Failure to Provide Ordered Drinking Cup
Summary
The facility failed to ensure that Resident 16 was consistently provided the drinking cup type that was ordered and care planned. The physician’s order dated 02/06/2025 directed Resident 16 to use a sippy cup for all drinks with no straws. The resident’s records also documented dementia, dysphagia, severe cognitive impairment, moderate assistance needed for eating, daily eating/swallowing skill practice, ADL self-care deficits, nutritional risk related to difficult swallowing, soft and bite-sized textures, mildly thick liquids, aspiration precautions, and no straws. The care plan was updated on 04/16/2025 to show use of 2-handled cups, and on 04/17/2025 to show staff cues to wake the resident and take bites/drinks throughout meals and use sippy cups for beverages. During observations on 04/27/2026 and 04/28/2026, Resident 16 was seen with regular brown plastic coffee mugs containing thickened liquids, with no lids and only one handle, and no sippy cups present. Signs above the bed stated head of bed elevated at all times, thicken liquids, and sippy cups only. On 04/29/2026, the physician’s order noted a lipped up cup for all drinks with no straws. During interview, nursing assistants stated the resident had to have thickened liquids, a spouted cup, and be sitting up, and that a regular coffee mug should never be given because it was a choking risk. The DON and Regional Director of Clinical Operations reviewed the orders and were uncertain whether a sippy cup and a lidded cup were the same type of cup, and acknowledged that a regular coffee mug was not the correct type of cup for the resident.
Penalty
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Failure to provide adaptive eating equipment: A resident with Alzheimer's disease, dementia, PCM, muscle weakness, and severely impaired cognition was supposed to receive a scoop plate with meals to support self-feeding. During lunch, staff served the meal on a regular plate instead, and the resident was observed with weak, unsteady hands while trying to scoop food. CNA confirmed the scoop plate was not provided, and the FSD and DON stated adaptive equipment should be provided with meals.
Adaptive feeding equipment was not provided as ordered for a resident with hemiplegia, DM2, and vascular dementia. The resident’s order required a high sided plate and rocker knife, and the care plan noted the need for both items at meals, but an observed lunch tray did not include either item. The resident said he frequently did not receive the rocker knife or high sided plate and that it made eating harder.
A resident with cerebral palsy, severe protein-calorie malnutrition, and severe cognitive impairment did not receive physician-ordered adaptive eating equipment at mealtime. The resident was observed eating from a standard plate with no divisions and using cups without straws, even though the meal card listed a divided plate and straw-equipped cups. The OT noted these items were needed to support self-feeding independence, and the care plan did not address the ordered equipment.
Failure to provide ordered adaptive drinking equipment: A resident who was cognitively intact and independent in eating had a care plan requiring a one-handled cup with a straw lid for beverages, but staff served hot coffee in a large Styrofoam cup instead. The resident spilled the coffee on himself, and an aide stated she was not aware of the resident’s adaptive cup requirement; the DON confirmed the resident should have been served hot liquids in the appropriate equipment.
Failure to provide ordered adaptive eating equipment. A resident with an order and care plan for a lip plate and built-up utensils was observed eating with standard utensils and had difficulty manipulating the fork, with food spilling from it. The OT stated the resident needed the adaptive equipment due to a change in hand dominance for eating, and the resident said the built-up utensils made eating much easier.
A resident who needed assistance with ADLs did not receive the adaptive feeding cup or utensil setup listed in the care plan. The resident’s liquid was served in a regular cup, and the meal tray did not match the ticket because the entree and sides were served together instead of in separate bowls. An aide confirmed the ordered adaptive equipment and meal presentation were not provided.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide the appropriate assistive eating utensil to Resident 85 during the lunch meal on 5/18/26. Resident 85 had diagnoses including Alzheimer's disease, dementia, moderate protein-calorie malnutrition, and muscle weakness. The MDS dated 1/8/26 indicated a BIMS score of 5 out of 15, showing severely impaired cognition, and also indicated the resident needed supervision or touching assistance with eating. The care plan identified malnutrition risk related to dementia and malnutrition, and the active physician's order called for a fortified regular diet with thin liquids. The resident's nutritional risk review dated 4/9/26 directed that a scoop plate be provided during all meals to support independence with self-feeding. During observation, staff served the lunch meal on a regular white dinner plate, and Resident 85 was seen with weak and unsteady hands while trying to scoop food. Resident 85 stated the scoop plate was not provided and that it would have helped with scooping food and prevented the tray from becoming cluttered. CNA 3 confirmed the scoop plate was not provided and stated the resident should have received one with every meal. The FSD and DON stated that adaptive eating equipment should be provided with meals to support independence, and the facility policy stated adaptive devices will be provided for residents who need or request them.
