Facility Fails to Honor Resident Drink Preferences
Summary
The facility failed to honor the drink preferences of seven residents, as identified in a review of the Menu Committee Minutes and through resident and staff interviews. The facility decided to stop offering soda as a beverage option, informing residents that soda would only be available in vending machines or as BINGO prizes. This decision was made without prior notice to the residents, and the vending machine prices were considered too high by the residents. As a result, residents who preferred soda, such as Residents 48, 101, 111, 134, 60, 135, and 46, were dissatisfied and felt their preferences were not respected. Interviews with the residents revealed their frustration with the facility's decision, as some residents had to rely on family members to provide soda, while others, like Resident 101, had no family support and could not afford the vending machine prices. The foodservice director and the administrator confirmed that the decision to remove soda was made by corporate due to its lack of nutritional value and cost. However, there was no documented evidence that the facility provided alternative drink options based on individual preferences, leading to a deficiency in meeting resident rights as per 28 Pa. Code 201.29(a).
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The facility failed to provide ordered altered-consistency liquids and adequate hydration for two residents with post-stroke dysphagia. One cognitively intact resident was observed with an untouched meal tray lacking any fluids, had dry skin and chapped lips, and reported receiving unpalatable meals and dry cereal without milk, while staff were unclear about the "no drinks on the tray" diet slip and only later identified the need for Level 2 (nectar thick) liquids. Another cognitively intact resident with an order for Level 2 liquids received a tray with no liquid texture information and regular juices, and reported that CNAs bring regular juice on request despite disliking thickened fluids and recognizing inadequate fluid intake. The RD/Kitchen Manager acknowledged that residents should receive correct-consistency fluids, be monitored for hydration and compliance, and have their fluid consistency needs clearly communicated to floor staff.
Multiple residents were observed eating their evening meals without any drinks at their tables, with some having consumed a significant portion of their food before beverages were offered. A CNA on duty was unsure why the residents had no drinks and only offered a beverage after being prompted, while the DON and Dietary Manager later confirmed that all residents should receive drinks with meals and that CNAs are responsible for preparing and delivering them. Facility policy requires staff to monitor food and fluid intake and address inadequate fluid consumption, but this was not followed for these residents during the observed meal.
Two residents with intact cognition and dependence on staff for most ADLs did not have bedside water pitchers and reported only receiving small amounts of fluids when requested or only at mealtimes, despite feeling thirsty and having dry mouths. Observations confirmed the absence of water pitchers and cups in their rooms. A CNA not assigned to one resident eventually brought a pitcher after noticing it was missing, while the assigned CNA stated they only provided water upon request. An LVN and the DON both stated that all residents who can swallow and are not on fluid restriction must have bedside water pitchers and that nursing staff are responsible for ensuring this, in line with facility policies on accommodating needs and supporting ADLs.
A resident with dementia, acute kidney failure, and documented concerns about food and fluid intake was repeatedly observed in common areas and in her room without fluids available and without being offered fluids between meals. A CNA confirmed that no fluids were given between breakfast and lunch, and the resident’s family reported that staff did not "push fluids," which they associated with a recent hospitalization for severe dehydration and abnormal lab values requiring IV fluids. The resident’s care plan identified risk for dehydration, and the facility’s hydration policy required offering sufficient fluids to maintain hydration, but these measures were not implemented for this resident.
Surveyors found that multiple residents did not have water pitchers, [NAME] cups, or other drinks at bedside, with some having only leftover juice from lunch, despite facility policies requiring fresh bedside water and a structured hydration program. One resident complained of feeling very hot and repeatedly requested a drink, and an LPN and a NA confirmed that several residents lacked bedside water. The facility’s written procedures assigned night shift staff to replace used water containers daily with clean, filled containers, and dietary staff to wash and supply pitchers, yet these processes did not result in consistent bedside hydration for the affected residents.
Staff failed to follow the facility’s hydration process and policy requiring NOC shift CNAs to replace and refill bedside water pitchers daily, resulting in two residents being observed on consecutive days with teal water pitchers only one-quarter full and not refilled. Both residents, who had conditions including DM, CKD, hypotension, lung CA, and a moderate cognitive deficit, reported that their pitchers had not been refilled for at least two days, despite care plans directing staff to encourage fluids, in-between snacks and fluids, and good nutrition and hydration to support skin health. A CNA acknowledged that the NOC shift appeared not to have refilled the pitchers, and the ADM stated that this failure could place residents at risk for dehydration.
