Parke View Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Burley, Idaho.
- Location
- 2303 Parke Avenue, Burley, Idaho 83318
- CMS Provider Number
- 135068
- Inspections on file
- 15
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Parke View Rehabilitation & Care Center during CMS and state inspections, most recent first.
Staff were observed entering multiple resident rooms without knocking or waiting for acknowledgement, including the room of a resident with significant medical conditions. A CNA admitted to not following protocol due to being late, and the DON confirmed that knocking is required but was not done during these rounds.
A resident with complex medical conditions, including hepatitis C and alcoholic cirrhosis, received a new diagnosis of bipolar disorder, but the facility did not update the resident's MDS assessment to reflect this significant change in status. Staff confirmed the assessment was not revised as required.
The facility did not timely update or submit required Level I PASRR documentation for three residents with mental illness or developmental disabilities after significant changes in their diagnoses or conditions. One resident was prescribed a new antipsychotic medication, another had a diagnosis changed to bipolar disorder, and a third had a longstanding schizophrenia diagnosis that was not reflected in PASRR records for years. In each case, the facility failed to notify the appropriate authorities within the required timeframe.
The facility did not follow its bowel care standing orders for two residents with chronic medical conditions, failing to initiate the required bowel management protocol when they went more than 72 hours without a BM. Documentation showed that the protocol was not started during multiple extended periods of constipation, despite clear facility guidelines and staff acknowledgment of the requirement.
Controlled medications were not consistently tracked or secured due to missing licensed nurse signatures on narcotic accountability records for two medication carts. Staff confirmed that two nurses should have signed the records when accepting or releasing the carts, but this was not always done, potentially affecting all residents receiving controlled medications.
Medication carts were observed left unlocked and unattended in multiple facility areas for several minutes, with no staff present. An RN admitted to forgetting to lock the cart, and the DON confirmed that carts are required to be locked when unattended.
A CNA was observed providing care to three residents in succession, obtaining vital signs without performing hand hygiene before, during, or after each interaction. The CNA admitted to not following hand hygiene protocols, and the DON confirmed this was not in line with facility expectations.
Sharps containers in the rooms of two residents were observed to be filled past the full line. An LPN and the DON both confirmed that the containers should have been changed when full, but this was not done.
The facility failed to assess two residents for their ability to self-administer medications, as required by policy. One resident, cognitively intact, was observed with pills left on the bedside table without proper documentation or orders for self-administration. Another resident, severely cognitively impaired, was given pills to take with breakfast, also lacking necessary assessments and documentation. Interviews confirmed the process for self-administration was not followed.
A resident with mental health diagnoses remained in the facility beyond the initial 30-day exception period without a completed PASARR Level I assessment. The Medical Records staff missed completing the assessment, and the DON was unaware of the oversight. The facility's policy requires proper PASARR screening, which was not followed, resulting in a deficiency.
A resident with a history of obstructive and reflux uropathy had their Foley catheter flushed by an LPN without a physician's order, contrary to facility protocol and nursing guidelines. The resident's urine was observed to be slightly blood-tinged, and the LPN mistakenly believed there was a standing order for the procedure. Interviews with facility staff confirmed the requirement for a physician's order before catheter flushing.
The facility failed to consider alternative measures before installing bed rails for two severely cognitively impaired residents, as required by their policy. Both residents' assessments lacked documentation of alternatives, only noting risks, benefits, and consent. Interviews with staff revealed a lack of awareness about the need to document alternatives, despite the facility's policy stating otherwise.
Expired medications were found in the TCU medication room, including Bisacodyl suppositories and a Tubersol vial with an unclear expiration date. A nurse confirmed the expired status, and the DON stated that outdated medications should be discarded. Facility policy requires checking expiration dates and dating multidose containers when opened.
Failure to Knock Before Entering Resident Rooms Compromises Dignity
Penalty
Summary
Staff failed to honor residents' rights to dignity and self-determination by entering resident rooms without knocking and waiting for acknowledgement. During afternoon CNA rounds, a CNA was observed entering five out of six resident rooms consecutively without knocking, including the room of a resident with multiple diagnoses such as diabetes and heart failure. When interviewed, the CNA acknowledged not following the expected protocol due to being late for shift change. The Director of Nursing confirmed that staff are required to knock before entering resident rooms, but this was not done during the observed incidents.
