Failure to Provide Correct Thickened Liquids for Resident with Dysphagia
Summary
The facility failed to provide drinks consistent with a resident's needs, specifically for a resident with dysphagia who required honey thick liquids. The resident was readmitted with a diagnosis of dysphagia and had a diet order for honey thick liquids. However, during an observation, a carton of nectar thick lemon water was found in the resident's hydration cooler, which was inconsistent with the prescribed diet. Interviews with staff revealed that the resident had expressed thirst, and due to a lack of available honey thick liquids, nectar thick liquids were mistakenly provided. The Dietary Manager confirmed that the facility had run out of pre-thickened honey thick liquids and had to source them from a sister facility. Staff interviews indicated that there was confusion and a lack of communication regarding the availability of thickened liquids, leading to the resident receiving the incorrect consistency. The Director of Nursing and the Administrator acknowledged the error, confirming that the resident should have received honey thick liquids to prevent aspiration.
Penalty
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Failure to Provide Fresh Water Consistently: Multiple residents reported not receiving fresh water every day, and several were observed with empty or stale water cups dated from the prior day. Residents said they had to ask repeatedly for water, including at night, and that staff sometimes refused because the CNA was assigned to the roommate. The DON stated water was passed each 12-hour shift with no required time, and resident council minutes documented repeated concerns about not receiving fresh water daily.
Surveyors found that multiple residents did not have water pitchers or drinking cups at their bedside on repeated observations, despite staff, including CNAs, the DON, and the Administrator, stating that residents should have constant access to fluids unless on fluid restriction or thickened liquids. Staff confirmed there were no such restrictions for these residents and could not explain the absence of water, and there was no written hydration maintenance policy in place.
The facility failed to provide ordered altered-consistency liquids and adequate hydration for two residents with post-stroke dysphagia. One cognitively intact resident was observed with an untouched meal tray lacking any fluids, had dry skin and chapped lips, and reported receiving unpalatable meals and dry cereal without milk, while staff were unclear about the "no drinks on the tray" diet slip and only later identified the need for Level 2 (nectar thick) liquids. Another cognitively intact resident with an order for Level 2 liquids received a tray with no liquid texture information and regular juices, and reported that CNAs bring regular juice on request despite disliking thickened fluids and recognizing inadequate fluid intake. The RD/Kitchen Manager acknowledged that residents should receive correct-consistency fluids, be monitored for hydration and compliance, and have their fluid consistency needs clearly communicated to floor staff.
Multiple residents were observed eating their evening meals without any drinks at their tables, with some having consumed a significant portion of their food before beverages were offered. A CNA on duty was unsure why the residents had no drinks and only offered a beverage after being prompted, while the DON and Dietary Manager later confirmed that all residents should receive drinks with meals and that CNAs are responsible for preparing and delivering them. Facility policy requires staff to monitor food and fluid intake and address inadequate fluid consumption, but this was not followed for these residents during the observed meal.
Two residents with intact cognition and dependence on staff for most ADLs did not have bedside water pitchers and reported only receiving small amounts of fluids when requested or only at mealtimes, despite feeling thirsty and having dry mouths. Observations confirmed the absence of water pitchers and cups in their rooms. A CNA not assigned to one resident eventually brought a pitcher after noticing it was missing, while the assigned CNA stated they only provided water upon request. An LVN and the DON both stated that all residents who can swallow and are not on fluid restriction must have bedside water pitchers and that nursing staff are responsible for ensuring this, in line with facility policies on accommodating needs and supporting ADLs.
A facility failed to consistently provide fresh bedside water to residents. During a group meeting, residents reported that water passes were missed, old cups were left in rooms for days, and some had to go elsewhere to get water. Resident council minutes showed the same concern over several months. Interviews and observations found dated cups still in use, no fresh cup or straw available for one resident, and staff acknowledging problems with timely water passes and cup shortages.