Failure to Provide Ordered Thickened Liquids and Adequate Hydration
Penalty
Summary
The facility failed to ensure residents received liquids consistent with their ordered altered consistencies and hydration needs. One resident with post-stroke swallowing difficulties, cognitively intact per an admission MDS, was observed with an untouched lunch tray that had no fluids. The resident had chapped lips and dry facial skin and reported that meals had been cold and unpalatable since admission, describing breakfast as a glob of eggs and an unmanageable muffin, and receiving dry cereal without milk on two mornings. A CNA, upon checking the diet slip, noted it stated no drinks on the tray and did not know what that meant, indicating they would need to ask the nurse. An LPN then reviewed the orders and identified that the resident required Level 2 (nectar thick) liquids, retrieved a single carton of nectar thick juice from a locked nourishment room, and provided it, with no other Level 2 beverages observed in the refrigerator. The LPN stated that aides would need to ask the nurse to know what type of liquid to give a resident. Another resident, also admitted with post-stroke swallowing difficulties and cognitively intact per the admission MDS, had a dietary order for Level 2 liquids. During a meal observation, this resident’s tray diet slip contained no information about liquid textures, and the tray included two containers of normal-consistency juice. Later, the resident was observed in bed drinking normal-consistency cranberry juice and reported that aides bring juice containers upon request, expressing dislike for nectar thickened fluids, especially water, but acknowledging not getting enough fluids. The Registered Dietician/Kitchen Manager stated that all residents should receive sufficient fluids of the correct consistency, that residents with altered fluid consistency should be monitored for compliance and hydration, and that there should be a quick reference system to communicate residents’ fluid consistency needs to floor staff. The report states that these failures placed residents at risk for dehydration, aspiration, and decreased quality of life.
Failure to Provide Drinks With Meals to Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide drinks with meals consistent with resident needs and preferences and sufficient to maintain hydration. During an evening meal observation on 03/01/26 at 5:28 PM, four residents (R1, R2, R3, and R4) were seated in the dining room with their meals in front of them but had no drinks at their tables. At that time, R2 and R3 had already eaten approximately one third of their food, and R4 had eaten approximately three quarters of his food, all without drinks present. By 5:44 PM, all four residents were still eating and still did not have drinks in front of them. At 5:45 PM, a CNA (V3) stated she did not know why the four residents did not have drinks and suggested they may have come late, and only then asked one resident (R2) if she wanted something to drink, to which R2 responded affirmatively. Later, the DON (V2) stated that all residents should receive a drink with their meals regardless of arrival time or table changes. The Dietary Manager (V4) confirmed that all residents should receive drinks with their meals, and that CNAs are responsible for preparing and delivering drinks, while the kitchen prepares beverage pitchers. The facility’s undated “24 hour Dining” policy states that staff will monitor residents’ food and fluid intake for adequate consumption and that any staff member observing inadequate fluid intake at meals will refer the resident to the DON and Dining Services Manager for follow-up, but this monitoring and provision of fluids did not occur for the four observed residents during the meal in question.
Failure to Provide Bedside Water Pitchers to Maintain Resident Hydration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received fluids consistent with their needs and preferences to maintain hydration, specifically for two residents who did not have water pitchers in their rooms. One resident was admitted with myasthenia gravis and sequelae of cerebral infarction, had intact cognitive skills, and was dependent on staff for most ADLs including transfers. This resident reported not having a water pitcher, receiving only small cups of water when requested, and experiencing dry lips and throat. On a subsequent day, the resident’s call light had been on for over 30 minutes while the resident was waiting to request water due to thirst and a dry mouth. Another resident, admitted with hemiplegia and diabetes mellitus, also had intact cognitive skills and was dependent on staff for most ADLs including transfers. This resident reported not being given a water pitcher and stated that water and juices were only provided during mealtimes. Observations confirmed there were no cups and no water pitcher in this resident’s room. Both residents were described in clinical documentation as alert, oriented, and capable of making decisions, yet they lacked ready access to fluids at the bedside. Staff interviews further clarified the circumstances leading to the deficiency. A CNA who was not assigned to one of the residents brought a water pitcher after noticing its absence and stated that all residents should have a water pitcher at the bedside to prevent dehydration. An LVN stated that all residents who can swallow and are not on fluid restriction must have a water pitcher at their bedside and that all staff are responsible for providing water. The CNA assigned to one of the residents stated they only provided water if the resident requested it and had assumed the resident did not need water when the resident answered “no” to a general offer of assistance. The DON stated that all residents who can swallow and are not on fluid restriction must have water pitchers at their bedside, that pitchers should be changed daily and as needed, and that nursing staff are responsible for assuring all residents have a water pitcher, consistent with facility policies on accommodation of needs and supporting ADLs.
