Arbor Valley Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 8211 Ustick Road, Boise, Idaho 83704
- CMS Provider Number
- 135079
- Inspections on file
- 19
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Arbor Valley Of Cascadia during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to ensure timely response to resident call lights, resulting in multiple instances where residents waited 30 minutes to several hours for assistance. Call light logs and resident interviews confirmed repeated delays, with some residents experiencing discomfort and extended waits for help with basic needs, especially during shifts with fewer staff. Staff acknowledged that call lights should be answered within 10 to 15 minutes, but this standard was not consistently achieved.
A resident with significant physical disabilities was observed being transported for a shower with an uncovered urinary catheter bag placed at his feet, contrary to facility policy requiring catheter bags to be covered. Staff stated that the bag was not covered during transport, and the CNO confirmed that covers are available and should have been used.
Two residents with complex medical histories were moved to different rooms without being given a written rationale or advance explanation for the transfer, as required by facility policy. Documentation for both room changes lacked the necessary rationale, and staff confirmed the use of outdated forms that did not require this information.
A resident with a history of major depressive disorder and a recent suicide attempt did not receive a required evaluation for specialized services as recommended by the state's Level II PASARR process. The necessary Mental Illness Evaluation and Determination report was missing from the medical record, and staff confirmed the evaluation had not been completed.
A resident with a history of traumatic subdural hemorrhage and major depressive disorder, including a recent suicide attempt, was admitted without the care plan reflecting required PASARR Level II recommendations for specialized mental health services. Review and staff interview confirmed the omission of these recommendations from the care plan, despite facility policy requiring their inclusion.
Two residents with significant respiratory conditions did not receive oxygen therapy as ordered by their physicians. One resident's oxygen concentrator was set to 0 liters per minute despite an order for 2 liters, and another resident's oxygen tubing was not connected to the concentrator despite an order for 4 liters. Nursing staff confirmed these lapses in care.
A resident with end stage renal disease and cerebral palsy reported significant pain and requested pain medication late at night, but did not receive it despite using the call light. Documentation did not reflect the resident's reported pain, and the following day, the resident experienced severe pain and was unable to attend dialysis due to lack of pain relief.
Surveyors identified failures in food storage, labeling, and hygiene, including serving expired food, improper labeling of resident and kitchen food items, and a staff member preparing food without a hair restraint. Supervisory staff confirmed these practices did not meet facility policy or food safety standards.
Staff did not follow infection control protocols during wound care and equipment cleaning. An LPN failed to perform hand hygiene between glove changes and did not change gloves after wound cleansing before applying new dressings to a resident with pressure ulcers. Additionally, a Hoyer lift used for resident transfer was not cleaned between uses and was left in the hallway without disinfection, contrary to facility policy.
A resident with cerebral palsy and acute respiratory failure was found to have her touch pad call light placed out of reach, contrary to her care plan. Staff acknowledged that the call light should have been accessible but was not, and an RN indicated frequent staff checks as a reason for the inaccessibility.
A resident with multiple diagnoses and a documented ability to make decisions was not assessed for safe smoking practices, despite facility policy requiring such evaluations. The resident's medical record and care plan lacked documentation of her smoking status, and the CNO was unaware she smoked, resulting in the required assessment not being completed.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights for multiple residents. Review of facility grievances, call light logs, and resident interviews revealed that several residents experienced significant delays, with some waiting up to an hour or more for assistance. Call light logs over a three-month period documented 1,770 instances where response times exceeded 30 minutes and 167 instances where the wait was longer than an hour. Residents reported waiting extended periods for help with essential needs, such as toileting, and described situations where staff turned off call lights without providing immediate assistance. Specific grievances included reports from residents who had to wait up to an hour or more for their call lights to be answered, particularly during shifts with limited staff coverage. Residents described waiting so long for assistance that it affected their comfort and ability to move, with one resident stating her legs went numb while waiting for help off the commode. Interviews with staff confirmed that call lights should be answered within 10 to 15 minutes, but this standard was not consistently met, as evidenced by the documented delays and resident accounts.