Failure to Provide Fresh Water Consistently
Penalty
Summary
The facility failed to ensure fresh water was passed and available to residents consistently and upon request for four residents reviewed for hydration: R4, R22, R79, and R101. On 4/6/26 at 9:30 AM, R101 and R22, who were roommates, were observed with Styrofoam cups dated 4/5/26 from 7:00 AM to 7:00 PM, and both stated that water had last been passed on the morning of 4/5/26 and had not been passed again by the time of the observation. On 4/6/26 at 10:04 AM, R79 was observed with a Styrofoam water cup dated 4/5/26 from 7:00 AM to 7:00 PM; when asked about fresh water, R79 shook the cup, which was empty, and said nobody had passed fresh water since Sunday morning 4/5/26. During an interview on 4/7/26 at 10:00 AM with 11 residents who wished to remain anonymous, 9 of 11 reported they did not receive fresh water every day. Residents described the problem as chronic, said they had gone a whole day without water, and reported that when they asked a CNA for water, the CNA assigned to their roommate would say they were not their CNA and would not get them water. One resident also reported not being given fresh water at night and said that when they asked, staff said they would bring it but never returned. Resident council minutes from October 2025 through March 2026 documented repeated concerns about not receiving fresh water every day. The DON stated that water was passed each 12-hour shift with no specific required time and that staff should provide water upon request or if cups were empty; the DON was not aware that water had not been passed on 4/5/26 after the first shift on A Hall. R101 had a history of stroke and diabetes and was cognitively intact; R79 had COPD and moderately impaired cognition. R4 was admitted with osteomyelitis of the left foot requiring toe amputation, IV antibiotics via PICC line, and AKI requiring hemodialysis, and was alert, oriented, and able to make needs known. R4 reported requesting a glass of water four to five times on Easter Sunday and not receiving anything to drink until the next day, despite knowing they needed to drink more because of urination concerns.
Failure to Ensure Bedside Access to Drinking Water for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to drinking water at their bedside, as observed for four residents out of five reviewed for access to drinking water. On multiple observations over several days, surveyors noted that these residents did not have water pitchers or drinking cups on or near their overbed tables. On 3/31, two residents were observed with only empty cups containing drops of clear liquid, and two other residents had no pitchers or cups at all. On 4/1, repeat observations showed that none of the four residents had water pitchers or cups at their bedside. On 4/6, the same four residents again had no water pitchers or drinking cups at bedside. Multiple CNAs interviewed stated that all residents should have access to drinking water at their bedside unless they are on a fluid restriction or require thickened liquids, and one CNA reported she could not think of any resident who should not have access to water in their room. CNAs working on the hall where the four residents resided confirmed that these residents were not on fluid restrictions or thickened liquids and could give no reason for the absence of water pitchers or cups. The DON verified during room checks that the four residents did not have water pitchers or cups at bedside and later stated there was no reason they should not have had water. The DON and the Administrator both stated that residents should always have or have constant access to fluids, and that water is expected to be passed regularly, but there was no written policy for hydration maintenance in place at the facility.
Failure to Provide Ordered Thickened Liquids and Adequate Hydration
Penalty
Summary
The facility failed to ensure residents received liquids consistent with their ordered altered consistencies and hydration needs. One resident with post-stroke swallowing difficulties, cognitively intact per an admission MDS, was observed with an untouched lunch tray that had no fluids. The resident had chapped lips and dry facial skin and reported that meals had been cold and unpalatable since admission, describing breakfast as a glob of eggs and an unmanageable muffin, and receiving dry cereal without milk on two mornings. A CNA, upon checking the diet slip, noted it stated no drinks on the tray and did not know what that meant, indicating they would need to ask the nurse. An LPN then reviewed the orders and identified that the resident required Level 2 (nectar thick) liquids, retrieved a single carton of nectar thick juice from a locked nourishment room, and provided it, with no other Level 2 beverages observed in the refrigerator. The LPN stated that aides would need to ask the nurse to know what type of liquid to give a resident. Another resident, also admitted with post-stroke swallowing difficulties and cognitively intact per the admission MDS, had a dietary order for Level 2 liquids. During a meal observation, this resident’s tray diet slip contained no information about liquid textures, and the tray included two containers of normal-consistency juice. Later, the resident was observed in bed drinking normal-consistency cranberry juice and reported that aides bring juice containers upon request, expressing dislike for nectar thickened fluids, especially water, but acknowledging not getting enough fluids. The Registered Dietician/Kitchen Manager stated that all residents should receive sufficient fluids of the correct consistency, that residents with altered fluid consistency should be monitored for compliance and hydration, and that there should be a quick reference system to communicate residents’ fluid consistency needs to floor staff. The report states that these failures placed residents at risk for dehydration, aspiration, and decreased quality of life.