Failure to Provide Adequate Fluids to Dependent Resident
Penalty
Summary
Surveyors identified that the facility failed to provide adequate fluids to maintain hydration for one dependent resident. Over multiple observations on consecutive days, the resident was repeatedly seen seated in a reclining wheelchair in the common area and in her room without any fluids available nearby. During the morning hours, no water or other fluids had been passed to the resident in her room or in the common area, and by late morning the resident remained without access to fluids. During a lunch dining observation, a CNA fed the resident a liquid diet meal that included broth, yogurt, a magic cup, a mighty shake, pudding, and juice, and the resident’s family took over feeding during the meal. The CNA reported that she had not given the resident any fluids between breakfast and lunch. The resident’s family member reported that staff had not “pushed fluids,” which they believed led to a recent hospitalization for dehydration and elevated sodium levels, and that family members came daily to feed the resident because staff did not feed or offer enough fluids. The family member stated that when they were unable to visit due to illness, the resident became dehydrated, and that the facility continued not to offer fluids even after the resident returned from the hospital. Record review showed the resident had multiple diagnoses including Alzheimer’s disease, dementia, acute kidney failure, and signs and symptoms concerning food and fluid intake. A recent ED note documented that the resident was admitted with severe dehydration, dry oral cavity, and significantly abnormal labs, including sodium of 170 and potassium of 3.0, and was treated with IV fluids. The resident’s care plan identified dehydration or potential for fluid deficit related to diuretic use, with an expectation that the resident would be free of dehydration symptoms, and the facility’s hydration policy required offering sufficient fluids to maintain proper hydration and health.
Failure to Provide Bedside Hydration Consistent With Resident Needs and Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents consistently had access to drinks at bedside in accordance with their needs, preferences, and the facility’s hydration policies. During surveyor observations, multiple residents were found without water pitchers, [NAME] cups, or any water at their bedside. One resident explicitly stated feeling very hot and repeatedly requested a drink, and an LPN confirmed that this resident had no drinks at bedside. Another resident and that resident’s roommate were also observed without any drinks at bedside, which the LPN again confirmed. A nursing assistant later verified that several additional residents had no water or water pitchers at bedside, with some having only leftover juice in Kennedy cups from lunch. The facility’s written Hydration Program policy stated that each resident should receive sufficient fluid intake to maintain proper hydration and health, and the Bedside Water Containers policy required that residents have fresh drinking water at bedside daily, with two complete water container sets per resident. The procedure assigned night shift staff to collect used water containers and replace them daily with clean containers filled with fresh water and ice, which were to be cleaned and sanitized by the food and nutrition services department and then stored inverted until needed. The Dietary Manager reported that water pitchers are replaced and washed in the morning, with dietary staff delivering clean pitchers early and other staff distributing ice and water. The Administrator reported that the facility conducts a hydration pass twice a day. Despite these policies and processes, survey findings showed that several residents did not have water or appropriate bedside fluids available at the time of observation.
Failure to Provide Fresh Bedside Water and Hydration per Policy
Penalty
Summary
The facility failed to ensure bedside water pitchers were filled or that fresh water was offered daily for two residents, resulting in water pitchers remaining only one-quarter full over multiple days. On two consecutive mornings, one resident was observed alert and oriented in a wheelchair with a teal bedside water pitcher that was one-quarter full; the resident reported that CNAs usually refilled his water but that it had not been done that morning, and later stated the pitcher had not been refilled either the previous day or that day. A CNA later confirmed, in the resident’s presence, that the NOC shift appeared not to have refilled this resident’s water pitcher for two days. This resident’s records showed diagnoses including diabetes mellitus, chronic kidney disease, and hypotension, and care plans directing staff to encourage fluids during the day to promote prompted voiding, assist and encourage in-between fluids and snacks due to risk for protein malnutrition, and encourage hydration related to hyperglycemia and skin integrity. Another resident was observed on two consecutive days with a teal water pitcher on the nightstand that was one-quarter full, first while alert, oriented, dressed, and eating lunch, and later with the water level unchanged from the prior day. This resident stated that CNAs usually refilled her water pitcher but that it had not been filled that day, and later reported it had not been filled the previous day or that day. In a subsequent observation with a CNA present, the CNA stated that the NOC shift is responsible for filling all residents’ water pitchers daily before the end of shift and acknowledged that it appeared the NOC shift did not refill this resident’s pitcher. This resident’s records indicated diagnoses including chronic kidney disease and lung cancer, a BIMS score of 11 indicating a moderate problem with thinking, and a care plan intervention to encourage good nutrition and hydration to promote healthier skin. The Administrator stated that the facility’s process is for NOC shift CNAs to replace and refill residents’ water pitchers with fresh water daily toward the end of each shift and acknowledged that failure to refill pitchers could place a resident at risk for dehydration. The facility’s policy on Resident Hydration and Prevention of Dehydration stated that nurses’ aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care.
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