Orchard View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Idaho.
- Location
- 1014 Burrell Avenue, Lewiston, Idaho 83501
- CMS Provider Number
- 135103
- Inspections on file
- 21
- Latest survey
- August 15, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Orchard View Post Acute during CMS and state inspections, most recent first.
A dog was observed wandering in and out of the dining area and into two residents' rooms during meal service, approaching multiple residents and begging for food. This occurred despite facility policy and federal guidelines prohibiting pets in dining areas during mealtimes, and was confirmed by both the DM and DON as a violation of proper sanitation standards.
Three residents had inaccurate medication information documented in their MDS assessments. Two residents were incorrectly coded as receiving insulin when they were only receiving a non-insulin hypoglycemic medication, and another was coded as receiving an anticoagulant when only an antiplatelet was prescribed. The MDS Coordinator confirmed these were data entry errors after reviewing the MARs.
A resident admitted with encephalopathy and post-joint replacement aftercare did not have a baseline care plan documented within 48 hours, as required by facility policy. The omission was confirmed by both the RCM and DON during review of the electronic medical record.
A resident with multiple psychiatric diagnoses, including bipolar disorder, depression, and PTSD, did not have these conditions addressed in their care plan. Although the resident was receiving medications, counseling, and psychiatric follow-up, the care plan failed to include these diagnoses and related interventions, contrary to facility policy and PASARR recommendations.
A resident with a history of neurogenic bladder and urinary tract infections was observed with indwelling catheter tubing dragging on the floor while seated in a wheelchair. Staff interviews revealed the tubing was not noticed on the floor, and the privacy bag used was described as too small, allowing the tubing to slip out. Facility policy required catheter tubing and collection bags to be kept off the ground, but this was not followed.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident, who was cognitively intact and had multiple medical and psychiatric diagnoses, reported an allegation of sexual abuse when a CNA checked her brief. The incident was not reported to the DON until several hours later, and the CNA was not immediately removed from duty as required by facility policy. The nurse on duty instead reassured the resident and took over her care, but did not follow the policy for immediate staff removal and reporting.
Expired medications and medical supplies were found in a medication storage room, including nasal spray, allergy relief tablets, and nicotine patches. The facility's policy requires immediate removal of outdated items, but these were still present. An LPN acknowledged the responsibility to check and dispose of expired items, and the DON confirmed they should have been removed.
The facility failed to properly label, date, and store food items in its kitchen, leading to potential contamination risks. Observations revealed undated and improperly stored food in various refrigeration units and dry storage areas, including opened packages of turkey slices, cheeses, condiments, and bread products. Additionally, a scoop was improperly stored in a container of brown sugar. The dietary manager confirmed these deficiencies, acknowledging the need for proper labeling and storage practices.
The facility failed to follow its planned menus, impacting residents' nutritional needs. A resident reported not receiving the planned meal due to ingredient shortages, attributed to budget constraints. Another resident was served breakfast without milk due to a delivery shortfall, and a resident received fewer pancakes than prescribed. These incidents highlight the facility's failure to adhere to its menu policies.
The facility failed to provide palatable meals to residents, as evidenced by complaints about unseasoned, tough, and lukewarm food. Observations revealed that kitchen staff did not follow standardized recipes due to unavailable ingredients, a result of budgetary restrictions. This led to meals that were not palatable, potentially causing unmet nutritional needs.
The facility failed to provide between-meal snacks to residents, as required by their policy. Despite the presence of snacks in refrigerators, residents, including those with diabetes, reported not receiving snacks when requested. Staff, particularly during the night shift, often reported a lack of available snacks after the kitchen closed, leading to unmet nutritional needs.
A resident with end-stage renal disease was not provided with the prescribed renal diet, as she was often served foods like oranges, which were not recommended for her condition. Despite her meal slip indicating her dislikes and dietary restrictions, the facility's dietary staff failed to adhere to these instructions, as confirmed by the Dietary Manager.
