Caldwell Care Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Caldwell, Idaho.
- Location
- 210 Cleveland Boulevard, Caldwell, Idaho 83605
- CMS Provider Number
- 135014
- Inspections on file
- 18
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Caldwell Care Of Cascadia during CMS and state inspections, most recent first.
The facility did not maintain an effective grievance process as required by its own policy, which called for addressing concerns from residents, families, and visitors and making prompt efforts to resolve them. When surveyors requested grievance records for several months, the facility could only produce grievances for a limited recent period and had no records for earlier months. The Administrator confirmed that no grievances were available for the earlier timeframe, and the CRN acknowledged that the grievance process had been identified as needing performance improvement, resulting in a lack of documented access to a functioning grievance system for residents.
Surveyors found that dietary staff prepared and served food while wearing rings and bracelets and performed hand hygiene without removing this jewelry, contrary to FDA Food Code guidance that such items can harbor soil and pathogenic organisms. In addition, kitchen cutting boards were observed to have dark stains embedded in the plastic grain, indicating they were scratched, difficult to clean, and potentially capable of harboring microorganisms. These practices affected all individuals consuming facility-prepared food and created a risk of food contamination and food-borne illness.
The facility failed to hold required quarterly care conferences for multiple residents with dementia, schizoaffective disorder, bipolar disorder, heart failure, dysphagia, and other conditions, documenting only initial or single conferences and no subsequent quarterly meetings in the EHR, as confirmed by leadership. The facility also did not timely revise care plans for two residents when their needs changed: one resident’s fall-related supervision intervention, ordered after a fall, was not added to the care plan until weeks later, and another resident’s toileting status remained documented as largely independent despite an MDS showing complete dependence on staff for toileting, a discrepancy acknowledged by the DON.
Staff failed to follow infection prevention and control practices during blood glucose monitoring and environmental cleaning. An RN performed a blood glucose check and handled insulin pens for a diabetic resident by placing the glucometer and insulin pens directly on the resident's bed surfaces without using a paper towel barrier, contrary to AHCA guidance and facility expectations. In a separate incident, a CNA cleaned a urine spill from a leaking urinary catheter bag in a common area by covering and wiping it with a dry towel while wearing gloves, but did not clean or disinfect the area afterward, despite CDC procedures requiring thorough cleaning and disinfection of body fluid spills.
A resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia, who was assessed as cognitively intact, was moved from one room to another without receiving a proper written explanation for the transfer as required by facility policy. The facility’s room change policy required a written rationale and an opportunity for the resident to see the new location, meet a new roommate, and ask questions. However, the room-to-room transfer form documented only that the POA was notified, with no explanation of why the move was required, and the Social Services Manager later acknowledged the form was not completed correctly. This failure created the potential for psychosocial harm related to the room change.
A resident with schizoaffective disorder, depression, and anxiety had multiple documented episodes of significantly elevated BP over a 90-day period, but nursing staff did not notify the physician as required. Record review showed no evidence of any physician notification regarding these abnormal vital signs, and in an interview the DON confirmed that the physician should have been notified immediately and could not provide documentation that this occurred.
Surveyors found that two residents lived in rooms with unrepaired and visibly patched walls, including exposed broken drywall and numerous white patches over colored paint. Both residents, who had mental health diagnoses and one with COPD, reported that the wall damage and patchwork had been present for an extended period. The facility's own policy required a safe, clean, comfortable, and homelike environment, but the Maintenance Director acknowledged the walls had only been patched and primed and had not yet been painted, and he was unaware of some of the existing wall damage.
The facility failed to accurately identify which resident was the victim and which was the aggressor in a resident-to-resident abuse report submitted to the state. One resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia was documented in the official abuse report as the victim after a bathroom-related altercation in which another resident was reported to have grabbed the resident’s shirt, with no injury found. However, a witness statement indicated that this resident had entered the other resident’s room and was actually the aggressor, and the other resident merely reacted by grabbing the shirt. The Administrator later acknowledged that the report had been completed incorrectly, contrary to facility policy requiring complete and accurate abuse reporting.
