Bridgeview Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in Twin Falls, Idaho.
- Location
- 1828 Bridgeview Blvd Suite 2, Twin Falls, Idaho 83301
- CMS Provider Number
- 135113
- Inspections on file
- 15
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Bridgeview Estates during CMS and state inspections, most recent first.
The facility did not ensure that meals were served at safe and appetizing temperatures, with hot foods sometimes below 135°F and cold foods above 41°F. Multiple residents reported that meals were cold, tasteless, or poorly prepared, and temperature logs for several meals were illegible. The Food Service Manager confirmed that required temperature standards and documentation were not consistently met.
Surveyors found that food items in the kitchen were not properly covered or dated, including cooked turkey, desserts, drinks, and sandwiches in the refrigerator, as well as opened boxes of green beans, chicken, and hamburger patties in the freezer. Dish washer and sanitizing bucket logs were incomplete, and containers of lemonade and iced tea served in the dining room were not labeled or dated. The Food Service Manager and DON confirmed these deficiencies, which did not meet professional standards.
A resident with emphysema and anxiety was found self-administering Cortisone-10 cream without a documented assessment to determine if self-administration was clinically appropriate. The DON confirmed that an assessment should have been completed but was not.
A resident with diagnoses including PTSD had this condition documented on PASRR assessments, but it was not reflected in multiple MDS assessments as required. The DON confirmed that PTSD should have been included in each MDS once identified on the PASRRs, but this was not done.
A resident with emphysema, anxiety, and PTSD did not have their PTSD diagnosis documented or addressed with goals and interventions in their comprehensive care plan. The DON confirmed this omission during the survey.
The facility did not update care plans for two residents after changes in their care needs. One resident continued to have a quad-cane listed in the care plan after it was replaced with a hemi-walker following a fall, and another resident's care plan did not include physician-ordered Tubi grips for severe lower extremity edema. These omissions were confirmed by the DON and placed residents at risk of not receiving appropriate care.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
Two residents did not receive respiratory care as ordered by their physicians. One resident with acute respiratory failure was not using prescribed continuous oxygen, and staff failed to update or discontinue the order despite documentation showing the resident was often on room air. Another resident using CPAP therapy had equipment left uncovered and reported infrequent cleaning, with staff not following required cleaning protocols or documenting maintenance as ordered.
Controlled medications were not properly tracked or secured due to missing required nurse signatures on narcotic accountability records for two medication carts. Audits revealed that multiple signatures were not documented as required when medication carts were accepted or released, and staff confirmed the lapse in procedure.
Staff failed to secure medications as required, including leaving an insulin pen unattended at a resident’s bedside and leaving a medication cart unlocked and unattended near the nurses’ station. Both the LPN and the DON acknowledged that these actions were not in compliance with facility policy, which mandates that all medications be securely stored and inaccessible to unauthorized individuals.
Surveyors found that trash cans in the kitchen food prep area were not sealable and lacked tight-fitting lids, as required by state and federal regulations. The Food Services Manager was unaware of the need for closed garbage can lids in these areas, creating a potential for pest and rodent attraction affecting all residents and staff.
A resident with multiple chronic conditions and a history of inappropriate sexual comments towards staff did not have these behaviors documented in the clinical record as required by physician order and care plan. Despite staff acknowledging the behaviors and their impact on care, such as missed showers, no entries were found in the TAR or progress notes over several months.
Failure to Maintain Palatable and Safe Meal Temperatures
Penalty
Summary
The facility failed to ensure that resident meals were palatable and maintained at safe and appetizing temperatures, as required by the 2022 FDA Food Code. Observations and interviews revealed that hot foods were sometimes served below the required 135 degrees F, and cold foods were served above the required 41 degrees F. Specifically, a lunch meal taste tray showed pudding at 65.1 degrees F and carrots at 129 degrees F, both outside the acceptable temperature ranges. The pudding's holding temperature log for that meal was recorded at 53 degrees F, which did not meet the standard. Additionally, holding temperature logs for several dinner meals in June were found to be illegible, indicating a lack of proper documentation and monitoring. Multiple residents reported dissatisfaction with the quality and temperature of the food, describing meals as cold, tasteless, overcooked, or mushy. One resident with multiple diagnoses, including Multiple Sclerosis and depression, stated that the food was not good, with tough meat and soggy vegetables, and noted that meal quality was worse on weekends. The Facility Food Service Manager acknowledged that the holding temperature for desserts should have been lower and that the temperature logs should have been legible, but they were not on several dates.
Deficient Food Storage, Labeling, and Documentation in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and documentation within the facility's kitchen. In the walk-in refrigerator, a large container of cooked turkey was found partially covered with plastic wrap that was submerged in liquid, and several trays of desserts, drinks, and zip-lock bags containing peanut butter and jelly sandwiches were not dated. In the walk-in freezer, large cardboard boxes of green beans, chicken, and hamburger patties were found opened to the air and not properly covered. The Food Service Manager confirmed that these items should have been properly covered and dated but were not. Further review of kitchen records revealed incomplete dish washer logs, with missing data for certain meals on specific dates, and missing entries in the kitchen sanitizing bucket PPM log for several time points. Additionally, containers of lemonade and iced tea served in the dining room were not labeled or dated, as confirmed by the DON. These actions and omissions were not in accordance with the Idaho Food Code and professional standards, and had the potential to affect all residents receiving meals prepared in the facility's kitchen.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including emphysema and anxiety, was observed with tubes of Cortisone-10 cream on her overbed table and reported self-administering the medication as needed. Review of the resident's medical record revealed there was no documented assessment to determine if she was safe to self-administer this medication. The Director of Nursing confirmed that an assessment should have been completed to allow the resident to keep and self-administer the Cortisone-10 cream, but this was not done.