A resident with high blood pressure did not receive their prescribed Losartan for four consecutive days due to a nurse's failure to administer the medication, despite documentation indicating otherwise. The error was discovered when another nurse noticed the doses were still in the blister pack, and the pharmacy confirmed only one pack was delivered.
The facility failed to honor the food preferences of two residents, leading to potential unmet nutritional needs. One resident was repeatedly not served peanut butter with pancakes as requested, while another was served eggs despite a preference for no eggs at breakfast. Both instances were confirmed by the Dietary Manager.
Dog Present in Dining Area During Meal Service
Penalty
Summary
The facility failed to maintain proper sanitation in the dining area by allowing a dog to wander freely during a meal service. During a lunch observation, the dog was seen moving in and out of the dining area, approaching several residents and begging for food, and entering two residents' rooms while they were eating. Both the Dietary Manager and the Director of Nursing confirmed that dogs should not be present in the dining room during mealtimes, in accordance with both the facility's policy and the FDA Food Code, which prohibit pets in dining areas during meals. The presence of the dog in the dining area and residents' rooms during meal service constituted a failure to adhere to established sanitation standards.
Inaccurate MDS Documentation of Medication Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the medication usage for three residents. For two residents with type 2 diabetes, the MDS indicated that they received insulin during the assessment period, when in fact, their Medication Administration Records (MAR) showed they were only receiving Ozempic, a hypoglycemic medication that is not insulin. The MDS Coordinator initially believed Ozempic was an insulin, but upon review, acknowledged the error and confirmed that neither resident was receiving insulin as documented in the MDS. Additionally, for a resident with a history of stroke, the MDS indicated use of an anticoagulant medication, while the MAR showed the resident was prescribed clopidogrel bisulfate, an antiplatelet medication, not an anticoagulant. The MDS Coordinator confirmed this was a data entry error. The Administrator stated there was no specific policy for MDS accuracy, and that the facility followed the guidance in the Resident Assessment Instrument (RAI) Manual.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was documented within 48 hours of admission for one of four residents reviewed for baseline care plans. Specifically, a resident admitted with medical diagnoses including encephalopathy and aftercare following total joint replacement did not have a baseline care plan initiated or completed in the electronic medical record. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, including initial goals, physician and dietary orders, therapy, and social services. Interviews with the Resident Care Manager and the Director of Nursing confirmed that the baseline care plan was not completed as required by policy.
Failure to Develop Comprehensive Care Plan for Psychiatric Diagnoses
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident that addressed all psychiatric diagnoses and needs. Record review showed that the resident was admitted with multiple psychiatric diagnoses, including bipolar disorder, major depression, insomnia, suicidal ideation, and post-traumatic stress disorder (PTSD). The resident's PASARR Level II evaluation and provider notes further documented these diagnoses and indicated a history of suicidal ideation and the need for specialized services, including counseling. Despite this, the resident's care plan did not address her diagnoses of PTSD, depression, or bipolar disorder. Interviews and policy review confirmed that the resident was receiving medications for depression and anxiety, daily visits from the Social Services Director (SSD), counseling services, and psychiatric follow-up. The SSD acknowledged that the resident's psychiatric diagnoses and PTSD triggers, such as using the telephone, were not included in the care plan. The facility's policy required that the care plan describe all services to attain or maintain the resident's highest practicable well-being, including specialized services recommended by PASARR, but this was not followed for the resident in question.