A resident with acute respiratory failure, pneumonia, and COPD experienced worsening respiratory status, did not respond to an albuterol treatment, and required transfer for a higher level of care. Although a transfer/discharge notice and bed-hold agreement were completed, the record lacked documentation that required information was sent to the receiving provider, including practitioner contact details, resident representative contact information, advance directive status, special instructions or precautions for ongoing care, and comprehensive care plan goals. The DON and CRN confirmed that this required transfer documentation was not present in the medical record.
A resident with multiple behavioral health diagnoses, whose primary diagnosis was recurrent major depressive disorder, had an inaccurately completed PASRR Level I that identified dementia/Alzheimer’s disease as the primary diagnosis. Record review and staff interview revealed the discrepancy between the medical record and the PASRR form, and the SW confirmed the PASRR Level I was completed incorrectly.
Surveyors found that staff did not follow professional standards in several clinical practices. A resident with an AV fistula for hemodialysis had multiple blood pressure readings documented on the access arm despite a care plan prohibiting this. Another resident with diabetes received Novolog and Toujeo via insulin pens that an RN failed to prime before dialing to the ordered doses, contrary to manufacturer instructions. A third resident receiving oral potassium chloride had the medication mixed with pudding and was not educated by an LPN about the need to drink a full glass of water afterward, even when the resident declined water.
Multiple residents did not receive ordered or care-planned interventions, including one resident with a fall history who was left sitting on the bed edge and subsequently fell, after which ordered orthostatic BP monitoring was not documented; another resident with muscle weakness and malnutrition who had physician-ordered pressure-relieving boots was repeatedly observed in common areas without the boots on; a resident with psychiatric diagnoses had an elevated BP that was not reassessed or further evaluated; and a resident with cardiac and swallowing issues had an ordered carrot splint for the right hand that was not applied despite observations of tightly fisted hands and fingertip pressure marks on the palm.
A resident with psychiatric conditions and impaired mobility experienced repeated falls from a wheelchair in the dining room after staff left the resident unsupervised. Following an initial fall, the IDT determined the resident should always be supervised in the dining room, but this intervention was not added to the care plan until much later. During this gap, the resident sustained another fall under similar circumstances. The DON confirmed that the supervision intervention was not incorporated into the care plan when it was first identified.
A resident with bipolar disorder, anxiety disorder, and traumatic brain injury was receiving Seroquel 300 mg daily, with a care plan directing staff to monitor and report psychoactive medication side effects. A consulting pharmacist documented that antipsychotic drugs can cause tardive dyskinesia and other movement disorders and recommended completion of an AIMS or DISCUS assessment at least every six months while the resident remained on antipsychotic therapy. The resident’s record showed the last AIMS assessment had been completed more than six months earlier, outside the recommended monitoring interval, and the DON confirmed that the pharmacist’s recommendation had not been implemented and no current AIMS assessment was present in the chart.
Surveyors found that two residents receiving Depakote for conditions including alcohol dependence, borderline personality disorder, Alzheimer’s disease, and suicidal ideations were not monitored for anticonvulsant side effects as required by their person-centered care plans. Although the care plans directed staff to monitor, notify the provider, and document specific symptoms such as over-sedation, agitation, confusion, mental status changes, visual disturbances, gait changes, behavioral changes, and weight changes, the clinical records contained no documentation of such monitoring. The DON confirmed that anticonvulsant monitoring was not present in the records, and the report noted this failure created the potential for harm if side effects were undetected.
Surveyors found that the facility failed to remove expired medications from the medication storage room. During an inspection of the medication room refrigerator with the ADON, five acetaminophen suppositories with a past expiration date were discovered still stored and available for use. The ADON confirmed the suppositories were expired and should not have remained in the refrigerator, creating the potential for adverse effects if administered.