Failure to Update MDS Assessment After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident. Specifically, a resident with multiple diagnoses, including acute hepatitis C and alcoholic cirrhosis of the liver, was given a new diagnosis of bipolar disorder. Despite this significant change in the resident's mental health status, the facility did not submit a significant change in status assessment to update the resident's MDS. This omission was confirmed through record review and staff interview, where social services staff acknowledged that the MDS had not been updated following the new diagnosis.
Failure to Timely Update and Submit PASRR Documentation After Significant Change in Condition
Penalty
Summary
The facility failed to update and submit required Level I PASRR documentation for residents with mental illness (MI) or developmental disability (DD) following significant changes in their diagnoses or conditions, as mandated by Idaho Medicaid Plan Benefit 16.03.26.475.03. For three residents, the facility did not complete or timely submit updated Level I PASRRs when new diagnoses or changes in mental health status occurred. One resident was prescribed Lithium Carbonate for mood stabilization, which required an updated Level I PASRR to be submitted within two working days, but this was not done. Another resident's diagnosis was changed from depressive disorder to bipolar disorder, necessitating an updated Level I PASRR, which was not completed until nearly two months later. In both cases, facility staff acknowledged the delay or lack of awareness regarding the required timeframe for submission. A third resident had a longstanding diagnosis of schizophrenia that was not reflected in the PASRR documentation for over eight years. The original Level I and Level II PASRRs only documented depressive disorder and mental retardation, omitting the schizophrenia diagnosis. The omission was only recently identified and an updated Level I PASRR was sent to the state, with the facility still awaiting an updated Level II PASRR. These failures resulted in inaccurate assessments and a lack of timely notification to the appropriate authorities as required by regulation.
Failure to Initiate Bowel Management Protocol per Standing Orders
Penalty
Summary
The facility failed to follow its established bowel care standing orders for administering specific medications when residents did not have a bowel movement (BM) within 72 hours. According to the facility's routine standing orders, medications such as Miralax, Senna, Dulcolax, and Magnesium Citrate were to be used as needed for constipation if a resident had not had a BM within the specified timeframe. However, documentation review revealed that for two residents, the bowel management protocol was not initiated as required. One resident, with a history of stroke and chronic obstructive pulmonary disease, went 96 hours between BMs without the protocol being started. Another resident, diagnosed with diabetes and chronic respiratory failure with hypoxia, experienced two separate intervals of 84 and 117 hours without a BM, during which the bowel management protocol was also not initiated. Staff interviews confirmed that the expectation was to begin the bowel management protocol when a resident had not had a BM for 72 hours or more, but this was not done for the affected residents. The medication administration records (MARs) for both residents showed no evidence that the protocol was followed during the periods of constipation, despite clear documentation in the CNA Task Bowel Activity logs indicating the extended intervals without BMs.
Failure to Properly 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 of three medication carts reviewed. During audits of the East Hall and North Hall medication carts, it was observed that the narcotic accountability records had missing signatures from licensed nurses who were responsible for signing when accepting or releasing the medication carts. Staff interviews confirmed that two nurses should have signed the records at each exchange, but this procedure was not consistently followed. This deficiency was identified through direct observation and staff statements, with the potential to affect all residents receiving controlled medications.
Unattended Medication Carts Left Unlocked
Penalty
Summary
Facility staff failed to ensure that medication carts were locked when unattended, as required for the safe storage of drugs and biologicals. On multiple occasions, an unlocked and unattended medication cart was observed in different areas of the facility, including the TCU hall outside the dining room and the 200 Hall, each time remaining unsecured for over three minutes without staff present. The responsible RN acknowledged forgetting to lock the cart and confirmed that medication carts are supposed to be locked when not attended. These observations were confirmed through interviews with the RN and the Director of Nursing.
Failure to Perform Hand Hygiene Between Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control practices by not performing hand hygiene before, during, or after providing care to multiple residents. On three separate occasions, a CNA was observed obtaining vital signs—including blood pressure, oxygen saturation, and temperature—for three different residents without performing hand hygiene upon entering, during, or exiting each resident's room. The CNA acknowledged not performing hand hygiene between resident-to-resident care, attributing it to a bad habit. The Director of Nursing confirmed that hand hygiene should have been performed during these care activities.