Failure to Maintain Catheter Tubing and Collection Bag Off the Floor
Penalty
Summary
The facility failed to ensure proper care of an indwelling urinary catheter for one resident, resulting in the catheter tubing and collection bag coming into contact with the floor. During an observation, the resident was seen sitting in a wheelchair in the activity area with the catheter tubing dragging on the floor as staff passed by. The facility's policy requires that catheter tubing and collection bags be kept off the ground to prevent complications, but this was not followed in this instance. Interviews with staff revealed that the catheter tubing was supposed to be checked several times a day, but the Certified Nursing Assistant did not notice the tubing was on the floor and acknowledged it should not have been there. The CNA also mentioned that the privacy bag used for the catheter seemed small, causing the tubing to come out. The Director of Nursing stated that catheter placement was checked every shift and expected staff to monitor it throughout the day. The resident involved had a history of neurogenic bladder, overactive bladder, and previous urinary tract infections, and was cognitively intact at the time of the incident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Immediately Remove Staff Accused of Abuse
Penalty
Summary
Facility staff failed to protect a resident from further abuse by not immediately removing a staff member accused of sexual abuse. According to facility policy, any staff member involved in an abuse allegation should be removed from their duties and sent home while an investigation is conducted. In this case, a resident with diagnoses including type II diabetes, overactive bladder, schizophrenia, anxiety, bipolar disorder, and cognitive communication deficit, who was cognitively intact, reported an allegation of sexual abuse when she awoke to a CNA checking her brief. The incident occurred at 1:05 AM, but was not reported to the DON until 8:05 AM. The CNA was not suspended until the DON received the report, contrary to policy requirements. Staff interviews revealed that the nurse on duty did not send the CNA home at the time of the incident and did not immediately report the allegation to the DON. Instead, the nurse reassured the resident and took over her care for the rest of the night, instructing the CNA not to return to the resident's room. The delay in reporting and failure to immediately remove the accused staff member from duty resulted in noncompliance with the facility's abuse policy and decreased the facility's ability to protect residents during the investigation.
Expired Medications and Supplies Found in Storage Room
Penalty
Summary
The facility failed to ensure that medications and medical supplies available for residents were not expired, as observed in one of the two medication storage rooms. During an inspection, several expired items were found, including Deep-Sea Nasal Spray, Allergy Relief tablets, Bisacodyl tablets, Nicotine patches, Niacin tablets, A & D ointment packets, cotton-tipped applicators, and alcohol wipes. The facility's policy, initiated in January 2023, requires outdated medications to be immediately removed and disposed of according to procedures. However, these expired items were still present, indicating a lapse in adherence to the policy. LPN present during the inspection acknowledged that it was the responsibility of all nurses to check and dispose of expired items, and the DON confirmed that the expired items should have been removed by the nursing staff.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its food storage and handling policies, resulting in multiple deficiencies observed in the kitchen's refrigeration and dry storage areas. During an inspection, it was found that various food items in the kitchen's Cooks reach-in refrigerator were opened and undated, including packages of turkey slices, cheeses, condiments, and bread products. Additionally, a container of Dijon wine mustard was found with a handwritten date indicating it should have been discarded after six months, but it was still present. Similar issues were noted in the Aides reach-in refrigerator and the walk-in refrigerator, where items like thickened juices, pureed peaches, and Neufchatel cheese with an expired use-by date were found undated and improperly stored. In the dry storage room, opened packages of spaghetti noodles, flour, and food thickener were left unprotected from contamination. Furthermore, a container of brown sugar was found with a scoop stored inside, violating the facility's policy against storing scoops in dry food goods. The facility's dietary manager confirmed these observations and acknowledged that food should be labeled, dated, and covered when opened and stored. The manager also stated that bread products should be dated when thawed and discarded if not used within seven days, as per the vendor's instructions.
Failure to Follow Planned Menus and Ensure Nutritional Needs
Penalty
Summary
The facility failed to adhere to its planned menus, which were intended to meet the nutritional needs of residents. On one occasion, a resident reported that the planned menu item, sweet and sour chicken with Asian stir-fry, was not served because the kitchen lacked the necessary ingredients. The Dietary Manager (DM) confirmed this, attributing the issue to budgetary constraints imposed by the previous Administrator, which led to insufficient food orders. The Interim Administrator later stated that there should be no budgetary restrictions affecting the kitchen's ability to serve the planned menu. In another instance, a resident was served breakfast without milk because the kitchen ran out of it. The DM was unaware of the shortage until shortly before breakfast service began, and the Administrator was not informed in time to rectify the situation. Additionally, a resident who was supposed to receive two pancakes for breakfast was only served one, which was confirmed by both the Administrator and the DM. These incidents highlight the facility's failure to follow its own menu policies, potentially impacting the nutritional intake of the residents.