The facility failed to follow its Antibiotic Stewardship Policy and McGeer’s Criteria when initiating antibiotic therapy for a suspected UTI in a resident with multiple diagnoses, including adult failure to thrive and a need for assistance with personal care. The resident’s care plan directed monitoring for specific urinary and systemic symptoms, and the resident was later noted to be increasingly lethargic with decreased muscle function. A provider ordered lab tests, including a urinalysis with culture and sensitivity, along with cefdinir for a UTI diagnosis, and the antibiotic was started before culture and sensitivity results were available. The urine culture and sensitivity were completed several days after antibiotic initiation, and the DON later confirmed the resident did not meet McGeer’s criteria for antibiotic treatment for UTI.
The facility failed to ensure resident rights were honored when past survey results and plans of correction were not readily accessible. A binder labeled “State Survey Results” was placed in a corridor pocket folder but was blocked by a stuffed chair with stacked equipment, two vital signs towers, and an extra-large padded specialized wheelchair, preventing easy access. During a Resident Council discussion, residents reported they were unaware of the facility’s responsibility to make the past three years of survey results available, did not know they had the right to review them, and did not know where the survey results were posted. The Administrator confirmed that the survey results were inaccessible due to being blocked by stored equipment.
The facility did not have an RN on duty for 8 consecutive hours on one of the reviewed days, with an LPN covering the RN duties instead. This staffing lapse created the potential for unmet nursing needs, affecting all residents.
The facility failed to properly store and label food items, as outdated yogurts and an ice cream container were found in storage past their use-by dates. The CDM acknowledged these items should have been removed according to the facility's policy and the Idaho Food Code.
The facility failed to provide proper respiratory care for residents requiring oxygen therapy, with incomplete physician orders and improper oxygen administration. A resident with panic disorder and dementia was found without his oxygen nasal cannula, while another resident with hemiplegia had an incomplete oxygen order. Additionally, a resident with acute respiratory failure was observed with a portable oxygen unit set at zero liters per minute, despite a physician's order for 2 liters per minute.
A resident with multiple diagnoses, including schizoaffective disorder and COPD, was transferred from a single-bed room to a four-bed room without receiving the required written notice. A CRN confirmed the absence of documentation indicating prior notification of the room change.
The facility did not maintain a safe and homelike environment in one of its shower rooms, where peeling paint was observed. A CNA noted the issue had been present for months, but no maintenance work order was found. The Maintenance Director was unaware of the problem, which affected the quality of life for residents using the shower room.
A resident with dementia exhibited aggressive behavior towards another resident with hemiplegia and end-stage renal disease, including placing them in a chokehold and pushing their wheelchair. The facility failed to prevent these incidents, placing all residents at risk of abuse.
A facility failed to provide a bed-hold notice to a resident with multiple diagnoses, including schizoaffective disorder and COPD, upon transfer to the hospital for worsening respiratory symptoms. The resident's record lacked documentation of the notice, and the DON confirmed this omission during an interview.
The facility failed to refer two residents with major mental illnesses for PASARR level 2 evaluations as required. One resident with bipolar disease and another with schizophrenia did not have the necessary evaluations completed, despite policy requirements and instructions from PASARR level 1 screenings.
The facility failed to complete timely PASARR screenings for two residents with mental disorders. One resident with bipolar disease had no PASARR Level 1 completed, while another with schizophrenia had the screening done 36 days post-admission. This non-compliance could affect the provision of necessary mental health services.
A facility failed to update a care plan for a resident with Parkinson's and bipolar disorder, who required 30-minute checks after a fall. Despite documentation in the care plan and interdisciplinary notes, the medical record lacked evidence of these checks being performed. The DON later acknowledged the oversight.
A facility failed to follow standard practices during a resident transfer and did not adhere to a care plan for monitoring weight loss. A CNA used a resident's belt loop instead of a gait belt, violating safety policy. Another resident experienced significant weight loss without the required notification to the MD, risking potential harm.
A resident with panic disorder and dementia was found without access to a call light, which was placed across the room, contrary to his care plan. The resident reported yelling for help due to pain but was not heard. A CNA admitted to forgetting to provide the call light, and the DON confirmed the requirement for staff to ensure call light access.
A resident with a history of stroke and diabetes reported nearly falling in the east shower room due to missing anti-slip pads. Observations confirmed the absence of non-slip strips, which had been missing for about two months. Despite a work order being submitted, the strips were not replaced until later.