Failure to Maintain Resident Dignity by Leaving Catheter Bag Uncovered
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as required by its Quality of Life policy, which specifies that staff must refrain from demeaning practices such as leaving urinary catheter bags uncovered. During an observation, a resident with Myotonic Muscular Dystrophy and functional quadriplegia was transferred via Hoyer lift for a shower, and after being covered with blankets, a CNA placed the resident's uncovered urinary catheter bag at his feet. The CNA stated that catheter bags are normally covered when the resident is in a wheelchair, but did not cover it during transport to the shower room. The CNO confirmed that catheter bags have covers and was unsure why the cover was not used in this instance, acknowledging that it should have been covered.
Failure to Provide Written Rationale for Room Transfers
Penalty
Summary
The facility failed to provide residents with prior written rationale regarding room changes, as required by its own Room to Room Transfer policy. The policy specifies that the facility must discuss transfers with residents and their families in advance, explain the rationale and rights, offer an opportunity to tour the new room, and introduce new roommates prior to the move. However, for two residents, these procedures were not followed. One resident, with a history of diabetes and a left leg amputation, was informed of his room transfer while outside and was not given a reason for the move. Documentation in his medical record did not include a rationale for the transfer, and he was not introduced to his new roommate beforehand. Additionally, after the move, he was unable to locate his prosthetic leg, which was later found in an inaccessible location. Another resident, with diagnoses including a cutaneous abscess and bipolar disorder, was also transferred to a different room without being provided a rationale. The room transfer notification in her medical record lacked any explanation for the move. Facility staff confirmed that an outdated room transfer document was used, which did not require documentation of the rationale for the transfer, resulting in the absence of required information for both residents.
Failure to Complete Required PASARR Specialized Services Evaluation
Penalty
Summary
The facility failed to ensure that a resident received specialized services as recommended by the state's Level II PASARR process. The resident was admitted with multiple diagnoses, including traumatic subdural hemorrhage and major depressive disorder, and had a documented history of depressive disorder and a recent suicide attempt. The PASARR Level I screening indicated the need for further evaluation, and the Level II screening required an individualized evaluation for specialized services by a Professional Independent Evaluator and the state's Mental Health Authority (MHA). Upon review of the resident's medical record, there was no documentation that the evaluation for specialized services by the state's MHA had been completed. Interviews with the Chief Nursing Officer (CNO) confirmed that the Mental Illness Evaluation and Determination report was not present in the resident's medical record, despite it being required. This lack of documentation and follow-through resulted in the resident not receiving the recommended specialized services.
Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan included recommended specialized services identified by the state's Level II PASARR process. The facility's policies require the interdisciplinary team to use PASARR recommendations when developing care plans, especially for residents with mental disorders. Despite these policies, a review of the care plan for a resident with diagnoses including traumatic subdural hemorrhage and major depressive disorder revealed that the care plan did not document the resident's mental health diagnosis or the recommendations from the PASARR Level II evaluation. The PASARR Level II had identified a depressive disorder, a recent suicide attempt, and the need for further individualized evaluation for specialized services. Staff interview confirmed that the care plan was missing the required PASARR recommendations. The facility's policies on trauma-informed care and care planning both emphasize the importance of addressing mental health needs and specialized services as identified by PASARR, but these were not reflected in the resident's care plan at the time of review.
