Adaptive Feeding Equipment Not Provided as Ordered
Summary
The facility failed to ensure adaptive feeding equipment was provided for one resident who required weighted utensils and two-handled cups to support self-feeding. The resident had moderate cognitive impairment and diagnoses including type 2 diabetes, acute cystitis, muscle weakness, history of transient ischemic attack and cerebral infarction, dysphasia, and protein-calorie malnutrition. The quarterly MDS indicated substantial/maximal assistance with personal and oral hygiene and setup/clean-up assistance with eating. The care plan, nutritional assessment, Kardex, and rehab communication all identified the need for weighted utensils and two-handled cups with lids at each meal and directed staff to encourage self-feeding. Despite those directions, meal tickets for breakfast and lunch listed weighted utensils and two-handled cups, but observations showed the resident’s trays were delivered with regular utensils and regular cups instead. On one occasion, a staff member placed the breakfast tray on the bedside table without providing setup or attempting to wake the resident. On another occasion, the lunch tray also lacked the ordered adaptive equipment. The resident stated she had not been receiving the weighted utensils and two-handled cups for quite some time and said the adaptive equipment made it much easier to eat independently because she had difficulty grasping and handling regular utensils and cups. Staff interviews confirmed the resident should have been receiving the adaptive equipment and that tray setup should match the meal ticket.
Penalty
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Failure to provide ordered adaptive eating equipment and utensils. Three residents with severe cognitive impairment and eating assistance needs did not receive the items listed on their diet tickets: one resident ordered disposable silverware received regular silverware, one resident ordered a divided plate received a regular plate, and one resident ordered no butter knife but had a butter knife on the tray. A DA verified the errors during meal tray preparation, and the facility policy stated adaptive assistive eating devices shall be provided for all meals.
A resident with diabetes and muscle weakness had a physician order and care plan intervention for a two-handled sippy cup with all meals, but during multiple observations the resident was seen eating breakfast in bed without the ordered adaptive cup. The NHA stated he would have expected the resident to have the ordered adaptive equipment at all meals.
A facility failed to provide ordered adaptive eating equipment and utensils at mealtimes for multiple residents. Residents were observed without Dycem, a scoop plate, or the ordered Kennedy cup despite tray cards and physician orders indicating these items, and staff confirmed the equipment was not present or had never been provided. One resident was also seen drinking from a regular coffee cup instead of the ordered special cup.
Failure to provide ordered sip cup during meal service. A resident with intellectual disability, autistic disorder, and severely impaired cognition had an order for a sip cup and supervision for eating, but was observed at lunch with only a full glass of tea and no sip cup. He said he wanted a drink but did not have his sip cup, so he did not drink anything until the MDS nurse obtained the sip cup from the kitchen and gave him tea. Interviews showed dietary and nursing staff were responsible for ensuring the sip cup was on the tray.
Failure to provide ordered meal assistive devices: A resident with Parkinsonism, dementia, and mildly impaired cognition had orders for weighted utensils, a plate guard, and a sippy cup with meals, and the care plan called for adaptive equipment. During breakfast, a CNA gave the resident juice in a glass with a straw because he was shaky, and no sippy or spouted cup was observed. An RN confirmed the order for a sippy cup with all meals.
A resident with dysphagia and a hx of stroke was ordered a slow-flow adaptive drinking cup with fluids, and the care plan and meal ticket also identified the need for the device. During a meal observation, a CNA served cranberry juice in a regular cup instead, and the resident drank from it and immediately coughed. The CNA, an LVN, the SLP, and the DON all acknowledged the resident should have received the ordered adaptive cup.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure residents were provided with adaptive eating equipment and utensils as ordered. Review of the facility policy stated that adaptive assistive eating devices shall be provided to residents who need them for all meals. During observation, Dietary Aide #910 prepared meal trays for residents and placed them in the food cart, but three residents did not receive the equipment specified on their diet tickets and orders. Resident #86 had diagnoses including unspecified protein-calorie malnutrition, depression, and diverticulitis of the intestine, and had severely impaired cognition and required supervision or touching for eating. Although the diet order specified disposable silverware for resident safety, the tray observed contained regular silverware instead of disposable silverware. Resident #80 had diagnoses including Parkinson's Disease, Alzheimer's Disease, and anxiety disorder, had severely impaired cognition, and required supervision or touching for eating; her diet ticket specified a divided plate, but her meal was served on a regular plate with no dividers. Resident #29 had diagnoses including bipolar disorder, unspecified protein-calorie malnutrition, and Alzheimer's Disease, had severely impaired cognition and required moderate assistance for eating; his diet ticket specified no butter knife, but his tray contained a butter knife.
