Bear Lake Memorial Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Montpelier, Idaho.
- Location
- 164 South Fifth Street, Montpelier, Idaho 83254
- CMS Provider Number
- 135070
- Inspections on file
- 14
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Bear Lake Memorial Skilled Nursing Facility during CMS and state inspections, most recent first.
Surveyors found multiple food service deficiencies, including outdated spices, undated cooking oil, and frozen items without use-by or opened dates, as well as opened breakfast biscuits without dates and snack items stored on the floor. Refrigerator temperature logs showed repeated readings above the acceptable range with no documentation that these were reported, despite policy requirements. In the resident snack refrigerator, food containers lacked date labels even though posted instructions required both name and date, and the DNS confirmed this expectation. During a lunch meal, dietary staff handled chicken fried steak with gloved hands while cutting it, then touched a resident’s shoulder and continued plating and cutting food for multiple residents without changing gloves or performing hand hygiene, contrary to proper infection control practices acknowledged by the FSM.
A resident with dementia and diabetes was started on Sertraline 25 mg daily for depression without documented informed consent. Record review showed no psychotropic medication acknowledgement consent for the resident’s current use of Sertraline. During interviews, the LSW confirmed the absence of the consent form, and the MDS RN acknowledged that the resident should have signed a psychotropic medication acknowledgement consent prior to administration but did not.
Surveyors found that the facility did not ensure call lights were within reach for two residents, contrary to its call system policy requiring residents to have a means to summon staff from their bed and other locations. One resident with atrial fibrillation and hypertension was seated in a recliner on one side of the bed while the call light was on a nightstand on the opposite side, out of reach. Another resident with ESRD, diabetes, and a history of repeated falls was seated in a recliner on one side of the bed while the call light was pinned to a curtain on the opposite side, also out of reach. An LPN and the Administrator both acknowledged that call lights should have been within reach and were not in these cases.
The facility failed to maintain a properly functioning room door, resulting in a door that jammed halfway and did not fully open to allow safe entrance or exit. A resident with paranoid schizophrenia and chronic kidney disease reported the door had been in this condition since being assigned to the room, and a surveyor later confirmed the door became stuck when opened. The Administrator stated he was unaware the problem persisted, noting that maintenance had previously attempted to repair the door but the issue had recurred.
Surveyors found that the facility did not revise care plans to reflect current needs and interventions for two residents. One resident with chronic pulmonary edema and a right foot wound experienced multiple falls, including one from a recliner, and used an adaptive shoe and a recliner spacer, but these interventions were not added to the care plan despite documentation of the fall in the medical record. Another resident with paranoid schizophrenia and chronic kidney disease used a low bed position to assist with getting out of bed, but this intervention was not documented in the care plan. An MDS RN acknowledged that these care plans should have been updated and were not.
Surveyors found that staff failed to follow professional standards for bowel care for two residents who went more than 72 hours without a BM. One resident with psychosis and dementia had a 96-hour gap between documented BMs; although Docusate was ordered and given BID, there was no documentation that the physician was notified after 72 hours without a BM, and the MDS RN confirmed staff should have contacted the physician but did not. Another resident with atrial fibrillation and hypertension had an 87-hour gap between BMs, with PRN orders for Milk of Magnesia, Bisacodyl suppository, and Docusate for constipation, yet there was no documentation that any of these PRN bowel medications were administered during that period.
Surveyors found that staff failed to follow facility policy and professional standards for respiratory care. A resident with a history of transient cerebral ischemic attack and chronic kidney disease had a documented SpO2 of 82% on room air with no nursing interventions recorded. In addition, oxygen was observed flowing into PAP devices for two residents with conditions including diabetes, hallucinations, and a lower leg fracture while the PAP devices were turned off and not in use, contrary to the facility’s CPAP/BiPAP policy requiring oxygen to be connected only after the device is on and disconnected before it is turned off.
The facility did not maintain the required minimum of 8 consecutive hours of RN coverage on at least one reviewed day. Review of monthly staffing records showed that on one specific day there were only 4.75 hours of RN coverage. The Administrator confirmed this limited RN coverage, and the DNS was unable to identify any additional RN hours worked that day. This lapse in RN staffing was identified during review of several days of RN coverage and was determined to have the potential to affect all residents.
The facility failed to maintain required historical nurse staffing information for the mandated 18-month period. Daily nurse staffing was documented on a dry erase whiteboard, and the Administrator later provided only monthly staffing schedules that lacked required daily details such as the facility name, scheduled vs actual hours worked, and daily census. The Administrator acknowledged that daily staffing sheets were not maintained because information was kept on the whiteboard, and an MDS RN confirmed that the whiteboard was erased and updated each morning, preventing retention of the required daily staffing records.
