchen and that the kitchen often forgets to send the limited supply of nose out cups.
Failure to provide ordered eating assistance: A resident with moderate cognitive impairment who needed staff supervision with eating was supposed to receive all foods in separate bowls at each meal. During lunch, the resident was observed eating in bed with food served on a regular plate instead of separate bowls, and an LPN confirmed the meal ticket called for separate bowls.
A resident with Parkinson’s disease, left-side weakness, and impaired upper extremity function was supposed to receive a rocker knife, lipped plate, and built-up utensils for meals, but staff did not consistently provide the ordered adaptive equipment. Surveyors observed the resident struggling to cut food and eat with regular utensils, while staff only intermittently offered help and did not ensure the resident received the equipment listed on the care plan, Kardex, and meal ticket.
Failure to provide adaptive eating equipment: A resident with Alzheimer's disease, dementia, PCM, muscle weakness, and severely impaired cognition was supposed to receive a scoop plate with meals to support self-feeding. During lunch, staff served the meal on a regular plate instead, and the resident was observed with weak, unsteady hands while trying to scoop food. CNA confirmed the scoop plate was not provided, and the FSD and DON stated adaptive equipment should be provided with meals.
Adaptive feeding equipment was not provided as ordered for a resident with hemiplegia, DM2, and vascular dementia. The resident’s order required a high sided plate and rocker knife, and the care plan noted the need for both items at meals, but an observed lunch tray did not include either item. The resident said he frequently did not receive the rocker knife or high sided plate and that it made eating harder.
Failure to Provide Ordered Adaptive Drinking Cup
Penalty
Summary
The facility failed to provide Resident #24 with the physician-ordered slow-flow adaptive drinking cup during the noon meal. Resident #24 had diagnoses including dysphagia and a history of stroke. The physician order dated 06/11/2024 required a slow-flow adaptive drinking cup with fluids, and the care plan dated 11/11/2025 identified the adaptive drinking cup as needed to promote safe swallowing and reduce the risk of aspiration. The meal ticket also indicated that Resident #24 required a slow-flow adaptive drinking cup with meals. During observation of meal service on 07/13/2026 at 12:15 pm, CNA D served cranberry juice in a regular drinking cup instead of the ordered adaptive cup. Resident #24 independently lifted the regular cup, drank the juice, and immediately coughed after swallowing. CNA D stated the resident should have been provided a slow-flow adaptive drinking cup and acknowledged the incorrect cup was served. LVN C stated she was responsible for making sure residents had what was ordered by the doctor and said the resident should have had a sippy cup. The SLP stated Resident #24 required thin liquids with small sips when drinking, and the DON stated staff are educated regarding adaptive equipment needs and that the slow-flow adaptive drinking cup is intended to regulate fluid intake and promote safer swallowing.
Failure to Provide Ordered Drinking Equipment
Penalty
Summary
The facility failed to ensure that staff provided assistive drinking equipment in accordance with a resident’s care plan for one resident who was severely cognitively impaired and required staff assistance for eating. The resident’s quarterly MDS assessment showed severe cognitive impairment, and the care plan, revised June 6, 2026, identified decreased intake with meals and risk for weight loss. The care plan directed that the resident’s food be served in bowls and that he use a nose out cup when drinking. During observation on July 1, 2026, the resident’s drink was served in a regular cup instead of the ordered nose out cup. When the nurse aide fed the resident, she used the regular cup, and once it was less than half full, the cup hit the resident’s nose while she was giving him a drink. The nurse aide stated the nose out cup did not come from the kitchen with the tray, that she called for one to be sent up, and that the kitchen staff usually forget to send one because there are only a few in the facility. The Nursing Home Administrator confirmed that the resident should have had his nose out cup for the meal.
