Franklin County Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Preston, Idaho.
- Location
- 44 North 1st East, Preston, Idaho 83263
- CMS Provider Number
- 135059
- Inspections on file
- 17
- Latest survey
- May 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Franklin County Transitional Care during CMS and state inspections, most recent first.
Surveyors identified deficiencies in food storage and labeling, including unsealed and undated food items in the walk-in freezer and nourishment room refrigerator. Both the Dietary Coordinator and assistant acknowledged that food items were not properly sealed, dated, or labeled with resident names as required by facility policy and the Idaho Food Code.
The facility did not ensure that residents and their representatives received assistance to exercise their right to formulate Advance Directives, as required by policy. For six residents with various medical conditions, there was no documentation of Advance Directives or evidence that assistance was offered, with the process limited to documenting CPR status. Both the DON and Social Worker confirmed that discussions or confirmations of Advance Directives were not documented during annual reviews.
A resident with multiple diagnoses, including diabetes and stroke, had inconsistent height measurements recorded in the MDS assessments, with entries alternating between 66 inches and 63 inches on different occasions. The administrator could not explain the discrepancies in the documentation.
The facility did not update care plans for two residents after multiple falls and wandering incidents. Despite documented investigations and recommendations by the Fall Committee and staff, interventions were not added to the care plans, and episodes of wandering were not addressed in care planning. The DON and Social Worker confirmed that care plans were not revised as required.
Surveyors found that two resident rooms had sink water temperatures above 120°F, with one resident reporting the water was very hot. Affected individuals included a resident with pneumonia and hemiplegia/hemiparesis after a stroke. These unsafe temperatures were confirmed by direct measurement and placed residents at risk for harm.
Licensed nurses failed to document interventions when a resident's oxygen saturation repeatedly fell below the physician-ordered threshold while on oxygen therapy. Despite multiple low SpO2 readings, nursing staff did not consistently take or record appropriate actions, as confirmed by the DON.
Controlled medications were not properly tracked or secured when a narcotic accountability record for a medication cart was found missing required signatures from two nurses during a review. Both an LPN and the DON confirmed that two nurses should have signed the record when accepting or releasing the cart, but this was not done.
Surveyors observed that a box of lorazepam, a controlled medication, was stored in a medication refrigerator without a separately locked compartment, contrary to requirements. Additionally, glucose test solutions were found undated after opening, and staff confirmed these should have been labeled.
The facility's abuse policy failed to include staff screening and training requirements, and protection measures for residents during investigations. The Administrator confirmed these deficiencies, despite annual abuse training covering required topics.
The facility failed to ensure residents received gradual dose reductions (GDRs) of psychotropic medications or a stop date for as-needed psychotropic medication unless clinically contraindicated. This deficiency was identified for three residents, who were on various psychotropic medications without GDR attempts or stop dates, despite stable moods and lack of identified problem behaviors. The consulting pharmacist did not make GDR recommendations, and the Medical Director confirmed the lack of GDRs and stop dates.
The facility failed to implement an antibiotic stewardship program, leading to the prolonged use of antibiotics without documented rationale for two residents. One resident received Bactrim DS for an undocumented infected hip wound, and another received Ciprodex Otic Suspension for an undocumented tympanic membrane perforation. The Infection Preventionist confirmed the lack of necessary documentation.
