Bingham Memorial Skilled Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Blackfoot, Idaho.
- Location
- 98 Poplar Street, Blackfoot, Idaho 83221
- CMS Provider Number
- 135007
- Inspections on file
- 17
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Bingham Memorial Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
Three residents received medications or treatments without complete or proper physician orders, including missing orders for eye drops, IV flushes, and absent flow rates for IV antibiotics. An LPN administered medications without documented orders, and the DON confirmed that required order details were missing.
Surveyors found that medications were repeatedly left unsecured, including an unlocked medication cart with keys left on top, medications left in resident rooms where residents could not self-administer, and loose pills found on the floor and in the medication cart. Staff confirmed that these practices did not meet required standards for medication security and storage.
Surveyors observed that staff failed to follow infection control protocols, including leaving personal drinks on a medication cart, not performing hand hygiene before donning gloves, and not implementing Enhanced Barrier Precautions for two residents with wounds and indwelling devices. Required PPE and signage were missing, and staff did not don gowns when providing care, despite physician orders for EBP.
Staff left a medication cart unattended with the computer screen displaying a resident's information and the cart unlocked. An LPN acknowledged not securing the computer or cart before leaving to perform other duties, resulting in a breach of privacy and confidentiality.
A resident with documented diagnoses of schizophrenia, bipolar disorder, anxiety, and PTSD was not referred for further evaluation after these conditions were identified in multiple assessments and physician notes. The facility did not update the PASRR Level I screening or notify the state mental health authority, despite clear evidence of serious mental illness.
Two residents with suprapubic catheters had this critical information omitted from their baseline care plans, despite the presence of supporting documentation in hospital discharge summaries and nursing assessments. The DON confirmed that these omissions were oversights, resulting in incomplete care instructions for caregivers within the first 48 hours of admission.
A resident with a suprapubic catheter and multiple complex medical conditions did not have a comprehensive, individualized care plan, as the plan failed to specify the catheter's type and size. The care plan contained incomplete, generic information, and the DON confirmed that required details were missing.
Controlled medications were not properly tracked or secured, as evidenced by missing nurse signatures on narcotic accountability records and discrepancies in the count of a resident's Butrans transdermal patches. Staff interviews confirmed that required documentation was not consistently completed, leading to unaccounted-for controlled substances.
Two residents with multiple medical conditions and intact cognition were found with their call light devices placed out of reach, contrary to facility policy. An RN confirmed that call lights should have been accessible to these residents.
The facility failed to properly store, distribute, and label food items, leading to potential contamination risks. Observations revealed improperly stored dry food, undated and outdated items in refrigerators, and improper storage practices in the freezer. These deficiencies placed residents at risk for adverse health outcomes, including food-borne illnesses.
The facility failed to update care plans for three residents, leading to a deficiency. A resident with diabetes and traumatic brain injury had no updates to her restorative care plan. Another resident with osteoporosis lacked documented care plan evaluations for over a year. A third resident with spinal stenosis had no record of receiving restorative services. The Restorative Services Nurse confirmed that routine screenings and care plan updates were not performed.
The facility failed to provide restorative nursing services to three residents, as required by their care plans. A resident with diabetes and traumatic brain injury, another with osteoporosis and chronic pain, and a third with spinal stenosis and muscle weakness did not receive documented restorative care. Staff interviews revealed that the facility's restorative program was being revamped, and there was no system for documenting therapy, leading to a lack of necessary services.
The facility failed to ensure infection control by not offering hand hygiene to two residents before meals served in their rooms. CNAs did not assist with hand washing, and both acknowledged the oversight. The DON confirmed that CNAs should have asked residents if they wanted to wash their hands before eating.
A resident's room was found with cracked flooring, a hole at the doorway, and leaf debris that had not been cleaned for several days. The DON acknowledged that housekeeping should have maintained cleanliness and repaired the flooring to prevent falls.
A resident with multiple diagnoses, including shoulder joint surgery and diabetes, reported needing help with dentures. However, a nurse's evaluation inaccurately noted the resident had their own teeth, and the MDS and care plan failed to document the need for dental care assistance. The DON acknowledged the assessment should have been more accurate.