Failure to Provide Ordered Adaptive Drinking Equipment
Penalty
Summary
Provide special eating equipment and utensils for residents who need them and appropriate assistance. Based on policy review, observations, clinical record review, and staff interview, the facility failed to provide a two-handled cup for one of 20 residents reviewed, Resident 65. Resident 65 had diagnoses including diabetes and muscle weakness, and the physician ordered a two-handled sippy cup with all meals starting June 18, 2026. The care plan also included the intervention for a two-handled sippy cup with all meals. However, during three separate observations, Resident 65 was seen sitting in bed eating breakfast without the ordered two-handled sippy cup. The Nursing Home Administrator stated he would have expected Resident 65 to have the ordered adaptive equipment at all meals.
Adaptive Eating Equipment Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that adaptive eating equipment and utensils were provided at mealtimes as ordered by the physician and as identified on residents’ tray cards and care plans. The facility policy stated that appropriate assistive devices and utensils would be provided as indicated in physician orders and the individualized plan of care. During observations and interviews, Resident #5 was seen at lunch without Dycem under the plate, although the tray card indicated Dycem and the resident’s order stated Dycem with meals; the resident said she gets Dycem sometimes, and the SLP confirmed none was present. Resident #62 was also observed at lunch without Dycem under the plate, despite the tray card and order calling for a Dycem mat and scoop plate with all meals; the nurse aide confirmed there was no Dycem and stated the plate usually has a ring around it, but this one did not. Resident #53 was observed without the ordered blue Kennedy cup and instead had a two-handled cup with a spouted lid. The LPN confirmed the resident did not have the ordered cup and stated the resident had never had one. Another resident was reported to usually not receive the two-handled cup with lid printed on the tray card; the LPN confirmed the resident did not receive the cup, stated she had never seen it in three years, and the resident said she never gets a special cup. The resident was observed drinking from a regular coffee cup during the dinner meal.
Failure to Provide Ordered Sip Cup During Meal Service
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who had an order for a sip cup and required supervision for eating. Resident #46 was a male with diagnoses including major depressive disorder, unspecified intellectual disabilities, and autistic disorder. His quarterly MDS indicated he sometimes understood others, sometimes made himself understood, and had a BIMS score of 1, indicating severely compromised cognition. His order summary showed a regular diet with mechanical soft texture, regular consistency, and a sip cup, and his care plan identified an ADL self-performance deficit with supervision for eating and use of a sip cup. During lunch observation, Resident #46 was eating in the dining room with a full glass of tea on his table and no sip cup present. A later observation and interview showed he still had no sip cup and had finished eating; he stated he wanted a drink but did not have his sip cup, so he did not drink anything. The MDS Nurse stated the resident should have had a sip cup and later obtained it from the kitchen, after which the resident drank two full sip cups of tea. Interviews with dietary and nursing leadership indicated the sip cup should have been on the tray and that dietary staff and nursing staff were responsible for ensuring it was provided.
Failure to Provide Ordered Meal Assistive Devices
Penalty
Summary
The facility failed to ensure Resident #33 had assistive devices in place for meals. Resident #33 was admitted with diagnoses including Parkinsonism, dementia, and a need for assistance with personal care. The MDS showed mildly impaired cognition, and the physician orders included a regular diet with level three texture, thin liquids, weighted utensils and a plate guard with each meal, a sippy cup with each meal, and double bread for breakfast. The care plan also identified the resident as at risk for altered nutritional status and included interventions to provide adaptive equipment. During breakfast observation, a CNA was assisting Resident #33 and stated the resident had a glass of juice with a straw to make it easier because he was shaky. No sippy cup or spouted cup was observed in use during the meal. An RN confirmed the resident had an order for a sippy cup or cup with spouted lid for all meals as an assistive device. The facility policy stated assistive devices are to be provided for residents who need them.
Failure to Provide Ordered Adaptive Drinking Cup
Penalty
Summary
The facility failed to provide Resident #24 with the physician-ordered slow-flow adaptive drinking cup during the noon meal. Resident #24 had diagnoses including dysphagia and a history of stroke. The physician order dated 06/11/2024 required a slow-flow adaptive drinking cup with fluids, and the care plan dated 11/11/2025 identified the adaptive drinking cup as needed to promote safe swallowing and reduce the risk of aspiration. The meal ticket also indicated that Resident #24 required a slow-flow adaptive drinking cup with meals. During observation of meal service on 07/13/2026 at 12:15 pm, CNA D served cranberry juice in a regular drinking cup instead of the ordered adaptive cup. Resident #24 independently lifted the regular cup, drank the juice, and immediately coughed after swallowing. CNA D stated the resident should have been provided a slow-flow adaptive drinking cup and acknowledged the incorrect cup was served. LVN C stated she was responsible for making sure residents had what was ordered by the doctor and said the resident should have had a sippy cup. The SLP stated Resident #24 required thin liquids with small sips when drinking, and the DON stated staff are educated regarding adaptive equipment needs and that the slow-flow adaptive drinking cup is intended to regulate fluid intake and promote safer swallowing.
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