Untrained Staff Assisted Resident With Dysphagia During Meals
Summary
The facility failed to ensure that Resident ID #46, who was readmitted in February 2025 with dysphagia and required a pureed diet, was assisted with meals by a qualified staff member. The resident’s care plan dated 6/9/2023 identified a risk for aspiration due to dysphagia and a prior choking episode during breakfast, and also noted that the resident had been observed pocketing food. During observation on 9/17/2025 at 8:19 AM, the Life Enrichment Director was seen assisting the resident with breakfast. During interview, the Life Enrichment Director stated that she had not been in a role that would have trained her to provide feeding assistance and had not completed a state-approved paid feeding assistant program. The Staff Development Coordinator stated that the Life Enrichment Director had not completed a competency for feeding assistance, and review of her online training did not show evidence of feeding-assistance training. The DNS was unable to provide evidence that the Life Enrichment Director had received state-approved training for feeding assistance and stated that staff would be expected to receive specialized training before assisting residents with meals.
Penalty
Resources
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Surveyors found that non‑nursing staff, including the Administrator and a Medical Records clerk, were assisting multiple dependent residents with eating without documented completion of a State‑approved feeding assistant training course. Observations showed residents with bilateral upper extremity weakness, contractures, inability to lift their arms, and reliance on verbal prompts to open their mouths being fed by these staff. Interviews with HR, the ADON, the ADMIN, and the RNC revealed confusion about where feeding assistance training was housed, missing or unavailable training records, and in‑service sheets that did not include the ADMIN or MR clerk as attendees. Record review from hire to current date confirmed no documented feeding assistant training for these staff, and the ADMIN reported the facility had no policy on feeding assistant training, despite regulatory requirements. The report states this failure could place residents who require assistance with eating at risk of aspiration and choking.
A resident with dysphagia, a mechanically altered diet, and documented coughing during meals was allowed to be fed by PNAs even though the care plan and swallow study identified aspiration concerns and safe-swallow precautions. Staff interviews showed PNAs assisted the resident routinely, one PNA reported coughing after every drink, and the DON stated the facility did not have residents PNAs could not assist, despite policy limiting residents with recurrent aspiration or difficulty swallowing to licensed or certified staff.
Staff failed to follow facility policy for assisting with in-room meals for three cognitively impaired residents who required varying levels of help with eating. One resident with metabolic encephalopathy, dementia, and total dependence for eating was found lying flat in bed with food in the mouth and on the linens while the meal tray remained mostly untouched and covered; the assigned CNA had been redirected to the dining room to assist two other residents needing feeding help and did not promptly return. For all three residents, care plans required documentation of PO intake at every meal, but intake records for the cited day showed either no intake data or "resident not available," and the CNA did not report decreased intake to an LVN as expected. Interviews revealed that usual restorative nursing assistant coverage in the dining room was absent that day, CNAs were managing multiple feeder residents, and charge nurse supervision did not ensure that feeding assistance and intake documentation were completed according to policy.
Failure to assess two residents for PFA feeding assistance: Two residents with severe cognitive impairment and dysphagia were assisted by trained PFAs even though their records did not show an IDT assessment approving them for the PFA program. Both residents had SLP findings documenting swallowing problems and specific feeding recommendations, yet the care plans did not identify them as appropriate for PFA support. One PFA reported assisting with meals and cueing, while the facility stated PFAs should not physically assist or cue residents with dysphagia.
A resident with severe cognitive impairment, dysphagia, a mechanically altered diet, and tube feedings was observed being fed by the SSD while lying in bed with the HOB at 30 to 45 degrees. The SSD was not a CNA, was not formally certified to feed residents, and the facility confirmed it did not employ paid feeding assistants. The resident’s care plan and ST note required staff assistance and safe positioning during meals, but the facility allowed an unqualified staff member to provide feeding assistance.
Untrained staff member fed a resident without approved paid feeding assistant training. A resident with dysphagia, essential tremor, protein-calorie malnutrition, and moderately impaired cognition was observed receiving breakfast assistance from an administrative assistant who had not completed the State-approved paid feeding assistant course. The resident’s care plan included aspiration precautions and adaptive devices, but did not reflect use of a feeding assistant, and the staff member was not listed among the facility’s trained paid feeding assistants.