Surveyors identified that controlled medications were not properly tracked on two medication carts, as required narcotic accountability sheets were missing one of the two licensed nurse signatures on multiple dates. An LPN and the DNS both confirmed that two nurses were supposed to sign the narcotic sheets when accepting or releasing the carts, but this did not occur as required. This documentation failure involved carts used for residents receiving controlled medications and created the potential for undetected misuse or diversion.
Surveyors found that medication carts were left unlocked and unattended, and expired medications were not removed. One med cart on a hall was observed unlocked while an LPN walked away to a resident room with no other nursing staff present, and the same cart was later seen unlocked in the nursing station area without licensed staff nearby. During an audit of another hall’s med cart with an LPN present, two expired bottles of Milk of Magnesia were discovered, along with white powder debris in a drawer, despite staff statements that carts should be locked when not in use, cleaned monthly, and cleared of expired meds.
Staff failed to follow infection prevention and control practices during food service and did not maintain current IPCP policies. During meal service, staff continued serving food without removing dirty gloves, performing hand hygiene, and redonning clean gloves, despite a facility policy requiring dietary staff to wash hands before work and when soiled. Separately, the IP and DNS acknowledged that IPCP policies lacked review or revision dates and had not been reviewed annually, and the facility could not provide documentation of required annual policy review, placing all residents at risk for contamination or infections.
The facility failed to maintain a safe and functional environment when a sharps container on one of two medication carts was allowed to become overfilled. Surveyors observed that the sharps container on the South Hall medication cart was filled past the full line and the flip-top lid could not move freely. An LPN acknowledged that the container should have been changed when full but was not, and the Administrator confirmed that sharps containers were expected to be changed when full, which had not occurred.
The facility failed to ensure a physician responded to a pharmacist's recommendations to review the use of prophylactic antibiotics for two residents with a history of UTIs. Both residents were prescribed Cephalexin for extended periods without justification. The pharmacist's recommendations in June 2024 were not addressed, and attempts to contact the prescribing physician were unsuccessful, potentially leading to adverse medication reactions.
The facility failed to ensure appropriate clinical indications for antibiotic use for two residents, leading to potential adverse drug reactions. One resident was prescribed Cephalexin prophylactically for over eight months without meeting UTI criteria, while another continued to receive Cephalexin for over four months despite a negative follow-up UA/CS. The DNS, ICP, and Pharmacist confirmed the inappropriate use of prophylactic antibiotics.
Food Storage, Labeling, Temperature Control, and Hand Hygiene Deficiencies in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, temperature control, and handling of food. During a kitchen tour, they observed outdated spices in dry storage and cooking areas, an undated squeeze bottle of cooking oil in the grilling area, and multiple bags of frozen breaded fish, tater tots, and French fries in the walk-in freezer without use-by or opened dates. In the dry storage area, two opened bags of breakfast biscuits lacked use-by dates, teriyaki sauce was stored past its use-by date, and three boxes of chips were stored directly on the floor. Review of the walk-in refrigerator temperature logs showed multiple recorded temperatures above 40°F on several dates, despite the log stating that temperatures must remain between 35°F and 41°F and that any out-of-range temperatures must be reported to a supervisor and maintenance with notation on the log. No such notations were present, and the Food Service Manager (FSM) acknowledged that outdated and non-dated food items should have been addressed and that elevated refrigerator temperatures should have been reported but were not. Surveyors also observed deficiencies in labeling of resident food items and in hand hygiene and glove use during meal service. In the resident snack refrigerator, two small containers of food were found, one labeled with a resident’s name but neither labeled with a date, despite a posted sign instructing that all items placed in the refrigerator must be labeled with a name and date. The Director of Nursing Services (DNS) confirmed that all items in the resident refrigerator should be dated but were not. During a lunch meal observation, dietary staff plated chicken fried steak by holding the meat on the plate with a gloved hand while cutting it into bite-size pieces with a pizza cutter, then delivered the plate to a resident, rubbed the resident’s shoulder, and returned to plating and cutting food for multiple residents without changing gloves or performing hand hygiene. The FSM later stated that after touching the resident’s shoulder, the staff member should have removed gloves, washed hands, and donned new gloves before continuing to serve food, but this did not occur.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to initiating a psychotropic medication for one resident. The resident was admitted with multiple diagnoses, including dementia and diabetes. On 1/21/26, a physician ordered Sertraline 25 mg once daily for depression. Record review showed there was no psychotropic medication acknowledgement consent on file for this resident’s current use of Sertraline. On 2/18/26 at 3:16 PM, the LSW confirmed there was no psychotropic medication acknowledgement consent for the resident, and at 3:18 PM, the MDS RN stated the resident should have signed a psychotropic medication acknowledgement consent prior to administration of Sertraline but had not. This lack of documented informed consent before starting the psychotropic medication constituted the identified deficiency.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
