Resident #20 had been living at Continuing Healthcare of Cuyahoga Falls since October 2021 with multiple diagnoses including dementia, dysphagia, and anxiety. Her care plan specifically required staff to provide assistance with all meals, snacks and supplements because she was at risk for malnutrition and weight loss.
The 56-bed facility's own assessment showed the resident needed setup or cleanup help with eating but was dependent on staff for all other daily living activities. Her cognitive test score was zero, indicating severe impairment.
Yet when inspectors observed the dining area on September 24 at 1:20 p.m., they watched Resident #20 trying unsuccessfully to open her milk carton. She couldn't use the built-up silverware fork provided and resorted to eating her corndog and bread with her hands.
Only after the surveyor intervened did facility staff realize the resident needed help.
The next morning brought a similar scene. At 8:38 a.m., inspectors found Resident #20 eating French toast with her hands because she couldn't manage the built-up silverware spoon for her cereal. When they spoke with her, the resident revealed she had been cutting up her own food with scissors.
The conversation itself proved difficult. Resident #20 was very hard to understand, and inspectors noted no communication tools at her bedside despite her care plan requiring staff to use "communication tools, terms, gestures the resident can understand" to address her communication impairment.
Certified Nursing Assistant #364, interviewed four minutes later, acknowledged the resident couldn't feed herself with the spoon. The aide said she had cut up the resident's food and that "resident was able to feed herself sometimes." She helped Resident #20 eat her cereal during the inspection.
The nursing assistant confirmed what inspectors had observed about communication barriers. She said Resident #20 "can sometimes be hard to understand" and admitted she had never seen communication tools at the bedside to help determine what the resident needed.
The facility's own policy, revised in March 2019, states it is responsible for providing necessary care to residents unable to carry out activities of daily living on their own "to ensure they maintain proper nutrition."
Records showed Resident #20's eating abilities fluctuated between independent and dependent from September 11 through September 24. But the care plan was unambiguous about her needs: assistance with all meals, snacks and supplements due to malnutrition risk.
The resident had lived with a colostomy, bladder dysfunction, and high blood pressure in addition to her cognitive and swallowing challenges. Her quarterly assessment confirmed she required help with eating setup or cleanup while remaining completely dependent on staff for other personal care.
Federal inspectors determined the facility failed to ensure adequate nutritional and communication assistance for the resident. The violation affected one of three residents reviewed for activities of daily living during the complaint investigation.
The deficiency carried a designation of minimal harm or potential for actual harm. Inspectors noted it represented non-compliance investigated under complaint number 2624366.
For a resident already at risk for weight loss and malnutrition, eating with her hands while struggling to open milk containers and communicate her needs represented exactly the kind of care failure her individualized plan was designed to prevent. The facility had identified her risks and specified the interventions required, but staff weren't consistently providing the assistance she needed to maintain proper nutrition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Continuing Healthcare of Cuyahoga Falls from 2025-11-19 including all violations, facility responses, and corrective action plans.
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