Failure to Provide Drinks With Meals to Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide drinks with meals consistent with resident needs and preferences and sufficient to maintain hydration. During an evening meal observation on 03/01/26 at 5:28 PM, four residents (R1, R2, R3, and R4) were seated in the dining room with their meals in front of them but had no drinks at their tables. At that time, R2 and R3 had already eaten approximately one third of their food, and R4 had eaten approximately three quarters of his food, all without drinks present. By 5:44 PM, all four residents were still eating and still did not have drinks in front of them. At 5:45 PM, a CNA (V3) stated she did not know why the four residents did not have drinks and suggested they may have come late, and only then asked one resident (R2) if she wanted something to drink, to which R2 responded affirmatively. Later, the DON (V2) stated that all residents should receive a drink with their meals regardless of arrival time or table changes. The Dietary Manager (V4) confirmed that all residents should receive drinks with their meals, and that CNAs are responsible for preparing and delivering drinks, while the kitchen prepares beverage pitchers. The facility’s undated “24 hour Dining” policy states that staff will monitor residents’ food and fluid intake for adequate consumption and that any staff member observing inadequate fluid intake at meals will refer the resident to the DON and Dining Services Manager for follow-up, but this monitoring and provision of fluids did not occur for the four observed residents during the meal in question.
Failure to Provide Bedside Water Pitchers to Maintain Resident Hydration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received fluids consistent with their needs and preferences to maintain hydration, specifically for two residents who did not have water pitchers in their rooms. One resident was admitted with myasthenia gravis and sequelae of cerebral infarction, had intact cognitive skills, and was dependent on staff for most ADLs including transfers. This resident reported not having a water pitcher, receiving only small cups of water when requested, and experiencing dry lips and throat. On a subsequent day, the resident’s call light had been on for over 30 minutes while the resident was waiting to request water due to thirst and a dry mouth. Another resident, admitted with hemiplegia and diabetes mellitus, also had intact cognitive skills and was dependent on staff for most ADLs including transfers. This resident reported not being given a water pitcher and stated that water and juices were only provided during mealtimes. Observations confirmed there were no cups and no water pitcher in this resident’s room. Both residents were described in clinical documentation as alert, oriented, and capable of making decisions, yet they lacked ready access to fluids at the bedside. Staff interviews further clarified the circumstances leading to the deficiency. A CNA who was not assigned to one of the residents brought a water pitcher after noticing its absence and stated that all residents should have a water pitcher at the bedside to prevent dehydration. An LVN stated that all residents who can swallow and are not on fluid restriction must have a water pitcher at their bedside and that all staff are responsible for providing water. The CNA assigned to one of the residents stated they only provided water if the resident requested it and had assumed the resident did not need water when the resident answered “no” to a general offer of assistance. The DON stated that all residents who can swallow and are not on fluid restriction must have water pitchers at their bedside, that pitchers should be changed daily and as needed, and that nursing staff are responsible for assuring all residents have a water pitcher, consistent with facility policies on accommodation of needs and supporting ADLs.
Inconsistent Fresh Water Provision and Water Passes
Penalty
Summary
The facility failed to provide fresh water for five reviewed residents and a confidential group of residents. During a confidential group meeting, residents reported that menus were not being followed and that fresh water was not consistently passed to rooms. One resident said they had to go to the dining room to get fresh water, another stated they were told to drink more water because their urine was dark but were not given water, and the group reported that on some weekends the same cup could remain from Friday to Monday. The group also stated they had raised the issue at Resident Council meetings and that it continued to be a problem. Resident Council minutes documented repeated concerns about water passes not being completed or being inconsistent, including comments that fresh water was still not being given at times, water passes were a hit or miss, certain staff never took care of it, and some residents had no water in their room to take medication or sip water if needed for a cough. During interviews, one resident had a Styrofoam cup of water dated 2/28/26 and stated staff said they ran out of cups and refilled old cups over and over, while another resident had a cup dated 2/27/26 and stated they did not always get fresh water. A dietary manager stated cups were ordered by kitchen and central supply, and central supply staff stated there had been an issue with not having enough cups a few months earlier and that aides were not always passing water timely or labeling and dating cups correctly. At the time of observation, one resident had a Styrofoam cup dated 2/22/26 with a small amount of soda in it, and the nightstand contained old beverages and no fresh cups. Another resident had a cup with a tea stain and a small amount of tea, stated they could not take a drink because they could not find a straw, and had no other cup or straws available. A third resident stated they got water sometimes and sometimes did not. The facility policy stated fresh bedside drinking water should be available at all times unless contraindicated, and residents should be assisted to periodically take a drink throughout the day.
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