Failure to Provide Ordered Eating Assistance
Penalty
Summary
The facility failed to ensure that staff provided assistive eating devices as ordered for one resident who was moderately cognitively impaired and required staff supervision with eating. The resident’s care plan stated she was at risk for altered nutrition and was to have all foods in separate bowls for each meal. During a lunch observation, the resident was eating in bed with her food served on a regular plate rather than in separate bowls, and her meal ticket also indicated that all food items were to be in separate bowls. An LPN later confirmed that the resident did not have her food items in separate bowls and should have, according to the meal ticket.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment and appropriate assistance for a resident with Parkinson’s disease, left-side weakness, diabetes, epilepsy, mood disorder, and insomnia. The resident’s MDS showed intact cognition with a BIMS score of 14 out of 15, upper extremity impairment, and a need for supervision or touching assistance with eating. The care plan, Kardex, and nutrition documentation identified the resident as needing a rocker knife, lipped plate, and built-up utensils, and noted the resident was at risk for malnutrition and had a history of weight loss and oral nutritional supplements. During observation, the resident was seen eating meals in a recliner with a tray on the lap or on a table in front of them, but did not have the ordered adaptive equipment. At lunch, the resident had a regular fork, knife, and spoon, attempted unsuccessfully to cut meat, and had tremors while eating. The resident stated staff did not offer help very often and said they had trouble eating because of tremors from Parkinson’s disease. The CNA who delivered the tray asked if help was needed cutting food, but the resident declined at that time and was told to call if anything was needed. At breakfast the next day, the resident again did not have a lipped plate or built-up utensils and was observed struggling to cut bacon, eggs, and toast. The CNA did not get up to assist and stated the resident did not usually ask to have food cut. The meal ticket still indicated a lipped plate, and dietary staff later acknowledged the resident had not received the lipped plate at breakfast. The DON stated the resident still required built-up silverware, and the dietary manager stated adaptive equipment orders were entered on the meal ticket and verbally communicated to staff.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide the appropriate assistive eating utensil to Resident 85 during the lunch meal on 5/18/26. Resident 85 had diagnoses including Alzheimer's disease, dementia, moderate protein-calorie malnutrition, and muscle weakness. The MDS dated 1/8/26 indicated a BIMS score of 5 out of 15, showing severely impaired cognition, and also indicated the resident needed supervision or touching assistance with eating. The care plan identified malnutrition risk related to dementia and malnutrition, and the active physician's order called for a fortified regular diet with thin liquids. The resident's nutritional risk review dated 4/9/26 directed that a scoop plate be provided during all meals to support independence with self-feeding. During observation, staff served the lunch meal on a regular white dinner plate, and Resident 85 was seen with weak and unsteady hands while trying to scoop food. Resident 85 stated the scoop plate was not provided and that it would have helped with scooping food and prevented the tray from becoming cluttered. CNA 3 confirmed the scoop plate was not provided and stated the resident should have received one with every meal. The FSD and DON stated that adaptive eating equipment should be provided with meals to support independence, and the facility policy stated adaptive devices will be provided for residents who need or request them.
Adaptive Feeding Equipment Not Provided as Ordered
Penalty
Summary
Failure to provide adaptive feeding equipment occurred for Resident #12, who had diagnoses including hemiplegia, type 2 diabetes mellitus, and vascular dementia. The resident’s quarterly MDS assessment indicated intact cognition and that he required set up for eating. A physician order dated 10/30/25 specified a regular diet with a high sided plate and a rocker knife, and the care plan last revised on 04/26/26 noted nutrition risk related to diabetes mellitus, hypertension, hemiplegia, and mild cognitive impairment, with the need for a high sided plate and rocker knife at meals. During observation on 05/20/26 at 1:20 P.M. with the RD, Resident #12’s lunch tray did not include the ordered high sided plate or rocker knife. At the time of the observation, the resident stated he frequently did not get the rocker knife or high sided plate and that it made it harder for him to eat his meals. The facility policy on Adaptive Feeding Equipment stated dietary must be notified of adaptive equipment needs and ensure the equipment is placed on the tray at each meal.
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