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.
A resident did not receive hot coffee as listed on the tray card during a dining room observation. When the surveyor asked if she wanted coffee, the resident said yes and received it after surveyor intervention. An LPN confirmed the coffee had not been served as printed, despite the facility policy stating that individual food and beverage preferences are identified for all residents.
Incorrect diet texture and thickened liquids were served to a resident on a minced and moist diet with nectar thick liquids due to aspiration risk and pocketing food. A lunch tray contained a whole chicken breast, noncompliant substitutions, and missing items, and the family said the tray was never corrected. The next day, beverages were again served without the ordered nectar thickness, and both the Administrator and KM confirmed the soy milk was not correct.
An LPN served a resident with dysphagia a drink that was not yet pudding thick, allowing him to take several sips before the inconsistency was recognized. The resident had orders for pureed food and pudding-thick liquids, with a history of cerebral infarction and swallowing impairment documented by SLP and MBSS findings.
Surveyors found that multiple residents did not have water pitchers, [NAME] cups, or other drinks at bedside, with some having only leftover juice from lunch, despite facility policies requiring fresh bedside water and a structured hydration program. One resident complained of feeling very hot and repeatedly requested a drink, and an LPN and a NA confirmed that several residents lacked bedside water. The facility’s written procedures assigned night shift staff to replace used water containers daily with clean, filled containers, and dietary staff to wash and supply pitchers, yet these processes did not result in consistent bedside hydration for the affected residents.
A resident with dysphagia and recent pneumonia was served regular consistency milk and coffee instead of the ordered nectar thickened liquids, despite clear physician orders and care plan instructions. The resident drank the thin liquids and experienced coughing, and the inconsistency was confirmed by both a surveyor and the interim DON during a meal observation.
A facility failed to ensure that two residents with dysphagia received beverages at the ordered consistency. One resident ordered honey-thick liquids and another ordered nectar-thick liquids were both observed with thin water at bedside, despite SLP involvement and documented swallowing impairment, including silent aspiration and ongoing aspiration of liquids. The surveyor confirmed the liquid inconsistency, and the issue was identified as an IJ.
A resident with an order for nectar thickened liquids was served honey thickened liquids during a meal, contrary to their care plan and physician's order. This failure was observed and reported by staff, and confirmed through review of the resident's records and care plan.
A resident with orders for honey-thick liquids was observed receiving a bedside drink that did not appear to meet the required moderately thick consistency. Staff gave conflicting instructions on how much thickener to use, with one LPN adding three pumps to 8 oz of water and the Unit Manager incorrectly referencing spoon-thick directions. The resident had recently been hospitalized for septic shock, acute/chronic hypoxic respiratory failure, and aspiration pneumonia, and the facility also had no honey-like pre-thickened liquids available in the nourishment pantry refrigerator.
Incorrect Liquid Consistency Provided to Residents on Thickened Liquids: Three residents with orders for nectar- or honey-thick liquids were observed receiving thin liquids, including water and chocolate milk that did not meet the ordered consistency. An NA confirmed one resident was allowed thin liquids, an LPN removed regular water from another resident’s tray, and an NA confirmed the third resident’s drink was thin rather than honey thick.
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