Failure to Provide Adaptive Equipment for Resident
Summary
The facility failed to provide adaptive equipment, specifically a two-handled cup, to a resident who required it for self-feeding due to hemiparesis following a stroke. The resident was admitted with a diagnosis that included hemiparesis and was cognitively intact, requiring setup and cleanup assistance with eating. Occupational therapy had recommended the use of a two-handled cup to maximize the resident's performance with self-feeding, and a physician's order was placed to ensure the cup was provided with all meals. Despite the order and communication to the dietary department, the resident was observed on multiple occasions without the two-handled cup during meals. Instead, the resident received drinks in cartons with straws, which were not suitable for their needs. The resident expressed difficulty in drinking without the two-handled cup, resulting in prolonged meal times and cold food. The staff, including CNAs and unit managers, were unaware of the requirement for the two-handled cup, and the cup was improperly stored in the resident's room, leading to its non-use. Interviews with the Director of Rehab, Food Service Director, and Director of Nursing revealed a breakdown in communication and procedure adherence. The staff failed to ensure the two-handled cup was available and used during meals, despite it being indicated on meal slips and ordered by the physician. The oversight in transcribing the physician's order into active orders and the improper storage of the cup contributed to the deficiency, highlighting a lapse in ensuring the resident's needs were met as per their care plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with renal failure and legal blindness, who required set-up assistance for meals, had physician orders for a renal diet with specific food restrictions and the use of a blue scoop bowl and plate guard. During multiple observed meals, the tray line provided only a plate guard and no scoop bowl, despite the meal ticket indicating the need for both. Dietary staff reported that previously available scoop bowls could no longer be found anywhere in the facility, resulting in the resident not receiving the ordered adaptive equipment during the observed meal services.
A resident with paraplegia and multiple comorbidities, who was cognitively intact and required set-up/clean-up assistance with eating, had meal tickets specifying the use of built-up utensils. On multiple observed meals, the resident’s trays did not include the ordered adaptive utensils, despite this requirement being clearly documented on the meal tickets and in facility policy. Staff interviews confirmed that the resident did not receive the built-up utensils as ordered.
Surveyors found that the facility did not provide adequate and appropriate eating utensils with resident meal trays. Observations showed meal trays being passed with only a spoon, sometimes plastic, and no additional utensils or napkins, with brown paper towels substituted instead. Dietary staff reported an ongoing shortage of metal silverware, napkins, and sometimes juice cups, and stated that plastic utensils were used for about half of all trays over several months. Several cognitively intact residents on various diets, some needing set-up assistance and others independent with eating, reported frequently receiving only a spoon, receiving plastic utensils for many meals, or occasionally receiving no utensils at all, and these reports were confirmed by concurrent observation of their lunch trays. Facility policy required that meals be served using reusable dishes and flatware, and administration acknowledged residents should receive appropriate silverware for all meals.
Two residents with severe cognitive and physical impairments did not receive the adaptive eating equipment prescribed in their care plans and physician orders during meal service. Observations confirmed that required items such as sippy cups and divided plates were missing from meal trays, despite being listed on tray tickets and documented as necessary for independent eating and drinking. Staff verified the absence of these devices during the survey.
Surveyors observed that meals and drinks were consistently served in disposable Styrofoam containers and cups due to an inadequate supply of dishes. The DM confirmed the shortage, and a resident stated that meals are always served on disposable products, with regular dishes rarely provided.
A resident with multiple medical conditions and feeding difficulties did not receive the ordered adaptive eating equipment, including a Kennedy cup and built-up utensils, during a meal. Despite physician orders and care plan interventions specifying these devices, the resident's tray was missing them, and this was confirmed by both the resident and an LPN. Facility policy requires provision of such adaptive devices for those who need them, but this was not followed.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered adaptive eating equipment for a resident who required it. The resident was admitted with diagnoses including hypertensive urgency, renal dialysis, glaucoma, and legal blindness. A quarterly MDS assessment documented that the resident was independent in daily decision making but required set-up assistance for meals. Physician orders specified a renal diet with regular texture and thin liquids, double protein, several food restrictions, an 1800 milliliter fluid restriction, and the use of a blue scoop bowl and plate guard related to renal failure. During a supper meal observation, the resident’s meal ticket indicated the need for both a blue scoop bowl and a plate guard, but the tray was prepared with only a plate guard. Further observations of subsequent meal tray lines showed that the required scoop bowl continued to be unavailable for the resident’s meals. At one lunch service, staff confirmed there were no scoop bowls available for the resident’s tray, despite the order specifying their use. Dietary staff interviews revealed that the facility previously had multiple scoop bowls but they could no longer locate them, and that only three had recently been available before they also went missing. Multiple staff, including dietary aides and the dietary manager, reported they were unable to find any scoop bowls in the kitchen, resident rooms, or on the units at the time of the observations. As a result, the resident did not receive the ordered adaptive equipment during the observed meals.
Failure to Provide Ordered Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide ordered adaptive eating utensils to a resident who required them. The resident, admitted with diagnoses including type 2 diabetes mellitus without complications, anxiety disorder, major depressive disorder, schizoid personality disorder, paraplegia, and malignant neoplasm of the female breast, was documented on a recent MDS assessment as cognitively intact and needing set-up/clean-up assistance with eating. The facility’s own policy on adaptive eating devices stated that special eating equipment and utensils would be provided as appropriate and that adaptive devices should be noted on each individual’s meal identification ticket. The resident’s meal tickets for multiple meals specified that built-up utensils (one each) were to be provided. Despite these documented requirements, surveyor observations on several meal occasions showed that the resident did not receive the ordered built-up utensils on the meal trays. On one breakfast and two lunch observations, the resident’s trays lacked the built-up utensils that were listed on the corresponding meal tickets. During these observations, the resident was seen eating meals in the room without the adaptive utensils. Staff interviews with Social Services and a CNA confirmed that the resident had not received the built-up utensils on the lunch trays, corroborating the surveyor’s findings that the facility did not follow the documented meal ticket instructions or its own policy regarding adaptive eating devices.