Surveyors determined the facility failed to ensure residents’ call lights were within reach, as required by the facility’s undated “Call System, Residents” policy, which states each resident must be provided a means to call staff directly for assistance from the bed, toileting/bathing areas, and from the floor. Resident #35, admitted with diagnoses including atrial fibrillation and high blood pressure, was observed on 2/17/26 at 10:27 AM sitting in a recliner placed on the left side of her bed while her call light was lying on the nightstand on the right side of the bed, out of her reach. At 10:30 AM, LPN #1 confirmed the call light should have been within Resident #35’s reach and was not. Resident #30, admitted with diagnoses including end stage renal disease, diabetes, and repeated falls, was observed on 2/17/26 at 1:25 PM sitting in a recliner on the right side of his bed while his call light was pinned to the room curtain on the left side of the bed, also out of his reach. At 1:42 PM, LPN #1 acknowledged that Resident #30’s call light should have been within reach and was not, and at 2:52 PM the Administrator likewise stated that resident call lights should be within residents’ reach and had not been in these instances. These findings, based on policy review, observation, record review, and staff interview, showed that for 2 of 12 residents reviewed for residents’ rights, the facility did not reasonably accommodate residents’ needs and preferences by ensuring their call lights were accessible.
Room Door Not Properly Functioning, Limiting Safe Entrance and Exit
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment by not maintaining a resident room door in proper working condition, resulting in a door that did not open correctly or fully to allow entrance or exit. Resident #23, who had been admitted with multiple diagnoses including paranoid schizophrenia and chronic kidney disease, reported that the door to his assigned room had been jammed since he was placed in that room. On 2/17/26 at 10:45 AM, a surveyor observed that the door to room [ROOM NUMBER] became jammed when opened only about halfway. On 2/18/26 at 1:15 PM, the Administrator stated he was unaware that the door to room [ROOM NUMBER] remained stuck, explaining that maintenance had previously attempted to repair the door and that the same issue must have recurred. This deficient practice was identified for 1 of 6 resident room doors observed and created the potential for diminished quality of life and psychosocial distress for residents when their room doors do not open correctly or fully to allow entrance or exit of the room.
Failure to Revise Care Plans to Reflect Current Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans to reflect residents’ current needs and interventions following changes in condition or care. For one resident with chronic pulmonary edema and an open right foot wound, the resident reported having fallen multiple times, with the most recent fall occurring when he slid off his recliner onto the floor. The medical record contained a progress note documenting the fall, and the resident stated the facility had provided him with a different recliner. However, review of the resident’s care plan showed no documented interventions related to the recent fall, no inclusion of the need for a spacer with the recliner, and no documented interventions related to the resident’s right adaptive shoe use. The MDS RN confirmed the care plan should have been revised to include these needs and had not been. A second resident, with diagnoses including paranoid schizophrenia and chronic kidney disease, was observed with his bed positioned very low to the ground, and he stated this made it easier for him to get out of bed. Review of this resident’s care plan showed that the use of a low bed position was not documented as an intervention. The MDS RN stated that the low bed position should have been included in the care plan and was not. The survey findings concluded that the facility did not ensure care plans were revised to reflect current needs and interventions for these residents, placing them at risk for adverse outcomes if care and services were not provided due to outdated care plans.
Failure to Follow Bowel Care Standards and Notify Physician After Prolonged Absence of Bowel Movements
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for bowel care by not contacting physicians when residents had no bowel movement (BM) for more than 72 hours. One resident with psychosis and dementia had a documented BM on 1/26/26 at 21:59 and not again until 1/30/26 at 21:53, a 96-hour interval. This resident had a physician’s order dated 10/1/25 for Docusate 100 mg orally twice daily for constipation, and the MAR showed it was administered twice daily throughout January 2026. However, there was no documentation in the medical record that the physician was contacted between 1/26/26 and 1/30/26 regarding the absence of a BM for over 72 hours. The MDS RN stated that nursing staff should have contacted the physician after 72 hours without a BM and had not done so. Another resident with atrial fibrillation and high blood pressure had a documented BM on 2/8/26 at 00:29 and not again until 2/12/26 at 15:05, an 87-hour interval. This resident had PRN orders for Milk of Magnesia 30 ml once daily by mouth for constipation, Bisacodyl 10 mg suppository rectally once daily if needed if Milk of Magnesia was not effective, and Docusate 100 mg orally twice daily as needed for constipation. Review of this resident’s medical record on 2/17/26 at 4:03 PM showed no documented administrations of any of the ordered bowel care medications between 2/8/26 and 2/12/26. These findings show that ordered bowel care interventions and physician notification parameters were not implemented or documented as required for two residents.
