River's Edge Rehabilitation & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Emmett, Idaho.
- Location
- 714 North Butte Avenue, Emmett, Idaho 83617
- CMS Provider Number
- 135020
- Inspections on file
- 19
- Latest survey
- February 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at River's Edge Rehabilitation & Living Center during CMS and state inspections, most recent first.
The facility did not adequately address or document responses to resident concerns raised in Resident Council meetings from June to November 2024. Issues included dietary, housekeeping, call light response times, and staffing. Despite a call light audit indicating room for improvement, no follow-up actions were documented or communicated to residents. Interviews confirmed ongoing issues and lack of written documentation of follow-up actions.
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for four residents, as required by the State Operations Manual. Residents with various diagnoses, including cerebral palsy, TBI, cancer, and heart failure, were transferred to the hospital without the Ombudsman being informed. The facility administrator was unaware of the notification requirement.
The facility did not ensure that full-time NAs were enrolled in or had completed a State-approved training and competency evaluation program within four months of employment. Four NAs were identified as working beyond this period without certification, which could negatively impact the 54 residents in the facility. The HR Manager confirmed the facility's non-compliance.
A facility failed to adhere to infection control practices when a staff member sorted dirty laundry without wearing a gown, as required by standard precautions. This breach was confirmed by the DON, who stated that both gloves and gowns should be worn during such tasks to prevent infection and cross-contamination.
A resident's room was found to have several maintenance issues, including a detached baseboard, improperly placed toilet paper, a grab bar with chipped paint, and a corroded sink. The Maintenance Director was not informed of these issues, as the Housekeeping Supervisor had not submitted work orders. The Housekeeping Supervisor and Administrator acknowledged the problems, noting the sink required replacement.
The facility failed to ensure accurate MDS assessments for three residents. One resident's assessments incorrectly documented an active pneumonia diagnosis, another's inaccurately recorded anticoagulant use, and a third's omitted a completed PASARR level II evaluation. These discrepancies were confirmed by the DON.
A facility failed to refer a resident for a PASARR level II evaluation after diagnosing them with major depressive disorder (MDD). Despite being prescribed antidepressants and having an updated care plan for managing depression and behavioral disturbances, the pre-admission PASARR level I screening was not forwarded for further evaluation. The DON was unaware of the oversight, which could have impacted the resident's mental health care coordination.
The facility failed to administer medications according to professional standards, affecting several residents. A resident with paraplegia received Norco instead of Tramadol due to a card mix-up. Another resident with esophagitis was given rivaroxaban meant for someone else during a training session. Additionally, a resident with respiratory failure was given Anoro Ellipta despite its discontinuation, as staff were unaware of the change. These incidents reflect a failure to follow the six rights of medication administration.
The facility failed to provide care according to professional standards and residents' care plans. A resident with diabetes had high blood glucose levels without documented physician notification, and another resident requiring two-person assistance was repositioned by one CNA alone. These actions did not comply with the care plans and protocols.
A medication error rate of 6.9% was identified in an LTC facility when a resident with diabetes received insulin without proper priming of the pens, as observed by surveyors. The RN failed to prime the insulin pens before administration, which was confirmed by staff interviews, potentially affecting the resident's blood sugar levels.
Failure to Address Resident Concerns
Penalty
Summary
The facility failed to address and resolve concerns raised by residents during Resident Council meetings from June 2024 through November 2024. The Resident Council minutes documented various issues such as dietary concerns, housekeeping, offsite activities, call light response times, staff behavior, and laundry problems. Despite these concerns being consistently raised in meetings, the minutes did not document any actions taken to address or resolve them. A call light audit conducted in October 2024 identified the need for improvement, but no follow-up actions were documented or communicated to the residents. Interviews with residents and staff revealed ongoing issues with housekeeping, staffing, heating, and call light response times. The Social Services Designee (SSD) and the Activities Director (AD) confirmed that concerns from Resident Council meetings were supposed to be addressed in staff meetings, but there was no written documentation of follow-up actions or responses provided to the residents. The Administrator acknowledged that while concerns were discussed in team meetings, they were not consistently documented or communicated back to the residents in writing.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for four out of five residents reviewed. This deficiency was identified through a review of the State Operations Manual, Appendix PP, which mandates that facilities must notify the resident, their representative, and the Ombudsman before any transfer or discharge. The facility did not comply with this requirement, as evidenced by the lack of documentation in the medical records of Residents #19, #30, #32, and #33, who were transferred to the hospital without the Ombudsman being informed. Resident #19, who had multiple diagnoses including spastic quadriplegic cerebral palsy and aphasia, was transferred to the hospital for possible gastrointestinal bleeding without Ombudsman notification. Similarly, Resident #30, with diagnoses including TBI, anxiety, and diabetes, and Resident #32, with cancer, anemia, and heart failure, were transferred without the required notification. Resident #33, with a fracture, anemia, and congestive heart failure, also experienced a facility-initiated hospital stay without Ombudsman notification. The facility administrator admitted to being unaware of the requirement to notify the Ombudsman of such transfers.
Non-Compliance with Nurse Aide Certification Requirements
Penalty
Summary
The facility failed to ensure that full-time nurse aides (NAs) were either enrolled in a State-approved training and competency evaluation program or had completed such a program within four months of employment. This deficiency was identified for four out of eleven NAs whose personnel files were reviewed. Specifically, NA #1, hired on November 21, 2023, NA #2, hired on April 11, 2024, who completed the class but had not tested, NA #3, hired on June 5, 2024, and NA #4, hired on June 13, 2024, were all working beyond the four-month period without obtaining their nurse aide certification. The HR Manager acknowledged the facility's non-compliance with the requirement for NAs to be certified within four months of their hire date. This oversight had the potential to negatively impact the 54 residents living in the facility.