Overfilled Sharps Containers Not Replaced When Full
Penalty
Summary
The facility failed to maintain a safe and functional environment as evidenced by the presence of overfilled sharps containers in the rooms of two residents. On separate occasions, observations revealed that the sharps containers in both rooms were filled past the designated full line. During these observations, an LPN confirmed that the containers should have been changed when full. The Director of Nursing also stated that sharps containers are to be changed when full. These findings were based on direct observation and staff interviews.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administer medications were properly assessed and evaluated for their cognitive and physical ability to do so, as well as reviewed by the Interdisciplinary Team (IDT). This deficiency was observed in two residents, R38 and R11, who were seen self-administering medications without the necessary assessments and documentation. R38, who was cognitively intact with a BIMS score of 13 out of 15, was observed with pills left on the bedside table by an LPN at the resident's request. However, there was no documentation in R38's electronic medical record (EMR) of an assessment for self-administration, nor was there an order or care plan documentation for self-administration of medications. Similarly, R11, who was severely cognitively impaired with a BIMS score of 3 out of 15, was observed with pills in the dining room, which had been given by an LPN to be taken with breakfast. Like R38, R11's EMR lacked documentation of an assessment for self-administration, and there was no order or care plan documentation for self-administration of medications. Interviews with the Director of Nursing (DON) and the Clinical Resource Nurse confirmed that the process for self-administration was not followed, as the necessary assessments and IDT involvement were absent. The facility's policy required evaluation of the resident's cognitive, communication, visual, and physical abilities before allowing self-administration, which was not adhered to in these cases.
Failure to Complete PASARR Level I Assessment
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level I assessment for a resident who remained in the facility beyond the initial 30-day exception period. The resident, who was admitted with diagnoses including schizoaffective disorder, major depressive disorder, anxiety disorder, and post-traumatic stress disorder, had an intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident's admission was initially exempt from a Level II screen due to a hospital exception, which required a PASARR to be completed if the stay exceeded 30 days. The Medical Records staff acknowledged missing the completion of the PASARR Level I for the resident, who had been in the facility for almost two months. The Director of Nursing was unaware that a new Level I assessment had not been completed after the resident's stay exceeded 30 days. The facility's policy mandates that each resident be properly screened using the PASARR specified by the state, but this was not adhered to in this case, leading to the deficiency.
Failure to Obtain Physician's Order for Catheter Flushing
Penalty
Summary
The facility failed to ensure a physician's order was in place before flushing a Foley catheter for a resident with an indwelling urinary catheter. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had a medical history of obstructive and reflux uropathy. During an observation, the resident was seen with slightly blood-tinged urine in the catheter tubing. A Licensed Practical Nurse (LPN) documented in the progress notes that the catheter was flushed after the resident returned from an ultrasound, despite the absence of a physician's order for this procedure. Interviews with the Director of Nursing (DON), Clinical Resource Nurse, and the LPN confirmed that a physician's order is required for flushing a Foley catheter, and the LPN acknowledged the error in assuming there was a standing order. The Assistant Director of Nursing (ADON) confirmed that the facility's nursing procedure reference, the Fundamentals of Nursing textbook, also requires verification of a physician's order before performing catheter irrigation. This oversight in following protocol could potentially introduce bacteria into the closed catheter system.
Failure to Consider Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to ensure that alternative measures were considered before the installation of side rails for two residents, both of whom were severely cognitively impaired. Resident 84 was admitted with diagnoses including difficulty in walking and aftercare for joint replacement, and Resident 26 was admitted with diagnoses including lack of coordination and unsteadiness on feet. Both residents had care plans indicating a risk for falls with side rails as an intervention, but their side rail assessments lacked documentation of alternative measures being considered. The assessments only included the risks, benefits, and consent obtained. Interviews with facility staff revealed a lack of awareness regarding the requirement to document alternative measures before implementing bed rails. An LPN stated that they did not consider alternative measures prior to bed rail implementation, and the DON was unaware of the need for such documentation. The facility's policy, revised in December 2023, stated that appropriate alternatives should be attempted before installing bed rails, but this was not followed in practice.
Expired Medications Found in TCU Medication Room
Penalty
Summary
The facility failed to ensure expired medications were discarded in the main medication room on the TCU unit, which was reviewed for outdated medications. During an observation, two boxes of Bisacodyl suppositories were found stored in the refrigerator with an outdated expiration date. Additionally, a vial of Tuberculin Purified Protein Derivative (Tubersol) was found with an unclear expiration date, as the box was marked as opened but the expiration was not determined. A Registered Nurse confirmed the suppositories were expired and should not be used, and the Director of Nursing confirmed that outdated medications should not be administered and must be discarded. The manufacturer's instructions for Tubersol indicate that a vial in use for 30 days should be discarded, and the facility's policy requires checking expiration dates before administering medications and dating multidose containers when opened.
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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