Failure to Provide Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents. One resident with cerebral palsy and acute respiratory failure was observed sleeping in bed with a nasal cannula in place, but the oxygen concentrator was set at 0 liters per minute, despite a physician's order and care plan specifying oxygen at 2 liters per minute via nasal cannula while in bed. Both a registered nurse and the chief nursing officer confirmed that the oxygen concentrator should have been set to 2 liters per minute but was not. Another resident with chronic heart failure and chronic respiratory failure with hypercapnia was observed sleeping in bed with an oxygen cannula in place, but the oxygen tubing was not connected to the oxygen concentrator. The physician's order required oxygen at 4 liters per minute via nasal cannula, and the care plan documented oxygen therapy as ordered. A registered nurse stated that the CNAs had put the resident to bed and must have forgotten to connect the tubing, and the charge nurse confirmed that the CNAs should have ensured the cannula was connected after moving the resident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for a resident with end stage renal disease and cerebral palsy. The resident, who was cognitively intact, reported experiencing pain late in the evening and used the call light to request pain medication between 11:30 pm and midnight. Although the call light was answered, the resident stated that the requested pain medication was not administered, resulting in her falling asleep without relief. Documentation in the medical record for that night indicated a pain level of 0 out of 10, despite the resident's report of pain. The following day, the resident reported a pain level of 10 out of 10 and stated she had to refuse dialysis due to unresolved pain from the previous night. The Resident Care Manager confirmed that the resident reported being in pain while waiting for pain medication that was never provided. The facility's policy requires appropriate treatment and services to maintain or improve residents' abilities, but in this instance, the resident's pain was not addressed as required.
Deficient Food Storage, Labeling, and Hygiene Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and hygiene practices within the facility's kitchen and resident food storage areas. Clean plastic containers were found stacked while still wet, contrary to proper drying procedures. Grape juice was served to residents despite being past its use-by date, and several food items in resident refrigerators, such as potato salad, salad greens, and frozen strawberries, were found to be expired or past their designated use-by dates. Additionally, an open box of ice cream bars lacked a use-by date, and cartons of food thickener in dry storage were observed to be past their best used-by dates. Staff interviews confirmed that these items should have been discarded according to facility policy and food safety standards. Further, a staff member was observed preparing food without wearing a required hairnet or hair restraint, which was acknowledged as a violation of facility policy by supervisory staff. These findings demonstrate a lack of adherence to professional standards and facility policies regarding food safety, labeling, and hygiene, as required by the FDA Food Code and the facility's own procedures. No information was provided regarding the medical history or condition of specific residents affected at the time of the deficiency.
Failure to Follow Infection Control Practices During Wound Care and Equipment Cleaning
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during wound care and equipment cleaning. Specifically, an LPN did not perform hand hygiene between glove changes while providing wound care to a resident with quadriplegia and pressure ulcers. The LPN removed soiled dressings, changed gloves without performing hand hygiene, and did not change gloves after cleansing the wounds before applying new dressings. The LPN later stated uncertainty regarding the facility's hand hygiene policy and acknowledged the correct procedure was not followed. Additionally, staff did not clean a Hoyer lift after use, leaving it in the hallway for over 20 minutes without disinfection between resident transfers. A nurse confirmed that the lift should have been cleaned immediately after use. These lapses were observed during care of a resident with multiple pressure ulcers and during resident transfers, contrary to the facility's established policies for hand hygiene, wound care, and equipment cleaning.
Call Light Pad Not Accessible to Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that all call light buttons or pads were easily accessible to residents, as observed in the case of one resident with multiple diagnoses, including cerebral palsy and acute respiratory failure. The resident's care plan specified the use of a touch pad call light and required staff to validate its placement upon leaving the resident. During observation, the call light pad was found on the bedside table and not accessible to the resident. An RN stated that the resident did not really need the call light pad because staff checked on her often. The Chief Nursing Officer later confirmed that staff should have ensured the call light pad was accessible on the resident's bed but had not done so.
Failure to Assess Resident for Safe Smoking Practices
Penalty
Summary
The facility failed to assess a resident for safe smoking practices as required by its Smoking Campus policy, which mandates an interdisciplinary evaluation of residents who wish to smoke upon admission, quarterly, with significant changes, or as needed. One resident, who was admitted and later readmitted with diagnoses including a cutaneous abscess of the abdominal wall and bipolar disorder, was found to be cognitively intact according to her most recent MDS assessment. Despite the resident stating she was an independent smoker, there was no documentation of a smoking assessment in her medical record, nor was her smoking status included in her care plan. The Chief Nursing Officer confirmed that they were unaware the resident smoked and acknowledged that the required assessment had not been completed.
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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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