Failure to Maintain and Implement an Effective Grievance Process
Penalty
Summary
The facility failed to ensure a grievance process was available for residents as required by its own Grievance Process policy, which stated that the grievance program addresses concerns of residents, family members, and visitors and that the facility should make prompt efforts to resolve grievances. During the survey, when the SA requested copies of grievances covering the period from September 2025 through March 2026, the facility was only able to provide grievances from January 2026 through March 2026 and had no additional grievances available for the earlier months. In an interview, the Administrator, with the CRN present, confirmed there were no grievances available prior to January 2026 and the CRN acknowledged that the facility had identified its grievance process as needing a performance improvement plan. This lack of an available and functioning grievance process created the potential for psychosocial harm if residents’ concerns were not identified and addressed in a timely manner. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency centered on the facility-wide failure to maintain and implement an effective grievance process over the specified time period.
Improper Jewelry Use and Unsanitary Cutting Boards During Food Preparation
Penalty
Summary
Surveyors identified a deficiency in food service practices related to staff wearing jewelry during food preparation and service. On the morning of 3/4/26, one dietary staff member and one dietary trainee were observed preparing and serving food while wearing rings, and the trainee was also wearing bracelets on both wrists. Hand hygiene was performed while the jewelry remained in place. According to the FDA Food Code, items of jewelry such as rings, bracelets, and watches may collect soil, be difficult to clean, and act as reservoirs for pathogenic organisms transmissible through food. The Dietary Manager stated that jewelry should not be worn while preparing or serving food and that if jewelry was permanent, gloves should be worn to cover it. A second deficiency involved the condition and cleanliness of cutting boards used in the kitchen. On the afternoon of 3/5/26, surveyors observed that the plastic cutting boards in the kitchen had dark-colored stains within the grains of the plastic. The FDA Food Code states that cutting surfaces that become scratched and scored may be difficult to clean and sanitize, allowing pathogenic microorganisms transmissible through food to accumulate and be transferred to foods prepared on those surfaces. The Culinary Manager stated that cutting boards should be replaced when they are not able to get clean or have stains removed. These deficiencies had the potential to affect the 59 residents who consumed food prepared by the facility and placed them at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.
Failure to Hold Quarterly Care Conferences and Timely Revise Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to conduct required quarterly care conferences and to timely revise care plans based on residents’ changing needs. Facility policy dated 9/3/25 required that care plans be created, reviewed, and revised by an interdisciplinary team (IDT) with resident and/or representative involvement, and that updates occur as needed based on residents’ response to interventions and changes in condition. Record review showed that multiple residents with complex medical and psychiatric diagnoses had only an initial or single quarterly care conference documented, with no evidence of subsequent quarterly conferences in the electronic health record. The Administrator and Clinical Resource Nurse confirmed that if a care conference was not documented in the electronic health record, it was not completed. For one resident with dementia, depression, anxiety, muscle weakness, and difficulty walking, a quarterly care conference was documented in July 2025, but there was no documentation of additional quarterly conferences around October 2025 or January 2026. Another resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia had a care conference in August 2025, with no further quarterly conferences documented for November 2025 or March 2026. A resident with paranoid schizophrenia, depression, anxiety, and difficulty walking had a care conference in June 2025, but there were no records of required quarterly conferences for September and December 2025, nor documentation that a March 2026 conference was scheduled. Additional residents with schizoaffective disorder, depression, anxiety, dementia, bipolar disorder, heart failure, dysphagia, and sleep apnea similarly lacked documentation of required quarterly care conferences after an initial or single documented meeting. The facility also failed to revise care plans in a timely manner for two residents when their care needs changed. One resident with paranoid schizophrenia, depression, anxiety, and difficulty walking had a fall care plan dated August 2023 that included various fall-prevention interventions and directed quarterly re-evaluation and revision with changes in condition or after a fall. A fall investigation on December 1, 2025 documented that the resident fell while unattended in the dining room, and the IDT directed that the resident be supervised at all times while in the dining room; however, this new supervision intervention was not added to the care plan until January 27, 2026. Another resident with major depressive disorder, anxiety disorder, and alcohol dependence had a care plan revised in April 2022 indicating independence with toileting and one-person assistance for occasional nighttime incontinence, but a later quarterly MDS documented that the resident was dependent on staff for all toileting needs. The DON confirmed the resident was dependent in toileting and that the care plan should have been revised to reflect the current care needs.
