Failure to Provide Thickened Liquids as Ordered for Residents with Dysphagia
Summary
The facility failed to follow physician-ordered diet instructions regarding fluid consistency for two residents with dysphagia. One resident, with a history of acute respiratory failure with hypoxia and gastro-esophageal reflux, was observed drinking regular water despite an order for nectar-thick liquids. The resident's meal ticket also indicated the need for thickened liquids, and this was confirmed by the Activity Director, who acknowledged that the water should have been thickened as per the order. Another resident, also diagnosed with acute respiratory failure with hypoxia and pneumonia, was observed coughing after drinking hot chocolate that was not thickened, despite an order for nectar-thick liquids. The Director of Nursing confirmed that the drink should have been thickened according to the resident's meal ticket and physician's order. The facility's policy on nutritional management of thickened liquids emphasizes the importance of following thickened liquid orders to prevent aspiration in residents with dysphagia.
Plan Of Correction
Drinks Available to Meet Needs/Preferences/Hydration How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #49 and Resident #79 were provided with thickened beverages according to their diet orders on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct beverages according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to provide water and water pitchers at the bedside between meals for several residents with thin liquid orders. During observation, a CNA and an LPN/DON noted residents without water or with empty pitchers, while the DON confirmed that residents not on fluid restriction should have water available at the bedside. Records showed the affected residents had thin liquid orders and care plans directing that diet orders be followed.
Failure to provide water and ice to a resident with hydration needs. A cognitively intact resident with anemia, UTI, and adult failure to thrive had a care plan for hydration and preferred water and ice, but observations showed an empty pitcher without a lid and the resident reported staff did not refill it or bring fluids unless asked. The resident said they had to drink bathroom water and walk to the kitchenette for water and ice, while CNA and LPN interviews showed inconsistent understanding of hydration rounds and responsibilities.
Failure to Provide Adequate Hydration: Three residents were observed without fresh ice water, and each stated they had not received any that day. Undated Styrofoam cups were found with either only a small amount of water or no water and no ice, and an LPN confirmed one cup was empty. The Administrator stated staff should be passing ice and water to residents.
Failure to Provide Ordered Thickened Liquids: A resident with dysphagia, COPD, and anxiety disorder had orders for a pureed diet with nectar-thick liquids, but breakfast service included milk that appeared thinner than ordered and later omitted the ordered nectar-thick cranberry juice and milk entirely, substituting nectar-thick water instead. Staff confirmed the inconsistency, and the DM stated the kitchen only had pre-thickened apple juice and water, while the RD noted that milk had to be thickened in-house and the facility had two residents with thickened-liquid orders.
Ice water was not consistently passed to residents three times daily as required by the facility policy. Residents reported that fresh ice water was often missed on second and third shifts, sometimes only passed once a day or delayed when requested, and observations found one resident with warm water and another with an empty cup. Staff, including LPNs, a CNA, and an agency LPN, described staffing shortages and lack of ice access after the kitchen closed as reasons ice water was not routinely provided, while the DON stated it should be passed every shift.
Failure to provide coffee when requested. A resident with moderate cognitive impairment was observed asking for coffee while in his wheelchair, but an LPN and an OT told him no because it was not coffee time and directed him to wait for posted coffee hours or a later event. The DON stated residents could ask staff for coffee after those hours and that residents should be able to have coffee whenever they wanted.
Water Not Available at Bedside for Residents With Thin Liquid Orders
Penalty
Summary
The facility failed to make water available for residents between meals and failed to make water pitchers available at the bedside for residents who had thin liquid orders. During observation on the units, several residents, including R2, R9, R10, R11, and R12, were seen without water or water pitchers at the bedside, and other residents were observed with empty water pitchers. When asked why residents did not have water pitchers or water available before lunch, a CNA stated that residents get water on their trays during mealtimes and later said residents should be given water in the pitchers daily, but she was not sure whether new pitchers were available in storage. The DON stated that residents with orders for thin liquids should have water available at the bedside unless they were on fluid restriction. The DON then identified residents on nectar thick liquids, honey thick liquids, and fluid restriction, and the five residents observed without water were not on those lists. Physician order sheets showed that R2, R9, R10, R11, and R12 all had orders for thin liquids, and their nutrition care plans stated that diet orders should be followed. The facility policy on water pass hydration states that water is to be provided to residents in a clean and sanitary manner to meet hydration needs.