Infection Control Breach in Laundry Handling
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as observed during a survey. A staff member in the laundry department was seen folding clean laundry and later admitted to sorting dirty laundry without wearing a gown, which is against the standard precautions outlined in the State Operation Manual Appendix PP. The manual specifies that gowns and gloves should be worn when handling potentially contaminated laundry to prevent infection and cross-contamination. The Director of Nursing confirmed that the correct procedure involves wearing both gloves and gowns during the sorting of dirty laundry.
Deficiency in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including dementia, malnutrition, and hypertension, was found to have a room with several issues. Observations included a six-inch section of baseboard near the bathroom that was not attached to the wall and a corner of the baseboard broken off. Additionally, a roll of toilet paper was improperly placed on the grab bar instead of the toilet paper holder. The grab bar itself had large sections of chipped and peeling paint. Furthermore, the hand washing sink was corroded with rust and chipped around the drain. The Maintenance Director was unaware of these issues, as the Housekeeping Supervisor was responsible for submitting work orders, which had not been done. The Housekeeping Supervisor acknowledged the improper placement of the toilet paper and, along with the Administrator, stated that the sink could not be cleaned and would need replacement.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For one resident, the quarterly and significant change MDS assessments incorrectly documented an active diagnosis of pneumonia, despite the condition having resolved months earlier. This discrepancy was confirmed by the Director of Nursing (DON) during an interview. Another resident's admission MDS assessment inaccurately recorded the use of an anticoagulant, which was not supported by the physician's orders. The DON confirmed the error after consulting with the MDS Coordinator. Additionally, a third resident's admission MDS assessment failed to document a completed PASARR level II evaluation, despite the medical record indicating it had been completed. The DON acknowledged this oversight during the review.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for a PASARR level II evaluation after the resident was diagnosed with a major mental illness, specifically major depressive disorder (MDD). The resident was admitted with multiple diagnoses, including MDD and dementia, and was prescribed antidepressant medication. The care plan was updated to include directions for managing the resident's depression and behavioral disturbances. However, the pre-admission PASARR level I screening identified the resident's MDD but was not forwarded to the appropriate state-designated authority for a level II evaluation. The deficiency was identified during a review of the resident's records and staff interviews. The Director of Nursing (DON) was unaware that the PASARR level I form was filled out incorrectly and that a level II evaluation should have been completed. This oversight had the potential to cause harm by not ensuring the resident's specialized mental health needs were evaluated and coordinated by the appropriate authority.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice, affecting multiple residents. Resident #18, who has diagnoses including paraplegia and chronic pain, was mistakenly given Norco instead of the prescribed Tramadol due to a mix-up with medication cards. Resident #25, with a diagnosis of esophagitis, was incorrectly administered rivaroxaban intended for another resident during a training session between LPN #1 and RN #1. These errors were documented in Medication Error Reports. Additionally, Resident #27, who suffers from chronic respiratory failure, was administered Anoro Ellipta despite the physician's order for ipratropium-Albuterol and the discontinuation of Anoro Ellipta. The medication technician and LPN involved were unaware of the discontinuation, leading to the administration of the wrong medication. These incidents highlight the facility's failure to adhere to the six rights of medication administration, creating potential adverse effects for the residents involved.
Failure to Follow Care Plans and Notify Physician
Penalty
Summary
The facility failed to provide resident-centered care in accordance with professional standards of nursing practice and residents' comprehensive care plans for two residents. Resident #6, who was admitted with multiple diagnoses including metabolic encephalopathy, diabetes, and hypoglycemia, had a physician's order to notify the provider if blood glucose levels were less than 70 mg/dl or greater than 400 mg/dl. However, on two occasions, Resident #6's blood glucose levels exceeded 400 mg/dl, and there was no documentation in the medical record that the physician was notified, despite the Director of Nursing stating that the nurse had informed the nurse practitioner. Resident #19, diagnosed with spastic quadriplegia, cerebral palsy, and aphasia, required two-person assistance for repositioning in bed as per his care plan. On one occasion, CNA #1 was observed repositioning and turning Resident #19 alone while changing his bed sheet, despite the care plan's requirement for two-person assistance. CNA #1 admitted to frequently performing the task alone, and the Unit Manager confirmed that the care plan required two staff members for bed mobility, indicating a failure to adhere to the resident's care plan.
Medication Error Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.9% error rate observed during the administration of insulin to a resident with diabetes. The resident was prescribed Insulin Glargine and Insulin Lispro, with specific instructions for administration based on blood glucose levels. On the day of observation, the resident's blood glucose was recorded at 256 mg/dl, requiring 15 units of Insulin Lispro according to the sliding scale. However, the RN administering the insulin did not prime the insulin pens before injecting the prescribed doses, which is a necessary step to ensure the full dose is delivered. The failure to prime the insulin pens was confirmed through staff interviews, where the RN admitted to not priming the pens, and the Unit Manager acknowledged that priming is required to ensure the resident receives the correct dose. This oversight in medication administration created the potential for the resident to experience fluctuations in blood sugar levels, as the full prescribed dose may not have been delivered. The deficiency was identified during a survey, highlighting a lapse in following proper medication administration protocols.
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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