Failure to Follow Infection Control Practices During Glucose Monitoring and Urine Spill Cleanup
Penalty
Summary
The deficiency involves failure to implement proper infection prevention and control practices during medication administration. A resident with multiple diagnoses including diabetes and asthma was observed during a blood glucose check and insulin administration. An RN entered the resident's room with a glucometer (with test strip inserted), two insulin pens, a lancet, and alcohol wipes, and placed the glucometer and insulin pens directly on the foot of the resident's bed. After performing hand hygiene and donning gloves, the RN then moved the glucometer to a position above the pillow where the resident's arm was resting to check the blood glucose level, again without using any barrier. The RN did not place a clean, dry paper towel or other barrier under the glucometer or insulin pens on either surface, despite guidance from the American Health Care Association that such equipment should be placed on a paper towel before being set on a resident's table or medication cart. The DON later stated that insulin pens and glucometers should be placed on top of a paper towel before placing them on any surface in residents' rooms. The deficiency also includes improper cleaning of a urine spill in a common area. A CNA was observed assisting another CNA with a urine spill from a leaking urinary catheter collection bag in a wing common area. The CNA placed a dry white towel over a small puddle of urine, donned gloves, wiped up the urine with the towel, and then left the area without further cleaning or disinfection. CDC environmental cleaning procedures for spills of blood or body fluids specify wearing appropriate PPE, confining and wiping up the spill with absorbent material to be disposed of as infectious waste, then thoroughly cleaning with neutral detergent and warm water, disinfecting with a facility-approved intermediate-level disinfectant, and sending reusable supplies for reprocessing. When later asked about the process for cleaning soiled areas, the CNA stated the process was to wear gloves, wipe up the soiled area, and use alcohol or disinfectant wipes, and acknowledged that no disinfectant was used on the urine spill and that the area should have been sanitized and housekeeping notified.
Failure to Provide Proper Written Notice and Explanation Before Room Change
Penalty
Summary
The facility failed to honor a resident’s right to receive written notice and explanation before a room change when staff moved Resident #13 to a new room without properly completing the required written notification. The facility’s “Resident Room Changes & Roommate Rights” policy, revised 8/31/25, required that when a resident is moved at the request of facility staff, the resident, family, and/or representative must receive a written explanation of why the move is required and be given an opportunity to see the new location, meet the new roommate, and ask questions. Resident #13, who had multiple diagnoses including schizoaffective disorder, insomnia, anxiety, depression, and dementia, and was documented as cognitively intact on a quarterly MDS assessment, was re-admitted to the facility and later transferred from one room to another. The “Notice of Room-to-Room Transfer” form for this move, signed 11/13/25, listed only “POA Notified” as the rationale for the transfer, with no further written explanation of the reason for the move. During interview, the Social Services Manager acknowledged that the notification of room change was not filled out correctly and should have identified in writing why the resident was moving rooms. This deficient practice created the potential for psychosocial harm if Resident #13 was not provided an opportunity to see the new location, meet a new roommate, or have questions answered related to the move.
Failure to Notify Physician of Repeated Elevated Blood Pressures
Penalty
Summary
Resident rights related to timely physician and family notification were not honored when abnormal clinical findings were not reported. One resident with multiple diagnoses including schizoaffective disorder, depression, and anxiety had four documented episodes of elevated blood pressure over a 90-day period, with readings of 171/104, 164/98, 171/99, and 173/104. Record review showed no documentation that the physician was notified of any of these elevated blood pressure readings. During an interview on 3/6/26 at 9:20 AM, the DON stated that nurses should have notified the physician immediately of the elevated blood pressures and was unable to provide any documentation that such notification occurred. This failure to notify the physician of abnormal vital signs was identified for 1 of 16 residents reviewed for physician notification and was determined by surveyors to have placed the resident at risk for harm.
