Bridgeview Estates

Inspectors wroteBased on observation, 2022 FDA Food Code, resident and staff interviews, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This deficient practice had the potential to affect all residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being.

Inspectors wroteBased on observation, interview, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to ensure residents were initially assessed to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #10). This failure created the potential for adverse effects if residents self-administered medications inappropriately.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure the MDS assessment accurately reflected the resident's status. This was true for 1 of 1 resident (Resident #10) whose MDS, care plan, and nursing assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and cared for or monitored due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement resident's comprehensive person-centered care plan. This was true for 1 of 1 resident (Resident #10) whose care plan was reviewed. This deficient practice of not developing and implementing care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to update care plans when changes occur to resident's care. This was true for 2 of 14 residents (#12 and #34) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided as resident's needs changed.

Inspectors wroteBased on facility standing orders, record review and staff interview, it was determined the facility failed to follow facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 3 of 4 Residents (#34, #41, and #43) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order.

Inspectors wroteBased on observation, policy review, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 5 residents (#34 and #43) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This was true for 1 of 19 Residents (Resident #28). This failure created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff.

Inspectors wroteBased on observation, interview, Department of Health and Welfare - Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure accurate and complete clinical records were maintained for each resident. This was true for 1 of 1 resident (Resident #12) whose records were reviewed. This deficient practice resulted in incomplete documentation and created the potential for harm if inappropriate care and/or treatments were provided to the resident.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure measures were in place to prevent possible cross-contamination from dirty to clean areas in the kitchen. This had the potential to affect the 41 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wrote1. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder and dementia. A physician's order, dated 3/16/22, directed staff to monitor and document Resident #25's behavior for self-isolation/lack of interest. A care plan, initiated 4/3/22, documented Resident #25 was prescribed psychotropic medications related to depressive disorder and staff were directed to administer her medications as ordered by the physician and observe her for any side effects of the medications every shift. Resident #25's care plan did not include the physician's order to monitor her behavior for self-isolation and lack of interest. On 4/28/22 at 3:39 PM, the DON stated Resident #25 was being monitored for negative mood such as self-isolation. The DON stated she did not see documentation in Resident #25's care plan for behavior monitoring. 2. [...]

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 1 of 5 residents (Resident #25) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medication was prescribed, the expected benefits, and the risks associated with the medications.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a resident's contact isolation was addressed on the baseline care plan. This was true for 1 of 5 residents (Resident #243) reviewed for baseline care plans. This failure created the potential for spread of infection if residents' contact isolation intervention was not initiated.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure medications were administered in a manner that was consistent with physician's orders and professional standards of practice. This was true for 3 of 6 residents (#20, #31, and #38) reviewed for medication administration. This failure created the potential for adverse effects for Resident #20 and Resident #38 should they experience a life-threatening situation due to low or high blood sugar, and for Resident #31 when he received doses in excess of physician orders for nasal spray.

Inspectors wroteBased on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 40 medications (5%) which affected 2 of 7 residents (#31 and #38) whose medication administration was observed during the medication pass. This failed practice placed residents at risk of not receiving medications as ordered by their physician and the potential for harm when Resident #31 received doses in excess of physician orders for a nasal spray and potential to affect the therapeutic level and effectiveness of Resident #38's insulin when it was administered after meals instead of before meals as ordered by her physician.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to coordinate care to prevent the development of an avoidable pressure ulcer. This was true for 1 of 2 residents (Resident #29) who were reviewed for pressure ulcers. Staff failed to follow physician orders to remove a leg brace and to conduct skin assessments. This resulted in harm for Resident #29 when they developed a pressure ulcer which required skin grafting and a lengthy healing period.

Inspectors wroteBased on record review, policy review, observation, resident interview, and staff interview, it was determined the facility failed to ensure the dignity of the residents was maintained. This was true for 2 of 3 residents (#16 and #50) who wore wrist bands and were reviewed for dignity. This failure created the potential for psychosocial harm and well-being should resident's self-worth and self-esteem be negatively affected.

Inspectors wroteBased on resident interview, staff interview, and record review, it was determined the facility failed to ensure residents were provided the opportunity to participate in the care planning process for the development and implementation of their person-centered plan of care. This was true for 1 of 24 residents (Resident #49) who were reviewed for care planning. The failure created the potential for harm if residents' care was provided inconsistent with their needs and preferences.

Inspectors wroteBased on staff interview, record review, review of the facility's admission packet, and policy review, it was determined the facility failed to ensure residents were provided written information regarding Advance Directives in a language they could understand and assisted them to formulate Advance Directives. This was true for 1 of 24 residents (Resident #1) who were reviewed for Advance Directives. The failure increased the risk Resident #1's health care preferences would not be honored if she became incapacitated and unable to communicate her wishes.

Inspectors wroteBased on record review, staff interview, home health provider staff interview, resident representative interview, it was determined the facility failed to ensure appropriate information was communicated to a home health care provider upon the discharge of a resident. This was true for 1 of 5 residents (Resident #157) who were reviewed for discharge from the facility. The deficient practice created the potential for harm if home health services were not provided as ordered for the resident.

Inspectors wroteBased on observation, resident interview, staff interview, and record review, it was determined the facility failed to ensure the baseline care plan included communication as a potential barrier for 1 of 3 residents (Resident #1) who were non-English speaking and who were reviewed. The failure created the potential for harm if the care and services provided did not meet her needs or was contrary to her wishes due to lack of direction regarding her preferred language.

Inspectors wroteBased on observation, resident and staff interview, and record review, it was determined the facility failed to ensure the care plan was revised to reflect a resident's current status and needs. This was true for 1 of 24 residents (Resident #1) whose care plans were reviewed. The failure to revise Resident #1's care plan when her dialysis access device site changed created the potential for harm if her care was not provided and/or decisions were made based on inaccurate information.

Inspectors wroteBased on observation, resident interview, staff interview, and record review, it was determined the facility failed to ensure activities met the interests and supported the physical, mental, and psychosocial well-being of each resident. This was true for 1 of 24 residents (Resident #1) who were reviewed for activities. This failure created the potential for residents to become bored or depressed when she was not provided with meaningful engagement throughout the day.

Inspectors wroteBased on record review, policy review, observation, resident interview, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 5 of 25 residents (#39, #46, #50, #258, and #260) who were reviewed for standards of practice. This failure created the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices.

Inspectors wroteBased on observation, resident interview, staff interview, and record review, review of the facility/dialysis provider agreement, and review of facility policy, it was determined the facility failed to ensure physician orders and the care plan related to dialysis care and services were updated and implemented when the access device site changed, and that pre and post-dialysis assessments were consistently completed for 1 of 1 resident (Resident #1) who was reviewed for dialysis. The failure created the potential for harm if undetected complications went untreated or there was a delay in treatment.

Inspectors wroteBased on policy review, observation, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration to residents. This was true for 1 resident (#4), 2 of 2 medication storage rooms, and 1 of 4 medication carts reviewed for storage and labeling medication. This failure had the potential for harm should residents receive expired medications with decreased efficacy, potency, and safety.

Inspectors wroteBased on staff interview and record review, the facility failed to implement the antibiotic stewardship protocol for 1 of 2 residents (Resident #50) who were reviewed for antibiotic use. This deficient practice created the potential for harm should residents receive ineffective or unnecessary treatment for a suspected urinary tract infection.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the posted daily nurse staffing information was complete. This failure created the potential for harm for all residents living in the facility, their family members, and/or visitors if they wanted to know the facility's staffing levels in comparison to the number of residents in the facility to ensure enough staff were present to meet the needs and cares of those residents.