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 hydration deficiency occurred on the dementia unit when 11 residents did not have a water pitcher or any fluids available at their bedside after lunch trays were collected and before the evening shift returned clean pitchers. The Unit Manager acknowledged the facility's hydration process, but confirmed the residents had no water available in their rooms at the time of observation.
Water Not Served With Meals: Staff did not offer or serve water to residents during observed meals. Three residents were seated at one meal and five residents were seated at another, and no water was provided at either meal. A resident stated they did not have water at meals, and the DM acknowledged staff did not serve water with meals and did not know it was required at every meal.
A resident with dementia, severe cognitive impairment, and a history of UTIs was repeatedly observed without fluids within reach, despite being able to drink independently and having no upper extremity impairment. Staff and the resident’s family confirmed she could drink on her own when water was placed on her bedside table, but surveyors found her water kept on a dresser or behind her head and out of reach, with no other hydration at the bedside.
Failure to Provide Ordered Nectar-Thick Liquids: A resident with Parkinson's disease and cognitive communication deficit had an order for nectar-thick liquids, but observations showed a bedside cup of thin water with a straw during the morning meal period. Staff stated CNAs provide water at the bedside each shift and check diets, and a CNA confirmed the resident was on thickened liquids but said she had not given him water that morning.
Failure to provide fresh water and hydration to residents with identified hydration needs. Resident council minutes and a grievance showed ongoing problems with ice water being passed inconsistently and water stations not receiving fresh water daily. Three residents with care plans calling for fluids as desired/accepted/tolerated were observed without fresh water at bedside, and each stated they were not getting fresh water reliably. A CNA said fresh water should be passed every shift, but routines varied and it was not always done; the Ombudsman also reported residents complained about not getting fresh water, iced tea, or juice between meals.
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.
Lack of Fluids at Bedside on Dementia Unit
Penalty
Summary
The facility failed to provide adequate fluids within reach for residents on the dementia unit. Review of the facility's Hydration Rounds Procedure showed that day shift was to collect water pitchers when collecting lunch trays and evening shift was to retrieve clean water pitchers from the kitchen, fill them with ice water, and pass them out to residents on the hall. During observation on 07/29/2026 at 3:20 PM with the Unit Manager, 11 residents on the dementia unit did not have a water pitcher or any fluids available to drink at their bedside. In interview, the Unit Manager acknowledged the facility's process for removing dirty pitchers at lunch and returning clean pitchers later, but stated she was unsure why the pitchers had not been replaced and confirmed that 11 residents did not have water available in their rooms at that time. The Administrator later acknowledged the facility had completed corrective actions related to hydration in the dementia unit and stated his expectation was that residents always have access to water or fluids at their bedside.
Water Not Served With Meals
Penalty
Summary
The facility failed to ensure residents received drinks consistent with their needs and preferences and sufficient to maintain hydration when staff did not offer or serve water with meals. During observation on 7/13/26 at 12:10 PM, three residents were seated at the dining room table and staff did not offer or serve water to any of them during the meal. During observation on 7/14/26 at 11:45 AM, five residents were seated at the dining room table and staff again did not offer or serve water to any of them with or during the meal. On 7/15/26 at 9:17 AM, Resident #2 stated that they did not have water at meals. Later that day, at 9:30 AM, Staff A, the Dietary Manager, acknowledged that staff did not serve residents water with meals and stated they did not know staff needed to serve water at every meal.
Hydration Not Kept Within Resident’s Reach
Penalty
Summary
The facility failed to provide fluids sufficient to maintain adequate hydration for one resident who had a history of UTIs, dementia, and severe cognitive impairment. The resident’s quarterly MDS showed a BIMS of 3, and the record indicated no upper extremity impairment and independence with eating. Her care plan included an intervention to encourage and assist with fluid intake daily, and the resident’s family member stated she could drink independently when water was placed within her reach. Survey observations showed the resident repeatedly had a cup of water placed on the left corner of her dresser or behind her head on the dresser, out of her reach and line of sight, with no other fluids at the bedside. During multiple observations, the resident was lying in bed and had no hydration within reach. Staff interviews confirmed the resident could drink independently and that residents should have hydration within their reach throughout the day. A CNA stated the water was kept on the dresser because staff believed the resident would spill it if it was placed close to her.
Failure to Provide Ordered Nectar-Thick Liquids
Penalty
Summary
The facility failed to provide the appropriate liquid consistency for one sampled resident who required nectar-thick liquids. Resident #120 was admitted with diagnoses of Parkinson's disease and cognitive communication deficit, and the quarterly MDS showed a BIMS score of 10, indicating low-to-moderate cognitive impairment. The physician's order dated 02/04/25 specified a no-added-salt diet with regular texture and nectar-thick liquid consistency. During observation on 07/08/26 at 8:38 AM, Resident #120 was in the room with a breakfast tray, and the meal ticket indicated no added salt, regular diet, and nectar-thick liquids. However, a 16-ounce Styrofoam cup of water at the bedside was observed to be thin and not thickened. A later observation at 9:59 AM again showed the resident in bed with the same thin water at the bedside and a straw inside the cup. When asked about the water, Resident #120 asked the Surveyor if they could hand him the cup. Staff interviews showed the unit manager stated CNAs provide water cups at the bedside each shift and are encouraged to review residents' diets before providing water, and a CNA stated she checks whether residents are on thickened liquids and confirmed Resident #120 was on thickened liquids, but said she had not given him water that morning.
Failure to Provide Fresh Water and Hydration
Penalty
Summary
The facility failed to provide hydration services, including fresh water, for three residents reviewed for hydration. Facility Resident Council Minutes from multiple meetings documented ongoing concerns that ice water was not being passed at times, that only certain staff would do it, and that ice water continued to be a problem. A grievance form also documented that ice water was only passed by certain CNAs and that water stations were not getting fresh water daily. The facility resident rights document stated residents must be cared for in a manner that promotes quality of life and physical and mental health, and the CNA job description included providing hydration to all residents. R5’s care plan identified risk for complications with hydration and directed that the resident be allowed to drink as desired, accepted, or tolerated. On observation, R5 did not have water in the bedside pitcher and stated no fresh water had been received that day; on another observation, the pitcher was only about one-fourth full and the resident said it was the same water as the day before. R9’s care plan identified risk for hydration complications and directed fluids as desired, accepted, or tolerated. R9 was observed without fresh water at bedside and stated fresh water was not reliably provided and that the resident did not even have a working call light; later, R9 again had no ice water and said none had been brought yet that day. R10’s care plan identified risk for impaired skin integrity and hydration and directed fluids as desired, accepted, or tolerated. R10 was observed without water at bedside and stated fresh ice water was not received every day. A CNA stated fresh water was supposed to be passed every shift and extra if requested, but that some CNAs had different routines and it was not always done. The Ombudsman also stated hydration stations had been taken away and residents complained about not getting fresh water and not being able to get iced tea or juice between meals.
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.
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