Failure to Maintain Homelike Room Environment Due to Unrepaired and Unpainted Walls
Penalty
Summary
Surveyors determined that the facility failed to honor residents' rights to a safe, clean, comfortable, and homelike environment when room walls were left unrepaired and with visible patchwork. The facility's Homelike Environment policy, revised 9/17/25, states that the facility supports residents' rights to such an environment to promote dignity, independence, and quality of life. During observations on 3/2/26, Resident #13's room was found to have a jagged vertical damaged line on the wall from floor to ceiling exposing broken drywall, along with other areas of the walls covered with white patches on top of colored paint. Resident #13, who had been re-admitted with schizoaffective disorder, insomnia, anxiety, depression, and dementia, stated that the white patches and damaged wall had been present since she relocated to the room in November 2025. On the same date, Resident #53's room was observed to have various white patches on painted walls, both small and large, throughout the room. Resident #53, who had been admitted with schizophrenia and COPD, stated that the white patches had been on the walls for as long as she could remember. On 3/5/26, the Maintenance Director reported that the walls in both residents' rooms had been patched and primed and were ready to be painted, but they had not yet been painted. He also stated he was unaware that Resident #13's room had any damaged walls that still needed to be fixed. These observations and statements showed that the facility did not ensure timely repair and consistent painting of residents' room walls, resulting in an environment that did not meet the homelike standard described in the facility's policy.
Inaccurate Identification of Victim and Aggressor in Abuse Report
Penalty
Summary
The facility failed to accurately report which resident was the victim and which was the aggressor in an abuse investigation submitted to the Idaho BFS LTC Reporting System. The facility’s Abuse – Reporting & Response: No Crime Suspected policy required that reports include sufficient detail to describe the nature of the alleged violation and that new or revised information be included in follow-up submissions to ensure completeness and accuracy. An abuse report dated 11/13/25 identified Resident #13 as the victim in a resident-to-resident interaction, documenting that another resident was heard banging on a restroom door while Resident #13 was using it, that Resident #13 exited the bathroom on the other resident’s side and began yelling, and that the other resident reacted by grabbing Resident #13’s shirt without making physical contact. The report further documented that Resident #13 complained of a hurt arm, which was assessed with no injury found, and that Resident #13 was moved to a new room the same day because the facility believed she should not share a bathroom with the other resident for their safety. Resident #13 had been re-admitted to the facility with multiple diagnoses, including schizoaffective disorder, insomnia, anxiety, depression, and dementia. A witness statement dated 11/13/25, however, documented that Resident #13 was the aggressor, entering the other resident’s room and yelling at her, and that the other resident reacted by grabbing Resident #13’s shirt. Despite this conflicting information, the abuse investigation submitted to the state continued to identify Resident #13 as the victim. During an interview on 3/5/26 at 10:21 AM, the Administrator stated he had filled out the report incorrectly and acknowledged that Resident #13 was actually the aggressor, not the victim as documented on the investigation report.
Missing Required Transfer Documentation for Acutely Ill Resident
Penalty
Summary
The facility failed to ensure that required transfer and discharge documentation was included in a resident’s medical record to support communication of essential information to the receiving healthcare provider. A resident admitted with acute respiratory failure, pneumonia, and COPD had a care plan initiated that identified altered respiratory status and directed staff to monitor and report signs of compromised airway. A progress note later documented that the resident was not responding to an albuterol breathing treatment and had declining oxygen saturation requiring a higher level of care, and a Notice of Transfer or Discharge and a bed-hold agreement were completed for an immediate transfer due to urgent medical needs. However, the resident’s record did not contain documentation that the following required information was sent to the receiving provider at the time of transfer: contact information for the practitioner responsible for the resident’s care, resident representative contact information, advance directive information, all special instructions or precautions for ongoing care as appropriate, and comprehensive care plan goals. On review, the DON and CRN confirmed that the required transfer and discharge documentation was missing from the resident’s record.
