Failure to Provide Correct Liquid Consistency for Resident
Summary
The facility failed to ensure that Resident #21 received liquids at the appropriate thickness as ordered by the physician. The resident, who had a medical order for spoon-thick liquids due to dysphagia, was nearly given regular consistency tea by an LPN during a meal. The surveyor intervened to prevent the resident from consuming the incorrect liquid consistency. The resident's medical record indicated a need for pudding-thick liquids, and the resident's door was marked with a sticker indicating this requirement. Despite these indicators, the LPN attempted to serve the resident a drink that was not properly thickened. The LPN responsible for assisting Resident #21 with her meal did not follow the proper procedure for thickening the liquid. After being stopped by the surveyor, the LPN attempted to thicken the tea using a bowl of thickener but did not measure the appropriate amount as directed by the manufacturer. The LPN relied on visual assessment rather than precise measurement, resulting in a liquid that was still not at the required pudding-thick consistency. The DON confirmed that staff typically add thickener until the liquid looks right, without using specific measurements. This deficiency was identified as an Immediate Jeopardy situation by the State Agency, as it posed a significant risk of aspiration for Resident #21. The facility's failure to provide the correct liquid consistency had the potential to affect other residents receiving thickened liquids, although at the time of the survey, only two other residents required thickened liquids. The incident highlighted a lack of adherence to physician orders and proper procedures for preparing thickened liquids, which could have led to serious health consequences for the resident.
Penalty
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A resident with multiple diagnoses, including pelvic fractures, CVA, MDD, anxiety, GERD, HTN, and HLD, had a care plan and nutrition eval documenting a preference for skim milk. The resident said staff never provided skim milk and told him/her only low-fat milk was available. The dietician confirmed skim milk was the stated preference and should have been provided, while invoices and kitchen observation showed only whole milk and 1% milk on hand, with no skim milk available.
A facility failed to provide drinks, including coffee and water, to residents seated in Dining Room A and Dining Room B while waiting for late meal trays. Observations showed multiple residents at both breakfast and lunch services sitting without drinks, and when residents asked for coffee or a snack, staff said there were no drinks yet or that drinks would come on the tray. Interviews with CNA, Resident Council, DS, and DCS confirmed meals were running behind and residents were not receiving drinks while waiting.
Inconsistent Access to Drinking Water: The facility failed to ensure fresh water was consistently available at the bedside for four residents who were cognitively intact and reported that pitchers were taken for cleaning and not returned, or that they had to ask for water before receiving any. Observations showed no pitcher or Styrofoam cup at several bedsides, and a dietary cart with stacked pitchers remained in the hallway for hours without being passed to residents. An LPN and a nurse aide described the routine for pitcher cleaning and ice water distribution, and the DON confirmed the facility protocol required fresh water and ice each shift.
Failure to provide drinks consistently and on request. A resident with dementia, dysphagia, and impaired cognition had no drinks in the room and asked for coffee because he was thirsty. A CNA said drinks were only given with meal trays and coffee came when the coffee cart arrived, while an LPN later provided water after the surveyor intervened. The facility policy stated residents with dementia will forget to drink and should be encouraged and assisted.
Inconsistent Access to Drinking Water: The facility failed to consistently make fresh drinking water readily accessible to several residents. Residents with BIMS scores of 15 and diagnoses including CAD, diabetes, HTN, depression, seizure disorder, and bilateral BKA reported that water was often provided at night but not reliably during the day, requiring them to ask for it or rely on bottled water kept in their rooms. The NHA confirmed the issue.
Failure to provide fresh water consistently affected two residents reviewed for hydration. One resident had severely impaired cognition, dementia, renal insufficiency, and diabetes, while another had intact cognition with urinary incontinence, arthritis, and diabetes. Observations showed fluids were not readily available or offered for extended periods, and staff and resident council notes confirmed that water pass was often not completed and fresh water was not consistently available, including at night.