Untrained Non‑Nursing Staff Providing Feeding Assistance Without Required Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff who were assisting residents with eating had successfully completed a State‑approved feeding assistant training course before providing this care. Over a three‑day observation period, surveyors observed the Medical Records (MR) clerk and the Administrator (ADMIN), both non‑nursing staff, feeding three unknown residents in the dining room who required full feeding assistance. One resident had bilateral upper extremity weakness and contractures, another sat upright in a specialized chair and did not attempt to lift either upper extremity, and another sat slightly hunched over and was not trying to lift their upper extremities. A further resident only opened their mouth for the ADMIN when verbally prompted. In each instance, CNA D confirmed that these residents needed feeding assistance. The report states that this failure could place residents who require assistance with eating at risk of aspiration and choking. During interviews and record reviews, the facility was unable to produce documentation that the ADMIN and MR clerk had completed a State‑approved feeding assistant training course. The HR representative stated that feeding assistance training was not part of the new hire packet, that some trainings were done as in‑services or department‑specific, and that paper copies could not be located, partly due to a change in company systems. HR later provided pre‑acquisition training paperwork that did not include feeding assistance training and acknowledged that the training for feeding assistance might not auto‑populate in the new system. The ADON believed feeding assistance training was included in dementia training and said it might be in Relias or in the DON’s office, but no documentation was produced. The ADMIN confirmed she could not locate training records and the in‑service sheets she provided did not list her or the MR clerk as attendees. The RNC verbally verified that the ADMIN and MR clerk had been present for training but had no signed documentation. Record review from hire to current date for the ADMIN and MR clerk showed no completed feeding assistance training, and an in‑service sheet for feeding assistance lacked their signatures. The ADMIN also stated the facility did not have a policy on training for feeding assistance, despite regulatory requirements that non‑nursing staff must complete a State‑approved course before assisting residents with feeding.
PNA Assisted Resident With Dysphagia and Coughing During Meals
Penalty
Summary
The facility failed to ensure that a resident with dysphagia and a high risk for aspiration was fed only by licensed or certified staff. Resident #20’s MDS identified a mechanically altered diet, and the care plan directed assistance with eating and monitoring for signs and symptoms of aspiration or difficulty swallowing. A video swallow study documented coughing during meals, a diagnosis of dysphagia, and recommendations for pureed food with mildly thick liquids and strict safe swallow precautions, including small bites and sips and a slow rate of intake. Despite these findings, the PNA-Resident Dining assessment determined that Resident #20 could eat with the assistance of a PNA. Staff interviews showed PNAs assisted the resident with meals on a regular basis, and one PNA reported the resident coughed after every drink and that she did not report the coughing to the nurse. The DON stated the facility did not have residents that PNAs could not assist, and later stated a PNA may assist if Speech Therapy approved, while also expecting the PNA to get a nurse if the resident started choking or coughing. The facility policy stated residents with recurrent lung aspiration or difficulty swallowing are to be fed only by nurses, nurse aides, or other licensed health professionals.