Failure to Follow Oxygen and PAP Device Protocols and Address Low SpO2
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services consistent with professional standards of practice and its own CPAP/BiPAP Support Level III policy. The policy directed staff to connect supplemental oxygen only after the CPAP machine was turned on and to disconnect oxygen before turning the CPAP machine off, and to adjust the flow rate as prescribed. For one resident with a history including transient cerebral ischemic attack and chronic kidney disease, the medical record showed an SpO2 of 82% on room air on a documented date, with no nursing interventions related to this low oxygen saturation recorded in the nursing notes. The MDS RN later stated that this low SpO2 level should have been addressed by nursing staff but was not. For two other residents with multiple diagnoses, including diabetes, hallucinations, and a lower right leg fracture, surveyors observed oxygen being bled into their PAP devices while the PAP devices were not turned on or in use. One resident’s oxygen was observed at 3 LPM and the other’s at 2 LPM under these conditions. In both cases, the MDS RN stated that the oxygen should have been turned off before the PAP device was turned off when the residents were done using the PAP devices, but this was not done. These observations and record reviews showed that staff did not follow the facility’s policy and professional standards for safe use of oxygen with PAP devices and did not document appropriate nursing response to a significantly low SpO2 reading.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, as required. During review of monthly scheduled staffing sheets from January 2025 through January 2026, surveyors identified that on 4/11/25 the facility did not have 8 consecutive hours of RN coverage. The Administrator confirmed that on that date the facility only had 4.75 hours of RN coverage. The DNS later stated she could not find any additional RN hours worked on 4/11/25 beyond the 4.75 hours already reported. This deficiency was based on record review of the facility’s monthly scheduled staffing sheets and staff interviews with the Administrator and DNS, and it was determined that this lapse in RN coverage occurred on 1 of 3 days reviewed for RN coverage, with the potential to affect all residents residing at the facility.
Failure to Maintain Required Historical Nurse Staffing Information
Penalty
Summary
The facility failed to maintain required nurse staffing information for 18 months after posting, as mandated. On 2/17/26 at 9:40 AM, surveyors observed the daily nurse staffing documented only on a dry erase whiteboard. Later that day at 4:10 PM, the Administrator provided monthly staffing scheduling sheets for the past 13 months, but these did not contain the required daily staffing details such as the facility name, scheduled versus actual hours worked, and the daily census. On 2/18/26 at 10:10 AM, the Administrator acknowledged the facility had not maintained 18 months of daily staffing sheets because the information was recorded on the dry erase whiteboard and not preserved. On 2/18/26 at 3:35 PM, the MDS RN confirmed that the daily whiteboard information was erased and replaced with new information each morning, resulting in the loss of historical daily staffing data. This failure had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who might wish to review the facility’s staffing levels, because the required historical daily staffing information was not retained as required.
Failure to Maintain Required Narcotic Accountability Signatures on Medication Carts
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications on both the South Hall and North Hall medication carts. During a medication cart audit on the South Hall, the narcotic accountability sheet covering 2/1/26 to 2/18/26 was missing one of the required licensed nurse signatures on four separate dates (2/2/26, 2/4/26, 2/8/26, and 2/17/26). During a similar audit on the North Hall, the narcotic accountability sheet for the same date range was missing one licensed nurse signature on 2/16/26. An LPN stated that two nurses were supposed to sign the narcotic accountability sheet when they accepted or released the medication cart, but this had not occurred on the identified dates. The DNS also confirmed that two nurses should have signed the narcotic accountability sheet when accepting or releasing the cart and acknowledged that this had not been done. The report states this failure created the potential for undetected misuse and/or diversion of controlled medications and could affect all residents receiving controlled medications in the facility. No specific residents, medical histories, or conditions were identified in the report; the deficiency was related to the facility’s process for narcotic accountability and documentation on the medication carts used for residents receiving controlled medications.