Plan Of Correction
F810 Assistive Devices - Eating Equipment/Utensils The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 4 now has a a dietary recommendation, care plan and an MD order obtained by hospice for adaptive equipment she is receiving the requested adaptive equipment with meal trays. The dietary manager verified resident # 4 has adaptive equipment as of 3-24-2026. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. DM audited on 3-19-2026 all residents' records and meal tickets for requested adaptive equipment; no additional adaptive equipment was needed. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DM in-serviced staff to provide any adaptive equipment noted on the meal tickets to the residents. Inservice completed 3-17-26 by the dietary manager. How the corrective action will be monitored to ensure the deficient practice will not recur. DM is auditing all meal tickets daily 4Xaweek X2 months audits began 3-19-1026 that the meal trays are being audited to ensure the adaptive equipment on the meal trays matches the meal ticket in regards to adaptive equipment being provided. The audit will include all trays including all trays with adaptive equipment. Results of audits submitted to QAPI committee weekly.Any concerns identified will result in immediate correction and re education.
Failure to Provide Adequate and Appropriate Eating Utensils for Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate eating utensils and special eating equipment to residents during meals, as required by facility policy. Surveyor observations on the morning of 01/22/26 showed CNAs passing breakfast trays that contained only a metal spoon, with no additional silverware or utensils present or offered. Later that morning, a dietary aide was observed transporting 15–20 meal trays on an open cart, each tray containing only a plastic spoon placed on a folded brown paper towel next to the covered plate. Interviews with dietary staff revealed there was an ongoing shortage of metal silverware, resulting in plastic utensils being used for at least half of the residents’ trays for each meal. Staff also reported the kitchen had been out of napkins since 01/20/26 and was using folded brown paper towels from a hand towel dispenser instead, and that the facility sometimes ran out of juice cups. One dietary aide stated there had been a shortage of silverware and utensils for at least six months. Review of the facility’s policy titled "Use of Disposable Dishes/Flatware" indicated that resident meals were to be served using reusable dishes and flatware. Multiple residents with varying diagnoses and functional statuses reported and demonstrated that they frequently did not receive appropriate utensils with their meals. Cognitively intact residents on regular, mechanical soft, carbohydrate-controlled, or no concentrated sweets diets, some requiring set-up assistance and others independent with eating, stated they often received only a spoon, sometimes plastic utensils, and at times no utensils at all. Examples included residents reporting receiving only a spoon to eat meat or salad, receiving plastic utensils for about half of their meals, and occasionally having to eat with their fingers. During each of these interviews at lunchtime on 01/22/26, observations confirmed that the residents’ trays contained only a metal spoon. The administrator later confirmed that residents should receive appropriate silverware for all meals, consistent with facility policy. This deficiency represents non-compliance investigated under Complaint Number 2693876.
Failure to Provide Required Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide appropriate assistive eating devices to residents who required them, as identified through record review, observation, and staff interviews. Specifically, two residents with severe cognitive impairment and significant physical limitations, including hemiplegia, hemiparesis, and Parkinson's, were observed during meal times without the adaptive equipment prescribed in their care plans and physician orders. For one resident, a sippy cup with lid/spout and a divided plate were ordered and documented as necessary to promote independence with beverages, but the resident did not receive the sippy cup during meal observation. For the second resident, a two-handled sippy cup, built-up utensils, and a scoop plate were ordered, but the resident did not have the two-handled sippy cup at the time of observation. These deficiencies were confirmed by reviewing tray tickets and through verification with two CNAs present during meal service. The issue was identified during a complaint investigation and also had the potential to affect additional residents who were documented as needing adaptive equipment for eating and drinking. The findings were based on direct observation, medical record review, and staff interviews, with no evidence that the required adaptive devices were provided at the time of the survey.
Inadequate Supply of Dishes Leads to Use of Disposable Containers
Penalty
Summary
The facility failed to provide an adequate supply of dishes for residents, resulting in meals and drinks being served in disposable Styrofoam containers and cups. Observations during breakfast and lunch on multiple hallways and in the dining room confirmed the use of disposable products for serving food and fluids. The Dietary Manager verified that there were not enough dishes available, necessitating the use of disposable containers. A resident reported that meals are always served on disposable products and expressed a preference for regular dishes, noting that actual plates are only provided occasionally. These findings were based on direct observations and interviews conducted during the survey.
Failure to Provide Required Adaptive Eating Equipment During Meals
Penalty
Summary
The facility failed to ensure that all residents requiring assistive eating devices had them available during meal times. Specifically, one resident with diagnoses including diabetes mellitus, respiratory failure with hypoxia, chronic kidney disease, heart failure, dysphagia, and other feeding difficulties, and who had intact cognition, did not receive the ordered adaptive equipment during breakfast. Physician orders and the resident's care plan specified the use of a divided plate, Kennedy cup, and built-up utensils for all meals as tolerated. However, during observation, the resident's breakfast tray only included regular utensils and Styrofoam cups with a lid and straw, and lacked the required Kennedy cup and built-up utensils. The resident confirmed during interview that she preferred and found it easier to use the Kennedy cup and built-up utensils, as these helped her eat and drink without making a mess. Review of the meal ticket on the tray also indicated that adaptive equipment was to be provided. An LPN verified that the resident was supposed to have the Kennedy cup and built-up utensils for all meals, and acknowledged that these were missing from the breakfast tray. Facility policy requires that adaptive devices be provided for residents who need or request them, but this was not followed in this instance.
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