Failure to Provide and Document Required Feeding Assistance and Intake Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedures for assisting residents with in-room meals, including providing needed feeding assistance, documenting meal intake, and ensuring appropriate reporting of decreased intake. For three cognitively impaired residents with significant functional limitations, staff did not consistently assist with feeding as required by their assessments and care plans, nor did they document meal intake percentages as directed. The facility also failed to ensure that a CNA notified licensed nursing staff when a resident had decreased meal intake. Resident 1 was admitted with multiple diagnoses including metabolic encephalopathy, dementia, diabetes, muscle weakness, anemia, hypertension, a pressure ulcer, and GERD. The MDS showed cognition was not intact and that Resident 1 required maximal assistance with eating and was dependent for toileting, showering, and transfers. A nutrition assessment indicated total assistance was required for eating, and the care plan identified decreased self-feeding abilities related to metabolic encephalopathy and dementia, as well as nutritional risk with an intervention to document PO intake at every meal. On observation, Resident 1 was found lying flat in bed with eyes closed, chewing with orange material in the mouth and on the lips, and a half-eaten piece of potato on the sheet next to the face. The meal tray was on the bedside table with the cover still on; the plate contained mostly uneaten food and an unopened juice. CNA 1, who was assigned to Resident 1 and stated this was the first time caring for this resident, did not begin feeding until later, after being redirected to assist other residents in the dining room, and there was no documentation of meal intake for Resident 1 on the cited date, nor evidence that decreased intake was reported to an LVN. Resident 3 had diagnoses including right-sided hemiplegia/hemiparesis, encephalopathy, UTI, COPD, diabetes, muscle weakness, aphasia, dysphagia, hyperlipidemia, anxiety disorder, and hypothyroidism, with an MDS indicating cognition was not intact and that supervision or touch assistance was required with eating. The care plan identified nutritional risk with an intervention to document PO intake at every meal, and a physician order specified a fortified regular pureed diet, level 4 texture, thin consistency, and that the resident was a feeder. Meal intake documentation for the referenced date showed “resident not available.” Resident 4, with hemiplegia/hemiparesis after cerebral infarction, asthma, epilepsy, protein-calorie malnutrition, muscle weakness, dysphagia, UTI, aphasia, hyperlipidemia, and hypertension, also had impaired cognition and required moderate assistance with eating. The care plan for Resident 4 included documenting PO intake at every meal, yet the same date’s intake record also indicated “resident not available.” Interviews revealed that CNA 1 was simultaneously assigned to Residents 1, 3, and 4 and was pulled to the dining room to assist Residents 3 and 4 when no restorative nursing assistants were present, leaving Resident 1 without timely feeding assistance and contributing to the lack of proper intake documentation and reporting for all three residents. Staff interviews further clarified the breakdown in supervision and adherence to policy. CNA 1 reported starting to feed Resident 1 but being told to go to the dining room to assist Residents 3 and 4, who also needed feeding assistance, and only returning later to finish feeding Resident 1. LVN 1 confirmed that Resident 1 required assistance with feeding and stated that CNA 1 did not request help or report any decreased intake, despite the expectation that CNAs report intake of less than 50% and complete a “stop and watch” form. The RNA stated that there are usually three RNAs assigned to the dining area to pass trays and feed residents, but on the day in question one RNA had called off and the remaining RNA was sent out with another resident to an appointment and did not return until mid-afternoon, leaving the dining room without RNA coverage. LVN 2 observed there were no RNAs in the dining room and that CNAs were taking residents back to their rooms. The ADON later explained that one RNA had called off and the other was at an appointment, and that charge nurses were expected to monitor whether residents needing feeding assistance were being helped and to supervise CNAs, including adjusting assignments when a CNA had multiple residents requiring feeding assistance. Despite these expectations and the written policy on assisting residents with in-room meals and documenting intake, the facility did not ensure that Residents 1, 3, and 4 were assisted with feeding as care planned, that their meal intake percentages were documented, or that decreased intake for Resident 1 was reported to licensed nursing staff. The facility’s written policy on assisting residents with in-room meals required staff to review the resident’s care plan, ensure appropriate positioning and preparation for meals, assist residents as necessary while encouraging self-feeding, and document the date and time of the procedure, the staff involved, the percentage of the meal consumed, the resident’s participation, and any special requests. Observations and record reviews showed that these steps were not followed for the three residents on the date in question. Resident 1 was not positioned upright as specified in the policy when first observed with food in the mouth and on the bed, and the tray remained covered and largely uneaten until CNA 1 returned. For Residents 1, 3, and 4, the required documentation of meal intake percentages was either missing or recorded as “resident not available,” and there was no evidence that CNA 1 notified an LVN or RN of Resident 1’s decreased intake, contrary to facility expectations and the care plan interventions. These combined observations, interviews, and record reviews demonstrate that the facility did not implement its own policy and procedures for assisting residents with in-room meals and did not ensure that residents were assessed and supported appropriately for feeding assistance, that meal intake was documented as care planned, or that decreased intake was reported to licensed staff for further evaluation.