The facility did not ensure medications were dated when opened, as observed with a Tubersol solution vial lacking an open date in the medication refrigerator. This oversight was confirmed by a nurse and acknowledged by the DON, potentially leading to the use of expired medications.
The facility failed to provide evening snacks to two residents, as required by policy. One resident with gastroenteritis and dehydration, and another with a fractured femur, reported never being offered snacks and were unaware they could request them, despite records showing refusals. The DON confirmed CNAs should have offered snacks.
Failure to Follow Professional Standards for Medication Orders and Administration
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed for three residents reviewed for quality of care. For one resident with a history of digestive system surgery and hip dislocation, an LPN administered Optase eye drops without a corresponding physician order documented in the medical record. The LPN confirmed that there were no orders for the medication, despite its administration. Another resident with sepsis and vascular dementia had a physician order for Invanz IV antibiotic that did not specify the required flow rate for administration. The DON confirmed that the flow rate should have been included in the order. A third resident, admitted after surgical amputation and with acute osteomyelitis, received IV medications including Daptomycin and Meropenem, but the orders lacked documentation of the flow rate and there was no order for the sodium chloride flush used. The DON acknowledged that both the IV flush and flow rate should have been documented in the medical record.
Failure to Secure and Properly Store Medications
Penalty
Summary
Surveyors observed multiple instances where medications and biologicals were not stored securely or labeled appropriately. On several occasions, the medication cart was found unlocked and unattended, with the keys left on top of the cart and no staff present. Additionally, medications were found left in resident rooms, including a bottle of allergy relief nasal spray and a syringe of heparin, despite residents being unable to self-administer their medications. A pill was also found on the floor in a hallway, and a loose tablet was discovered in the bottom drawer of the medication cart during an audit. Staff interviews confirmed that the medication cart should have been locked when unattended and that medications should not have been left in resident rooms or unsecured areas. The Director of Nursing and other staff acknowledged these lapses in medication security and storage. These observations and staff statements demonstrate a failure to follow accepted professional principles for the labeling and secure storage of drugs and biologicals within the facility.
Failure to Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observed deficiencies. A medication cart was found with personal drinks placed on top, in violation of OSHA Bloodborne Pathogens regulations prohibiting food and drink in areas where there is a risk of exposure to infectious materials. Staff acknowledged that personal drinks should not have been on the medication cart. Additionally, staff did not consistently follow hand hygiene protocols, as one staff member donned gloves before administering an injection without performing hand hygiene, contrary to the facility's policy. Residents with indwelling medical devices and wounds, who had physician orders for Enhanced Barrier Precautions (EBP), were not provided with appropriate signage or personal protective equipment (PPE) supplies outside their rooms. Staff entered these residents' rooms and performed care, including IV medication administration and wound care, without donning required PPE such as gowns. Staff interviews confirmed awareness that EBP protocols, including signage and PPE availability, should have been implemented for these residents, but these measures were not in place at the time of observation.
Failure to Secure Medication Cart and Resident Information
Penalty
Summary
Staff failed to maintain the privacy and confidentiality of residents' personal and medical records as required by facility policy and HIPAA regulations. On two separate occasions, a medication cart was observed left unattended in the hallway with the computer screen open to resident information and the cart itself unlocked. No staff were present at the cart during these times. During interviews, the LPN responsible acknowledged that she should have locked the computer and secured the cart before leaving to attend to other duties, such as entering the dining room or administering medications to a resident. These lapses in protocol resulted in resident information being accessible and visible to unauthorized individuals, contrary to the facility's documented privacy practices.
Failure to Refer for PASRR Level II Evaluation After Identification of Serious Mental Illness
Penalty
Summary
The facility failed to refer a resident for further evaluation after the resident was diagnosed with multiple serious mental illnesses, including schizophrenia, bipolar disorder, anxiety, and PTSD. Although the resident's PASRR Level I screening initially indicated no serious mental illness, subsequent documentation in the resident's history and physical, MDS assessment, and psychiatric physician notes all identified these diagnoses. Despite this information, the facility did not update the PASRR Level I screening or contact the state mental health authority for further evaluation, as confirmed by interviews with the administrator and social worker.