Facility Fails to Provide Palatable Meals
Penalty
Summary
The facility failed to provide palatable food to its residents, as evidenced by multiple complaints from residents and observations during a survey. Seven residents, all assessed to be cognitively intact or moderately impaired, expressed dissatisfaction with the food quality, citing issues such as lack of seasoning, tough meat, and lukewarm temperatures. Additionally, Resident Council Meeting Minutes documented ongoing concerns about food palatability, including overcooked vegetables, poor food quality, and improperly cooked meats. During a survey, it was observed that the kitchen staff did not follow standardized recipes due to unavailable ingredients, which were not purchased due to budgetary restrictions imposed by the previous Administrator. The Dietary Manager confirmed the lack of necessary ingredients and the deviation from recipes, which contributed to the bland and unappetizing meals served to residents. This failure to adhere to the facility's food preparation policy resulted in meals that were not palatable, potentially leading to unmet nutritional needs for the residents.
Failure to Provide Between-Meal Snacks to Residents
Penalty
Summary
The facility failed to provide between-meal snacks to residents, as required by their policy, which states that nourishing snacks should be available 24 hours a day. Observations and interviews revealed that residents, including those with diabetes and chronic conditions, were not offered snacks between meals, and when requested, staff often reported that no snacks were available. This was confirmed by multiple residents during interviews and was a recurring issue noted in Resident Council Meeting Minutes over several months. Despite the facility's policy and the presence of snacks in refrigerators on different hallways, staff, particularly during the night shift, reported a lack of available snacks after the kitchen closed at 7:00 PM. The Director of Nursing (DM) stated that snacks should be restocked before the kitchen closes, but this was not consistently happening, leading to unmet nutritional needs for residents who requested snacks outside of traditional meal times.
Failure to Provide Prescribed Renal Diet
Penalty
Summary
The facility failed to ensure a therapeutic diet was served to a resident who was prescribed a renal diet, placing her at risk for complications related to her kidney disease. The resident, who was admitted with multiple diagnoses including diabetes and end-stage renal disease requiring hemodialysis, had a physician order for a consistent carbohydrate/renal diet. Her dietary meal slip directed the kitchen staff to serve her a renal diet and specified that she disliked bananas and oranges. Despite these instructions, the resident reported being often served bananas and oranges, which are not recommended for her prescribed diet. The resident expressed difficulty in resisting the temptation to eat oranges, which she liked but were not suitable for her condition. The Dietary Manager confirmed that the prescribed therapeutic diets are noted on meal slips and that the resident should not have been served oranges, acknowledging a failure in following the meal slip instructions.
Failure to Administer Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a resident was protected from significant medication errors, specifically regarding the administration of blood pressure medication. The resident, who had multiple diagnoses including diabetes, high blood pressure, and schizophrenia, was prescribed Losartan to manage elevated blood pressure. However, the medication was not administered for four consecutive days, as discovered by another nurse. The error was identified when it was noted that the doses had not been removed from the blister pack, despite documentation indicating they had been given. The investigation revealed that the nurse responsible for administering the medication claimed to have done so, but the pharmacy confirmed only one blister pack was delivered, and the doses remained unused. This discrepancy indicated that the medication was not administered as required, leading to the resident continuing to experience elevated blood pressures. The Director of Nursing confirmed the failure to administer the medication as ordered.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor known food preferences for two residents, leading to potential unmet nutritional needs. Resident #25, who was cognitively intact, reported that his food preferences were noted on his meal tray slip, but the kitchen staff did not follow these instructions. On multiple occasions, Resident #25 was not served peanut butter with his pancakes, despite his meal tray slip specifying this preference. This was confirmed by the Administrator and the Dietary Manager (DM), who acknowledged that the meal tray slip was not followed. Similarly, Resident #10, also cognitively intact, was served food that did not align with his documented preferences. His meal tray slip indicated a preference for no eggs at breakfast, yet he was served two hard fried eggs. Resident #10 had informed the staff of his preference, but it was not honored. The DM confirmed that Resident #10's preferences were not followed, acknowledging the oversight in meal preparation.
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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