Unlocked Med Carts and Expired Medications Found During Audit
Penalty
Summary
The deficiency involves failure to ensure medications were secured in locked medication carts and that expired medications were removed from use. On entry to the facility, the North Hall medication cart was observed unlocked and unattended while an LPN walked away down the hall to a resident room, with no other nursing staff present around the cart. Later, the same medication cart in the nursing station area was again observed unlocked with no licensed nursing staff present, and the surveyor waited 10 minutes before encountering a CNA and requesting to speak with the MDS RN. The MDS RN stated that medication carts were to be locked when not in use and when no nursing staff were present, but this had not occurred. During an audit of the South Hall medication cart with an LPN present, two bottles of Milk of Magnesia were found with a manufacturer-printed expiration date of 10/25, and the LPN acknowledged these should have been discarded but had not been. The same audit revealed white, fine powder debris along the length of the back edge of the third drawer of the medication cart. The LPN stated that medication carts were cleaned monthly and should not have had debris in the drawers. The MDS RN also stated that expired medications should have been removed from the medication cart, but this had not been done.
Failure to Follow Hand Hygiene and Maintain Current IPCP Policies
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices during food service and in the management of infection control policies. Based on observation, staff did not remove soiled gloves, perform hand hygiene, and don clean gloves before continuing to serve food to residents, contrary to the facility’s undated Hand Washing policy that required dietary staff to wash hands before starting work and when hands were soiled. This practice had the potential to contaminate served food items and make residents ill. In addition, the facility failed to ensure current infection control standards of practice were implemented by not conducting at least an annual review of Infection Prevention and Control Program (IPCP) policies and procedures. During an interview, the Infection Preventionist (IP) presented IPCP policies that had no review or revision dates, and the facility could not provide documentation that these policies had been reviewed annually. The IP acknowledged that the IPCP policies had not been reviewed or revised annually and stated there were many such policies. The Director of Nursing Services (DNS) also confirmed that the IPCP policies had not been reviewed annually and that they should have been, placing all residents at risk for contamination or infections.
Overfilled Sharps Container on Medication Cart
Penalty
Summary
The facility failed to maintain a safe and functional environment when a sharps container on one of two medication carts was allowed to become overfilled. On two separate observations, the sharps container on the South Hall medication cart was noted to be filled past the indicated full line, and the flip-top lid was not freely movable. During an interview, a licensed practical nurse acknowledged that the sharps container should have been changed when it was full but had not been. In a separate interview, the Administrator also confirmed that the sharps containers were expected to be changed when full and that this had not occurred. This deficiency involved the medication cart area and sharps disposal system used by staff, with no specific residents identified in the report. The failure was noted by surveyors on multiple days and confirmed by both nursing and administrative staff as not meeting the facility’s own expectations for timely replacement of full sharps containers.
Failure to Address Pharmacist's Recommendations on Prophylactic Antibiotics
Penalty
Summary
The facility failed to ensure that the physician responded to the pharmacist's recommendations regarding the use of prophylactic antibiotics for two residents, R3 and R4, who were being reviewed for unnecessary medications. Both residents had a history of urinary tract infections (UTIs) and were prescribed Cephalexin, an antibiotic, for UTI prophylaxis. R3 had been taking the antibiotic for over eight months, while R4 had been on it for over four months. The pharmacist's monthly drug regimen review in June 2024 recommended that the physician review the necessity of these prophylactic antibiotics, but there was no evidence of a response from the physician. The Director of Nursing Services confirmed that the physician did not respond to the pharmacist's recommendations made in June 2024. Attempts to reach the prescribing physician were unsuccessful. This lack of response and action from the physician had the potential for both residents to experience adverse medication reactions due to the continued use of antibiotics without proper justification.
Inappropriate Antibiotic Use for Two Residents
Penalty
Summary
The facility failed to ensure appropriate clinical indications for the use of antibiotics for two residents, leading to potential adverse drug reactions. Resident 3 was admitted with a history of UTIs and was prescribed Cephalexin prophylactically without meeting the criteria for a UTI. Despite having no symptoms or signs of a UTI, the resident continued to receive the antibiotic for over eight months. The Director of Nursing Services (DNS) and the Infection Control Preventionist (ICP) confirmed that the resident did not meet the criteria for a UTI and that the antibiotic was prescribed without justification. Resident 4, also with a history of UTIs, was initially treated with Omnicef for a UTI based on a UA result. However, the treatment was changed to Cipro after consultation with the physician. A follow-up UA/CS showed no UTI, yet the resident continued to receive Cephalexin prophylactically for over four months without any signs or symptoms of a UTI. The DNS, ICP, and Pharmacist confirmed that the use of prophylactic antibiotics was not recommended and that the criteria for prescribing them were not met. The report highlights the facility's failure to adhere to its own policy and CDC guidelines on antibiotic stewardship, which emphasize the importance of appropriate antibiotic use to prevent resistance and adverse reactions. The facility's actions resulted in the unnecessary administration of antibiotics to both residents, despite the absence of clinical indications for their use.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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