Failure to Document Suprapubic Catheters on Baseline Care Plans
Penalty
Summary
The facility failed to include necessary healthcare information on the baseline care plans for two residents within 48 hours of admission. Specifically, both residents had suprapubic catheters in place as documented in their hospital discharge summaries, licensed nurse assessments, and other medical records. However, this critical information was omitted from their baseline care plans, which are intended to guide caregivers in providing effective and person-centered care immediately upon admission. For the first resident, who had multiple diagnoses including a stage 3 pressure ulcer, MRSA, and neurogenic bladder, the presence of a suprapubic catheter was not documented on the baseline care plan despite being noted in the hospital discharge summary. Similarly, the second resident, admitted after joint replacement surgery and with chronic kidney disease and an overactive bladder, also had a suprapubic catheter that was not included in the baseline care plan, even though it was documented in the hospital discharge instructions, nurse assessment, and MDS. The Director of Nursing confirmed that the omission of the suprapubic catheter from both residents' baseline care plans was an oversight.
Incomplete and Non-Person-Centered Catheter Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive and individualized care plan was developed and implemented for a resident with multiple diagnoses, including a stage 3 pressure ulcer, MRSA, and neurogenic bladder. The resident's admission Minimum Data Set (MDS) documented the presence of a suprapubic catheter, but the comprehensive care plan did not specify the size or type of catheter as required. Instead, the care plan contained generic language with placeholders for catheter details that were not completed. This lack of person-centered information was confirmed during a staff interview, where the Director of Nursing acknowledged that the care plan should have included the specific type and size of catheter but did not.
Failure to Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by a review of one medication cart. The narcotic accountability record for the cart, covering a period from 11/1/25 to 11/19/25, was found to have 16 missing licensed nurse signatures. Additionally, the narcotic count sheet for a resident's Butrans transdermal 7.5mg patch indicated that 10 patches were available, but only 2 patches were physically present in the narcotic box. Upon further review with the Director of Nursing (DON), it was determined that only 4 patches had been delivered, and 2 patches had not been signed out on the narcotic count sheet. Staff interviews revealed that nurses were expected to sign the narcotic accept/release sheet when accepting or releasing the medication cart, but this was not consistently done. The MDS coordinator was unable to explain the discrepancy in the count of the Butrans patches and stated he would investigate further. The DON confirmed that a missing Butrans patch had been signed out on the Medication Administration Record (MAR) but not on the narcotic count sheet, as required by facility policy.
Inaccessible Call Light Devices for Residents
Penalty
Summary
Surveyors determined that the facility failed to ensure all call light buttons or pads were easily accessible to residents, as required by facility policy. During observations, two residents with multiple diagnoses and documented cognitive intactness were found to have their call light devices draped over the head of the bed, between the bed and the wall, making them inaccessible. Both residents' care plans indicated they were able to consistently use their call lights. An RN confirmed that the call lights should have been within reach of the residents.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to properly store, distribute, and label food items in accordance with professional standards and the Idaho Food Code. Observations revealed several instances of non-compliance, including improperly stored dry food items such as pearl barley and granola, which were not disposed of within the required timeframe. In the reach-in refrigerator, there were undated facility-prepared items like ranch dressing cups, sugar-free ice cream cups, and a slice of pie, as well as an unsealed whipped cream past its use-by date. Additionally, in the walk-in refrigerator, raw meat used for meatballs was improperly thawed, and a three-bean salad and vanilla pudding were kept beyond the facility's 72-hour policy for disposal. Further issues were identified in the walk-in freezer, where raw frozen chicken was stored above facility-made pizza, and water from the freezer unit had dripped onto boxes, causing water damage. In the patient care area snack storage room, there were undated and outdated items, including an opened ice cream container, loaves of bread past their best-used-by dates, an almond milk container past the 72-hour disposal date, and undated single-serve juice cups. These deficiencies in food storage and labeling practices placed residents at risk for potential contamination and adverse health outcomes, including food-borne illnesses.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were revised to reflect their current needs and interventions, as evidenced by the cases of three residents. Resident #1, who was admitted with multiple diagnoses including diabetes and traumatic brain injury, had a care plan dated 1/18/21 that required a restorative program to maintain mobility. However, her medical record did not show any evaluation or updates to her restorative care plan interventions. Similarly, Resident #4, with diagnoses including osteoporosis and chronic pain, had a care plan that required therapy reviews every three months. Despite documented therapy assessments, there was no evidence of care plan evaluations or updates between 4/13/21 and 6/27/22. Resident #15, admitted with spinal stenosis and muscle weakness, had a care plan dated 10/18/22 that included participation in a restorative plan of care. However, there was no documentation that Resident #15 received the restorative services outlined in his care plan. The facility's Restorative Services Nurse confirmed that routine screenings for restorative services were not being performed, and care plans were not updated with resident changes, contributing to the deficiency.