Failure to Provide Resident’s Preferred Milk
Penalty
Summary
The facility failed to ensure that a resident received the drink of preference identified on the care plan and nutritional assessment. The resident was admitted in February 2026 with diagnoses including fractures of the right and left pelvis, major depressive disorder, cerebral infarction, generalized anxiety disorder, hypothyroidism, GERD, hypertension, and hyperlipidemia. The admission MDS dated 03/24/26 indicated the resident was alert, oriented, his/her own decision maker, and scored 15/15 on the BIMS. The nutrition evaluation dated 3/02/26 documented that the resident was on a low-fat, low-sodium diet, understood the therapeutic diet, and drank skim milk, and the therapeutic diet care plan also listed skim milk only as a preference. During a telephone interview, the resident stated that he/she had spoken with the dietician multiple times about preferring skim milk and never received it, and staff told him/her the facility did not have skim milk and only had low-fat milk. The dietician confirmed that skim milk was the resident’s preference and stated that low-fat milk and skim milk are not exactly the same, and that the resident should have received skim milk. Review of milk invoices showed only whole milk and 1% milk were delivered, with no skim milk included, and an onsite kitchen observation found 1% low-fat milk and whole milk in the refrigerator with no skim milk present. The FSD stated the facility ordered milk weekly and had whole milk and 1% low-fat milk, while the Administrator stated that if skim milk was not ordered or delivered, the facility did not have it and that the resident should have received the preference of skim milk.
Late Meal Service Without Drinks in Dining Rooms
Penalty
Summary
The facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration, for residents in Dining Room A and Dining Room B during meal services. On 06/14/2026, at 12:02 p.m. in Dining Room A, eight unknown residents were seated without any drinks while waiting for a late lunch; the meal had not arrived, tray pass did not begin until 12:19 p.m., and residents asked about coffee but were told there was none yet. Later that day at 12:22 p.m. in Dining Room B, 12 unknown residents were also seated without drinks while waiting for lunch, and tray pass did not begin until 12:33 p.m. Similar observations were made on 06/15/2026 and 06/16/2026. On 06/15/2026, seven unknown residents in Dining Room A and 14 unknown residents in Dining Room B were observed seated without drinks while waiting for late meal trays; residents asked for coffee or a snack and were told there were no drinks yet and they would come on the tray. On 06/16/2026, meal trays were delayed in both dining rooms, and residents again waited without drinks; in Dining Room B, only 4 or 5 of 13 residents had coffee in front of them while the remaining residents waited with no drinks, and staff told residents the kitchen had run out and they would have drinks on their trays. Interviews with CNA B, Resident Council, DS, and DCS confirmed that meals were running late and that residents were not receiving drinks while waiting, and grievance records noted complaints about late meals affecting food temperatures.
Inconsistent Access to Drinking Water
Penalty
Summary
The facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain comfort for four of 24 residents observed for the presence of drinking water. The facility policy titled Serving Drinking Water, last reviewed in June 2025, stated that the facility would provide a fresh supply of drinking water and adequate fluids for residents. During the survey, a dietary cart with water pitchers stacked on it was observed in the hallway across from the nursing station on the C and D units at 10:00 AM and again at 12:30 PM, and the pitchers were still not passed to residents later in the day. Resident 1, Resident 2, Resident 3, and Resident 4 were all cognitively intact with BIMS scores of 15. Resident 1 stated her water pitcher had been taken during the night to be cleaned and had not been returned, and no pitcher or Styrofoam cup was observed at her bedside. Resident 2 stated he needed to drink as much as possible and that his pitcher had been taken during the night but not returned, with no pitcher or Styrofoam cup observed in his room. Resident 3 stated that if she did not ask for water, she did not get it, and that night shift was not consistent in bringing a water pitcher; no pitcher or Styrofoam cup was observed in her room. Resident 4 stated she woke up thirsty, had no water available at the bedside, and did not receive water until she asked for it around 11:00 AM; a pitcher was later observed at her bedside. An LPN stated pitchers are collected every other night for cleaning and residents are usually given a Styrofoam cup with water, while a nurse aide stated residents are to receive ice water each shift but the pitchers had not yet been passed during her shift. The DON confirmed that facility protocol required residents to receive fresh water and ice each shift and that on nights when pitchers are cleaned, residents are to be provided Styrofoam cups that can be refilled as needed.