Deficient Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and labeling practices. In the walk-in freezer, a bag of biscuits was found unsealed and exposed to room air, and a large Ziploc bag of sandwiches was not dated. Additionally, there was significant ice buildup on the floor and fans of the walk-in freezer unit. The Dietary Coordinator confirmed that these issues, including improper sealing and dating of food items, needed to be addressed. Further inspection of the nourishment room refrigerator revealed an opened relish container without an open date or resident name, an opened container of homemade jelly/jam with only a year marked on the lid and no resident name, and a Ziploc bag of sliced cheese with no date. The assistant Dietary Coordinator acknowledged that all refrigerated resident food items must be dated and labeled with resident names or be disposed of, which was not done in these instances.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an Advance Directive, as required by facility policy. Record review, policy review, document review, and staff interviews revealed that for six residents, there was no documentation of Advance Directives in their medical records, nor evidence that the facility had offered assistance in formulating such directives. The facility's policy outlined specific procedures for providing information about medical treatment decisions, obtaining signatures, and referring residents to social services for assistance with Advance Directives, but these steps were not documented as completed for the affected residents. For each of the six residents reviewed, including individuals with diagnoses such as dementia, depression, chronic kidney disease, chronic respiratory disease, chronic obstructive pulmonary disease, anoxic brain damage, diabetes, and chronic viral hepatitis, there was a lack of documentation regarding Advance Directives. The only documentation present was related to CPR status, which the DON confirmed was the extent of the facility's process for Advance Directives. The Social Worker also confirmed that during annual admission reviews, there was no documentation that Advance Directives were discussed or confirmed with these residents. Additionally, the facility's document provided to residents, "Your Rights As A Patient To Make Medical Treatment Decisions," only contained information about living wills and durable power of attorney for health care, and did not include documentation declaring the status of an Advance Directive. This incomplete process and lack of documentation were consistent across all six residents reviewed, indicating a systemic failure to follow the facility's own policy and federal requirements regarding Advance Directives.
Inaccurate MDS Assessment Due to Inconsistent Height Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident's status, as evidenced by inconsistent documentation of a resident's height across multiple assessment dates. Specifically, the resident's height was alternately recorded as 66 inches and 63 inches on different MDS assessments, with no explanation for the discrepancies. The issue was identified through observation, interview, and record review, and the facility administrator was unable to provide a reason for the inconsistent height entries. The resident involved had multiple diagnoses, including diabetes and stroke.
Failure to Update Care Plans After Falls and Wandering Incidents
Penalty
Summary
The facility failed to ensure that care plans were revised and updated for residents following significant events, as required by facility policy. For one resident with chronic obstructive pulmonary disease and depression, multiple falls were documented over several months. Although the facility's Fall Committee investigated each incident and recommended specific interventions—such as moving the resident's room, providing a urinal at bedside, adjusting oxygen tubing, and ensuring non-skid footwear—these interventions were not incorporated into the resident's care plan after each fall. The Director of Nursing confirmed that the care plans should have been updated to reflect these interventions but were not. Another resident with dementia and hypertension experienced several wandering incidents, including one where the resident wandered outside the facility. Progress notes documented multiple episodes of wandering, and the admission assessment indicated a history of wandering. However, the resident's care plan did not include documentation of these incidents or interventions to address wandering. Both the Social Worker and Director of Nursing acknowledged that the care plan had not been updated to reflect these issues.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure safe water temperatures in resident rooms, as observed in two out of five rooms checked. Specifically, water temperatures in two resident rooms were found to be above 120 degrees Fahrenheit, with one room measuring 125 degrees F and another at 126 degrees F. A resident with multiple diagnoses, including pneumonia and hemiplegia/hemiparesis following a stroke, reported that the water in his room was very hot. These findings were confirmed through direct measurement of the sink water temperatures during the survey. The State Operations Manual Appendix PP, 483.25d, Table 1, was referenced to illustrate the risk of burns at various water temperatures and exposure times, highlighting that the temperatures found in the resident rooms exceeded safe levels for bathing and could cause harm.
Failure to Document and Intervene for Low Oxygen Saturation
Penalty
Summary
Licensed nurses at the facility failed to demonstrate appropriate competencies in managing oxygen therapy for a resident with multiple diagnoses, including anxiety disorder and dementia. The resident had a physician's order for oxygen via nasal cannula at 2-3L to maintain oxygen saturation (SpO2) above 90%. Despite this order, there were multiple documented instances where the resident's SpO2 levels fell below the prescribed threshold while on oxygen, and no nursing interventions were documented in response to these low readings. The report details several occasions over a period of months where SpO2 values ranged from 84% to 89% while the resident was receiving oxygen, with no evidence that licensed nurses took action or documented any interventions, except for one instance where a nurse instructed the resident to take deep breaths. The Director of Nursing confirmed that staff should have documented interventions for each low SpO2 reading but did not. This deficiency was identified for four out of fifteen licensed nurses and had the potential to affect all residents assessed for oxygen therapy.