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide necessary restorative nursing services to maintain or improve the residents' ability to perform activities of daily living. This deficiency was identified for three residents who were supposed to receive restorative care but did not. Resident #1, with diagnoses including diabetes and traumatic brain injury, was discharged from therapy services and referred to restorative nursing services, but there was no documentation of her receiving these services. Similarly, Resident #4, with osteoporosis and chronic pain, had a care plan indicating the need for restorative services, but her medical record showed she was not receiving them. Resident #15, with spinal stenosis and muscle weakness, was recommended for restorative services, but his medical record also lacked documentation of such services being provided. The deficiency was further highlighted by staff interviews, which revealed systemic issues in the facility's restorative program. The Activities Director admitted to not following care plan interventions and not documenting the exercises performed with residents. CNA #1 and RN #2 acknowledged that the facility's restorative program was undergoing changes, and there was no proper documentation system in place for recording restorative therapy. The Director of Nursing confirmed that restorative therapy minutes were not documented and that the program was under review by the Quality Assurance and Performance Improvement (QAPI) team.
Failure to Ensure Resident Hand Hygiene Before Meals
Penalty
Summary
The facility failed to ensure adherence to infection control and prevention practices by not offering or encouraging hand hygiene for residents before meals served in their rooms. This deficiency was observed during meal service for two residents, who were not offered assistance with hand washing by the CNAs responsible for their care. Specifically, a surveyor noted that food trays were delivered and set up on the overbed tables of these residents without any offer of hand hygiene assistance. Both CNAs acknowledged that they should have offered hand washing but were unaware of any facility requirement to do so. The Director of Nursing confirmed that CNAs should have been asking residents if they would like to wash their hands before meals.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe and clean, homelike environment for a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including a displaced fracture of the left femur and difficulty walking, was found to have a room with numerous small cracks in the flooring, a large crack with a hole at the doorway entrance, and leaf debris on the floor that had been present for several days. These observations were made over a period of several days, and the Director of Nursing (DON) acknowledged that housekeeping should have been sweeping and mopping residents' rooms daily and removing any debris. Additionally, the hole in the floor should have been repaired to prevent falls.
Inaccurate MDS Assessment for Resident's Dental Care Needs
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including shoulder joint surgery, diabetes, muscle weakness, and abnormal gait and mobility, reported needing assistance with cleaning and inserting dentures. However, a nurse's evaluation inaccurately documented that the resident had his own teeth, and the admission MDS did not include documentation of the need for assistance with dental care. Additionally, the resident's care plan lacked interventions for dental care. The Director of Nursing acknowledged that the nurse should have conducted a better assessment to identify the resident's need for assistance with dentures.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to ensure that medications available for residents were properly dated when opened and were not expired. During an inspection of the medication storage room, a vial of Tubersol solution was found in the resident medication refrigerator without an open date. This observation was made in the presence of a registered nurse, who confirmed the absence of an open date on both the vial and its box. The Director of Nursing acknowledged that the Tubersol solution should have been dated upon opening. This oversight created the potential for residents to receive expired medications with decreased efficacy, as per CDC guidelines, which require multi-dose vials to be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to provide evening snacks to residents in accordance with their needs, preferences, and requests, as required by their policy. This deficiency was identified for two residents who attended a Resident Council meeting. One resident, admitted with diagnoses including gastroenteritis, colitis, nausea, and dehydration, reported never being offered evening snacks and was unaware she could request them, despite documentation indicating she refused snacks on multiple occasions. Similarly, another resident with a displaced fracture of the left femur and difficulty walking also stated she was never offered evening snacks and did not know she could ask for them, although records showed she refused snacks on several dates. The Director of Nursing confirmed that CNAs should have offered evening snacks to each resident.
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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