Failure to Provide Drinks Consistently and on Request
Penalty
Summary
The facility failed to ensure drinks were provided regularly and upon resident request for one resident reviewed for hydration. The resident had diagnoses including dementia without behaviors, psychotic disturbance, vascular dementia, dysphagia, and pulmonary disease. The MDS showed a BIMS of 99 indicating impaired cognition, and the care plan included interventions to provide favorite foods and fluids for altered nutrition. There was no order for fluid restrictions in the medical record. During observation and interview, the resident had no drinks or hydration in the room and requested coffee, stating he was thirsty. A CNA stated the resident would get coffee when the coffee cart came, but could not say when that would occur and said staff did not pass out drinks or water, with residents getting drinks only on meal trays. The CNA confirmed a second time that residents only got drinks with meal trays. An LPN later confirmed that after the surveyor asked about the resident's hydration and drinks, the resident was given water until the coffee cart arrived. Observation showed meals arrived on the unit around 12:30 P.M. The facility policy stated residents with dementia will forget to drink and should be provided encouragement and assistance.
Inconsistent Access to Drinking Water
Penalty
Summary
The facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain comfort for four of 20 residents reviewed. The facility policy stated nursing staff would fill water pitchers or Styrofoam cups with ice and fresh water and place them at bedside, and that water would be provided or passed every shift unless contraindicated by diagnosis or physician order. However, resident interviews showed that water was not consistently provided during the day shift and often was only brought during the night shift. Resident R49, with CAD, diabetes, and depression and a BIMS score of 15, stated she had to ask during the day for water and that water was usually brought during the night shift. Resident R19, with seizure disorder, diabetes, and hypertension and a BIMS score of 15, stated he had to ask at least fifty percent of the time during the day for water and kept bottled water in his room because he always had water available from his own supply. Resident R56, with CAD, diabetes, and hypertension and a BIMS score of 15, stated water was only occasionally given during the day and was brought every night shift, but during the day he had to ask when it was not provided. Resident R11, with bilateral below-the-knee amputation, diabetes, and depression and a BIMS score of 15, stated water was brought during the day inconsistently and every night shift. The NHA confirmed the facility failed to ensure fresh drinking water was consistently readily accessible to residents.
Failure to Provide Fresh Water Consistently
Penalty
Summary
The facility failed to routinely offer fresh water to residents for extended periods of time for 2 of 4 residents reviewed for hydration, including a resident with severe cognitive impairment and another resident with intact cognition. Resident #15 had a BIMS score of 3 out of 15, indicating severely impaired cognition, and diagnoses that included Alzheimer's dementia, renal insufficiency, and diabetes mellitus; the resident also required set up/clean up assistance with eating and took a diuretic, antidepressant, and antipsychotic. The task intake record for fluids outside of meals showed no data found for the last 30 days, and during observation the resident was seated in a recliner in the common area without fluids readily available and without a table placed near him, although fluids were later given during medication administration and breakfast. Resident #11 had diagnoses including urinary incontinence, arthritis, and diabetes, was occasionally incontinent of urine, required assistance of one staff for toileting hygiene, and had a BIMS score of 14 out of 15. During observation, the resident sat in a wheelchair in the dining room, then was moved to the common area, chapel, and back to the common area and dining room, and staff did not offer fluids from 9:09 AM until 11:18 AM. Resident council notes also documented concerns that there was no fresh ice water and that fresh water at night was an issue, and staff interviews confirmed that water pass was supposed to occur each shift but was often not completed because staff were too busy or could not get to it. The DON stated that once a shift water should be passed and that residents in the 200 hall should have a pitcher beside them in the common area.
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