Inaccurate MDS Assessment Documentation for PTSD Diagnosis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status. Specifically, a resident admitted with multiple diagnoses, including emphysema, anxiety, and post-traumatic stress disorder (PTSD), had PTSD documented on both Level I and Level II PASRR assessments. However, multiple MDS assessments for this resident did not indicate PTSD under the relevant section. The Director of Nursing confirmed that PTSD should have been documented in each MDS once it was listed on the PASRRs, but it was not. This discrepancy was identified through observation, interview, and record review.
Failure to Care Plan for PTSD Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with multiple diagnoses, including emphysema, anxiety, and PTSD. Observation, interview, and record review revealed that the resident's care plan did not document the PTSD diagnosis or include related goals and interventions. The Director of Nursing confirmed that the PTSD diagnosis should have been included in the care plan but was not.
Failure to Update Care Plans Following Changes in Resident Needs
Penalty
Summary
The facility failed to update and revise care plans in response to changes in residents' care needs, as required by policy. For one resident with COPD, congestive heart failure, and a history of repeated falls, a fall incident occurred when a quad-cane bent during a transfer, resulting in injury. Although the intervention was to replace the quad-cane with a hemi-walker, subsequent physical therapy documentation reflected the use of a hemi-walker, but the resident's care plan continued to list the quad-cane as the assistive device. The care plan was not updated to reflect the change in mobility aid, despite staff acknowledgment that the change had occurred after the fall. Another resident with acute respiratory failure and cellulitis of the lower limb had a physician's order for daily use of Tubi grips for edema management. Observations and weekly skin assessments documented severe edema and noncompliance with Tubi grips and foot elevation, but the care plan did not include the use of Tubi grips as an intervention. The Director of Nursing confirmed that the care plan should have included this intervention but did not. These failures to update care plans placed residents at risk of not receiving appropriate care as their needs changed.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Provide Physician-Ordered Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents. One resident with a history of acute respiratory failure with hypoxia and cellulitis of the right lower limb was observed not using his prescribed oxygen concentrator, stating he used it only when he felt it was needed. Despite a physician's order for continuous oxygen at 3 liters per minute via nasal cannula, documentation showed the resident was frequently on room air with varying oxygen saturation levels, and nursing staff did not contact the physician to update or discontinue the order as required. Another resident, diagnosed with diabetes and requiring assistance with personal care, was observed with CPAP nasal pillows left uncovered on the bedside table. The resident reported that it had been a while since staff had cleaned the mask and had never seen the humidifier cleaned. Facility policy required daily cleaning of the CPAP mask and weekly cleaning of the humidifier, with documentation in the patient record. However, there was no documentation of mask cleaning on a specific date, and the DON confirmed that nurses were not cleaning the mask or humidifier according to the physician's order and care plan.
Failure to Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing licensed nurse signatures on narcotic accountability records for two medication carts. During audits of the Sawtooth Hall and Sun Valley Hall medication carts, it was observed that the narcotic accountability records had three and five missing nurse signatures, respectively, over the documented periods. Staff interviews confirmed that two nurses were required to sign the narcotic accountability record when accepting or releasing the medication cart, but this procedure was not consistently followed. The Director of Nursing also acknowledged that the required signatures were missing at the times of cart transfer.
Failure to Secure Medications and Lock Medication Cart
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were securely stored and inaccessible to unauthorized individuals, as required by facility policy. Specifically, an LPN administered oral medications to a resident with spinal stenosis and diabetes, then left an insulin pen unattended on the resident’s overbed table while leaving the room to retrieve a needle. The LPN later acknowledged that the insulin pen should not have been left at the bedside. The Director of Nursing confirmed that medications should not have been left unattended in the resident’s room. Additionally, an unattended and unlocked medication cart was observed next to the nurses’ station. A medication aide confirmed that the cart should have been locked when not attended. The Director of Nursing reiterated that medication carts are to be locked when staff are not present. These actions were not in accordance with the facility’s policies on medication storage and administration, which require all medications to be securely stored and inaccessible to residents and visitors.
Improperly Covered Kitchen Garbage Cans
Penalty
Summary
Surveyors observed that various trash cans in the kitchen food preparation area were not properly sealable, as they had round holes cut in the center to keep them open. These garbage cans were not equipped with tight-fitting lids, contrary to the requirements outlined in the Idaho Administrative Rules and the U.S. Food and Drug Administration 2022 Food Code. During the survey, the Food Services Manager stated she was not aware of the requirement to have closed garbage can lids in the food preparation areas. This failure to properly cover garbage containers had the potential to attract pests and rodents into the kitchen, affecting all residents and staff in the facility.
Failure to Document Resident Behaviors and Interventions in Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident with multiple diagnoses, including COPD, congestive heart failure, and a history of repeated falls. A physician's order required documentation of the resident's inappropriate sexual comments towards staff on the Treatment Administration Record (TAR), including the number of episodes, interventions, and outcomes. The care plan also indicated that behavior tracking was in place for these behaviors. However, review of the resident's TAR and progress notes over several months revealed no documentation of any sexually inappropriate comments or behaviors, despite staff and administrative acknowledgment that such incidents occurred and resulted in the resident not receiving showers on specific dates. The Director of Nursing confirmed that these behaviors should have been documented but were not.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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