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 signatures on the narcotic accountability record for one of two medication carts reviewed. During an audit of the Hall B medication cart, it was observed that the narcotic accountability record covering a ten-day period did not have the required two licensed nurse signatures to document acceptance or release of the medication cart. Both an LPN and the Director of Nursing confirmed that two nurses should have signed the record when the cart was accepted or released. This lapse in documentation was identified through record review and staff interviews.
Controlled Medications Not Properly Secured; Biologicals Not Labeled When Opened
Penalty
Summary
Surveyors found that controlled medications, specifically a box of lorazepam (a Schedule IV controlled substance), were stored on a medication refrigerator shelf that did not have a separately locked compartment for controlled drugs, as required. Although both the medication refrigerator and cabinet were locked, there was no additional locked compartment inside the refrigerator for controlled substances. Additionally, biologicals such as glucose test solutions were observed to be undated when opened. Staff interviews confirmed that the glucose test solution bottles should have been dated upon opening, but this was not done.
Deficient Abuse Policy
Penalty
Summary
The facility failed to ensure their abuse policy included screening and training of employees, and protection for residents during an investigation. The policy, dated 5/18/20, did not include screening requirements of staff to prevent abuse, nor did it specify to whom, how, and when to report incidents of abuse and neglect. Additionally, the policy lacked details on how the facility would protect a resident during an investigation of an allegation of abuse. During an interview, the Administrator confirmed that the abuse policy was lacking in these areas, although annual abuse training for employees covered all required topics.
Failure to Implement Gradual Dose Reductions and Stop Dates for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents received gradual dose reductions (GDRs) of psychotropic medications or a stop date ordered for as-needed psychotropic medication unless clinically contraindicated. This deficiency was identified for three residents. Resident #8, who was admitted with anxiety and depression, had been on escitalopram for over two years without any GDR recommendations or attempts, despite not displaying the identified problem behaviors. Resident #13, also with anxiety and depression, had no GDRs for Seroquel and no stop date or reevaluation for as-needed Ativan after 14 days of use. Additionally, Resident #18, with depression, was on multiple psychotropic medications without GDR attempts and had no diagnosis justifying the use of Risperdal for a movement disorder or psychotic disorder. The records showed that the consulting pharmacist did not make GDR recommendations for these residents, and the Medical Director confirmed the lack of GDRs and stop dates for the medications in question. Resident #8's care plan included monitoring for depressive symptoms and behaviors, but no changes were recommended in the psychotropic medication review forms over multiple months. Resident #13's psychotropic medication review forms also showed no changes recommended, and the resident's moods were stable. However, the resident's record did not include GDRs for Seroquel or a stop date for Ativan. Resident #18's care plan documented a behavior management plan for depressive and anxiety symptoms, but the resident had not demonstrated these symptoms since November 2023. Despite this, the resident's record did not include GDRs for Risperdal, Bupropion, and Venlafaxine. The Medical Director and Director of Nursing confirmed the consulting pharmacist did not make GDR recommendations for these residents, and there was no stop date for the as-needed Ativan ordered for Resident #13.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program, resulting in the continued use of antibiotics without a documented rationale for two residents. Resident #8, who was admitted with multiple diagnoses including dementia and anxiety, received Bactrim DS for an infected hip wound for over two years without any documentation of an infected hip wound in his record. Similarly, Resident #13, admitted with diagnoses including anxiety and chronic kidney disease, was prescribed Ciprodex Otic Suspension for a tympanic membrane perforation, despite no documentation of a ruptured eardrum in his record. The Infection Preventionist confirmed the lack of documentation for both residents, indicating a failure to ensure appropriate use of antibiotics.
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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