Failure to Provide Water and Ice to a Resident
Penalty
Summary
The facility failed to provide drinks, including water and ice, consistent with a resident’s needs and preferences and sufficient to maintain hydration for one resident. The resident was admitted with unspecified anemia, urinary tract infection, and adult failure to thrive. The MDS documented the resident was cognitively intact and able to make themselves understood. The care plan directed that the resident remain well hydrated and included thin liquids as an intervention, and the facility’s nourishment and clinical nutrition policies stated residents should have access to appropriate hydration and water should be provided multiple times each day. During observation and interview, the resident showed an empty water pitcher that had no lid and stated the lid broke and a CNA never returned with a replacement. On a later observation, the pitcher was still on the nightstand without a lid and remained empty, and the resident stated they had no water to drink and staff had not filled the pitcher the prior evening or night. The resident stated staff did not bring water unless they asked for it, that they liked water and ice, and that they had to drink bathroom water on several occasions because staff did not bring water to them. The resident later stated they finally received a lid only after telling staff the State was present, but staff still did not bring water or ice. They reported having to fill a travel cup with bathroom water and walking to the kitchenette to get their own water and ice. CNA interviews indicated staff were responsible for ensuring water and ice were available, typically during rounds every two hours or per care plan, but several aides and an LPN described different routines and were unsure of the specific hydration policy. The ADON stated CNAs should be bringing water to residents every shift and supplementally between meals.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to provide adequate hydration for Residents #55, #107, and #68. On 05/11/26 at 12:25 PM, Resident #55 stated they would like some ice water and reported they had not received any fresh ice water that day. An observation at that time found a 12-ounce Styrofoam cup that was undated and contained only a small amount of water with no ice. When the Activities Director was asked to come to the room, the director confirmed the cup was not dated and contained only a small amount of water with no ice. At 12:35 PM, Resident #107, who shared a room with Resident #68, stated that neither resident had been given any ice water that day. An observation found an undated 12-ounce Styrofoam cup on the over-the-bed table with no water or ice inside. Resident #68 also stated they had not received fresh ice water that day, and the same observation showed an undated cup with no water or ice. When the LPN was asked to come into the room, the LPN confirmed there was no water or ice in the cup. Later, the Administrator was notified and stated that staff should be passing ice and water to residents.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide liquids at the ordered consistency for Resident #68, who was admitted with diagnoses including dysphagia, chronic obstructive pulmonary disease, and anxiety disorder. Physician orders for April 2026 specified a no added salt diet with pureed texture and nectar-thick liquids, and the diet ticket reflected nectar-thick cranberry juice and milk along with a divided plate. During breakfast observation on 04/27/26, the cranberry juice was nectar thick, but the milk appeared thinner than ordered; the Assistant Director of Nursing confirmed the issue and thickened the milk to nectar consistency. On 04/29/26, the resident’s breakfast tray did not include the ordered milk or cranberry juice and instead contained two eight-ounce glasses of nectar-thick water. The resident stated he liked cranberry juice. The Transportation Scheduler confirmed the resident did not receive his preferred thickened liquids and said she would contact the kitchen. The Dietary Manager stated the kitchen only had pre-thickened apple juice and water and that, because no pre-thickened cranberry juice was available, dietary did not provide cranberry juice to the resident. She also stated he was the only resident receiving nectar-thick liquids, although the facility identified two residents with thickened-liquid orders. The Registered Dietitian stated that pre-thickened juices were available, but milk had to be thickened in-house. The facility policy stated that any liquid requiring thickening must be prepared to the correct consistency if not provided as such.
Ice Water Not Passed Consistently
Penalty
Summary
The facility failed to ensure fresh ice water was passed to residents three times per day in accordance with its Water Pass-Hydration Policy, which states that fresh cold ice water will be provided to each resident a minimum of three times each day unless contraindicated. The Census Report documented 77 residents in the facility, and the deficiency was identified through observation, interview, and record review. A resident concern form documented that one resident had asked for ice water after 4:00 AM and was told by two unknown CNAs that they could not do that between 4:00 AM and 6:00 AM. During observations, one resident had a cup of warm water on the bedside table, another had an empty water cup, and both residents stated that fresh ice water was not consistently passed three times a day. One resident reported that staff occasionally passed fresh ice water on second shift and rarely on third shift, while another stated the facility was lucky if ice water was passed one time a day. Staff interviews supported these concerns: an LPN stated that ice water often did not get passed on third shift, an agency LPN reported staffing shortages that made it impossible to complete tasks including providing ice water, another LPN stated third shift could not always access ice after the kitchen closed, a CNA reported fresh ice water was often not passed on second shift due to staffing and agency use, and the DON stated ice water should be passed every shift.
Failure to Provide Coffee When Requested
Penalty
Summary
The facility failed to provide drinks consistent with Resident #R7’s preferences when he requested coffee. Resident #R7 was admitted to the facility and his quarterly MDS with an ARD of 02/20/2026 showed a BIMS of 8, indicating moderate cognitive impairment. On 05/05/2026 at 12:25 p.m., he was observed self-propelling in his wheelchair while holding a drinking tumbler and waving it in the air. When asked if he wanted coffee, he indicated yes, and S4LPN was notified that he wanted coffee. S4LPN shook her head and said no. At 12:28 p.m., S15OT told Resident #R7 he could not have coffee because it was not coffee time and said he could only have coffee at the posted coffee times. She also stated he did not ask for water and only wanted coffee all day, and told him he could get coffee later at a party. On 05/06/2026, S4LPN confirmed she told him he could not have coffee and stated residents should be able to have coffee whenever they wanted. The posted coffee sign showed coffee was available only from 7:00 a.m. to 8:00 a.m. and 10:00 a.m. to 10:30 a.m., while S2DON stated residents could ask staff for coffee after those hours and that residents should be able to have coffee whenever they wanted.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.