Adaptive Feeding Equipment Not Provided as Ordered
Penalty
Summary
Failure to provide adaptive feeding equipment occurred for Resident #12, who had diagnoses including hemiplegia, type 2 diabetes mellitus, and vascular dementia. The resident’s quarterly MDS assessment indicated intact cognition and that he required set up for eating. A physician order dated 10/30/25 specified a regular diet with a high sided plate and a rocker knife, and the care plan last revised on 04/26/26 noted nutrition risk related to diabetes mellitus, hypertension, hemiplegia, and mild cognitive impairment, with the need for a high sided plate and rocker knife at meals. During observation on 05/20/26 at 1:20 P.M. with the RD, Resident #12’s lunch tray did not include the ordered high sided plate or rocker knife. At the time of the observation, the resident stated he frequently did not get the rocker knife or high sided plate and that it made it harder for him to eat his meals. The facility policy on Adaptive Feeding Equipment stated dietary must be notified of adaptive equipment needs and ensure the equipment is placed on the tray at each meal.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for Resident #20, including a physician-ordered divided plate and a 4 oz cup with straw and lid for drinking. On 05/20/2026 at 12:52 PM, the resident’s lunch was observed on a standard dinner plate with no divisions and cups with no straw, despite the meal card listing adaptive equipment as a divided plate, lid for hot beverage, and straw. Resident #20 was a [AGE]-year-old female admitted with cerebral palsy, unspecified severe protein-calorie malnutrition, and paranoid schizoaffective disorder. Record review showed the resident had a BIMS score of 03 and required partial/moderate assistance for eating. A doctor order dated 04/14/2026 and revised 05/18/2026 specified a divided plate and small 4 oz cups with straw, and OT clarification stated these items were recommended to promote loading utensils, ease access to liquids, and support independence with self-feeding tasks. The comprehensive care plan dated 05/20/26 did not address the resident’s need for a divided plate or small 4 oz cups with a straw at mealtime.
Failure to Provide Ordered Adaptive Drinking Equipment
Penalty
Summary
The facility failed to ensure that staff provided assistive drinking equipment in accordance with a resident’s care plan for one resident reviewed. The resident’s quarterly MDS assessment dated April 23, 2026, indicated that he was cognitively intact, always understood and was always understood by others, and was independent in eating. His care plan, dated September 24, 2025, specified that he required a one-handled cup with a straw lid for beverages. An investigation into a coffee spill found that on May 6, 2026, the resident was served coffee in a large Styrofoam cup instead of the adaptive cup identified in his care plan. After being served the coffee, he spilled it on himself. A nurse aide stated that she poured coffee into large Styrofoam cups for the resident and his roommate, helped add sugar and cream, and was not aware that the resident required a one-handled cup with a straw lid. The DON confirmed that the resident should have been served hot liquids in the adaptive equipment required by his care plan.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for Resident #68, who had a care plan intervention and physician order to use a lip plate and built-up utensils with every meal. During observation on 5/13/26, Resident #68 was seen eating breakfast in the second-floor day room using a spouted cup, lip plate, and standard utensils, and had difficulty manipulating the fork with food spilling from it. Record review showed an order dated 4/21/26 for adaptive equipment, and the Occupational Therapist stated that the resident needed the lip plate and built-up utensils due to a change in hand dominance for eating. The resident later stated that the built-up utensils made eating much easier and asked where more could be obtained. The facility policy stated that assistive devices and utensils would be provided as identified in the individualized plan of care.
Failure to Provide Ordered Adaptive Eating Equipment and Meal Setup
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required assistance with ADLs. Resident 5’s care plan identified the need for a spouted sippy cup and red foam built-up handles on spoons to assist with eating and drinking. During observation on May 6, 2026, the resident was in bed with a lunch tray in front of her, but her liquid was served in a regular cup and no sippy cup was observed. Review of the meal ticket also showed the resident was to receive food in separate bowls, but the entree and sides were served together on one plate. An interview with the nurse aide confirmed the resident did not receive the adaptive feeding cup or the food presentation specified in the care plan and meal ticket.
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