Failure to Assess Residents for PFA Feeding Assistance
Penalty
Summary
The facility did not ensure that two residents, both with dysphagia and severe cognitive impairment, were assessed for appropriateness for the Paid Feeding Assistant (PFA) program before PFAs assisted them with dining. The facility’s Dining Assistant policy required a Registered Nurse assessment to determine whether a resident had complicated swallowing or feeding concerns and stated that only residents without such concerns could be physically assisted by Dining Assistants under licensed nurse supervision. However, the records for both residents did not show an interdisciplinary assessment or evaluation documenting whether they were appropriate for PFA assistance. One resident had diagnoses including dementia with behavioral disturbance, history of cerebral infarction, protein-calorie malnutrition, and psychosis, and a speech-language pathology (SLP) evaluation documented oropharyngeal dysphagia. The resident’s MDS showed severely impaired cognition, and the resident had a guardian for healthcare decisions. The SLP evaluation and discharge summary described the resident as needing feeding assistance, being at risk for aspiration due to dependence on staff for feeding, and requiring specific mealtime strategies such as decreased distractions, upright positioning, slow rate, small bites, alternating liquids and solids, and cueing. Despite this, two trained PFAs reported assisting the resident with meals, and one later clarified that the assistance was cueing rather than physical feeding. The second resident had diagnoses including severe dementia with anxiety, pneumonia, acute cough, and oropharyngeal dysphagia, with an MDS BIMS score of 00 indicating severely impaired cognition and an activated POAHC. The resident’s SLP evaluation documented difficulty swallowing, choking on medications, coughing on liquids, poor liquid intake, and risk for choking, aspiration, and inadequate intake. The SLP discharge recommendations included upright positioning, slow rate, small bites, feeding assistance if sleepy, and alternating liquids and solids. A trained PFA reported assisting this resident with meals and later clarified that the assistance involved cueing during one-to-one supervision, but the resident’s record and care plan did not show an assessment approving PFA involvement.
Unqualified staff assisted a resident with feeding
Penalty
Summary
The facility failed to ensure that a resident who required assistance with eating received that assistance from qualified staff. R47’s MDS indicated severe cognitive impairment, dependence on staff for eating assistance, a mechanically altered diet, and use of a feeding tube. The care plan stated that R47 required staff assistance with eating, and the speech therapy discharge note documented dysphagia, respiratory failure, and traumatic brain injury, recommending a minced and moist diet with thin liquids, staff supervision/assistance at mealtime to swallow safely, and positioning at 90 degrees while eating or drinking. The order summary also reflected a minced and moist diet with thin liquids and tube feedings twice daily. During observation, R47 was seen lying in bed with the head of the bed at a 30-to-45-degree angle while the social services director sat beside him and fed him by bringing utensils of food to his mouth. The social services director confirmed he had assisted R47 with eating, stated he had helped residents with feeding in the past, and acknowledged he was not a CNA and was not formally certified to feed residents. The administrator confirmed the facility did not employ paid feeding assistants and stated the social services director had no prior facility training for feeding. The DON stated that only nurses and nursing assistants had met the requirements to feed residents and that the social services director had not met those requirements. A policy on assisting residents with eating was requested but not received.
Untrained staff member fed resident without approved paid feeding assistant training
Penalty
Summary
The facility did not ensure that feeding assistants had successfully completed a State-approved training course before providing dining assistance, and a staff member who had not completed that training was observed physically assisting Resident #34 with breakfast. Resident #34 had diagnoses including dysphagia, essential tremor, and protein-calorie malnutrition, and the Minimum Data Set dated 09/01/2025 indicated moderately impaired cognition and the need for set-up assistance with eating. The resident’s comprehensive care plan, reviewed on 09/09/2025, showed aspiration precautions and the use of adaptive devices during meals, but did not reflect the use of a feeding assistant. During the observation, Administrative Assistant #1 was the only staff member in the dining room and was providing feeding assistance to Resident #34. Facility records showed that paid feeding assistant training had been provided in July 2017 and August 2023, and only three staff had completed the approved training; Administrative Assistant #1 was not on that list. In interviews, Administrative Assistant #1 stated that non-CNA and non-licensed staff were assigned to cooking, serving, and cleaning duties and did not identify feeding residents as an assigned task. The Administrator stated that staff who were not CNAs, LPNs, RNs, or trained paid feeding assistants could not feed residents, and later confirmed that Administrative Assistant #1 had received training during the COVID pandemic but had not completed the State-approved training program.
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