Inaccurate PASRR Level I Primary Diagnosis Documentation
Penalty
Summary
The facility failed to ensure that a resident’s Preadmission Screening and Resident Review (PASRR) accurately reflected the resident’s primary diagnosis, resulting in an incorrect PASRR Level I determination. The resident was admitted with multiple diagnoses, including major depressive disorder, anxiety disorder, and alcohol dependence, and record review showed the primary diagnosis was recurrent major depressive disorder. However, the PASRR Level I, dated 9/9/25, documented “Yes” in Box 12, indicating the individual had a primary diagnosis of dementia or Alzheimer’s disease. During an interview on 3/5/26 at 4:45 PM, the Social Worker confirmed that this PASRR Level I had been inaccurately completed. This inaccuracy was identified through record review and staff interview, which showed a discrepancy between the documented primary diagnosis in the medical record and the diagnosis selected on the PASRR Level I form.
Failure to Follow Professional Standards in BP Monitoring and Medication Administration
Penalty
Summary
The deficiency involves failures to follow accepted professional standards of clinical practice during care and medication administration for multiple residents. For a resident with end stage renal disease and an AV fistula in the left forearm for hemodialysis, the care plan specified that blood pressures should not be taken on the left arm. Despite this, the resident’s vital sign records showed 18 blood pressure readings documented as taken on the left arm over a 90‑day period. The DON later confirmed the record showed blood pressures taken on the left arm and suggested the person measuring the blood pressure may have documented incorrectly, while also stating there had been no adverse outcomes and that the resident was aware blood pressures should not be taken on that arm. Additional deficiencies were identified in insulin administration and oral medication administration. For a resident with diabetes, physician orders required Novolog (insulin aspart) three times daily and Toujeo (insulin glargine) twice daily. During observation, an RN sanitized and re‑needled both insulin pens, dialed each pen directly to the ordered dose, and administered the injections without priming either pen, contrary to the manufacturers’ Instructions for Use that require priming to ensure proper dosing. For another resident with heart failure, dysphagia, and sleep apnea who was ordered potassium chloride 20 mEq twice daily, an LPN dissolved the potassium chloride in a small amount of water, mixed it with pudding, and administered it. When the resident declined water afterward, the LPN did not provide education about the importance of drinking a full glass of water after taking potassium chloride, despite reference material indicating it should be taken with food or just after a meal and followed with a full glass of water to reduce stomach irritation.
Failure to Implement Care Plan Interventions and Physician Orders for Multiple Residents
Penalty
Summary
The deficiency involves failures to implement resident-centered care plan interventions and physician-ordered treatments for multiple residents. One resident with a history of falls and a need for assistance with personal care was care planned for one-person assistance with ambulation and transfers and for staff to monitor her position in bed and in her wheelchair for safety. While a CNA was assisting with dressing, the resident was left sitting on the edge of the bed while the CNA stepped away to the closet, during which time the resident stood and fell forward, striking her face on the floor. Following this fall, the interdisciplinary team determined that orthostatic blood pressures should be monitored, but the facility was unable to provide any documentation that orthostatic blood pressures were obtained. Another resident with muscle weakness, dementia, and protein-calorie malnutrition had a care plan and physician order directing that pressure-relieving boots be applied bilaterally when in bed and in a wheelchair, but he was repeatedly observed in common areas without the boots, which were seen on his bedside nightstand. An LPN stated the resident only wore the boots in bed, and the DON confirmed the resident should have had the boots on at all times. Additional deficiencies included failure to reassess an elevated blood pressure and to implement a physician-ordered splint. A resident with schizoaffective disorder, depression, and anxiety had a documented blood pressure of 171/104, with no record of a reassessment of the blood pressure or assessment for related symptoms on that date. The DON stated that nurses should have notified the provider and reassessed the resident but could not provide documentation that this occurred. Another resident with heart failure, dysphagia, and sleep apnea had a physician’s order for a carrot splint to the right hand with monitoring for skin alteration twice daily. Despite this order, the resident was observed multiple times with both hands closed in fists and no carrot splint applied. When staff assisted in opening the right hand, pressure marks from the fingertips were noted on the palm, and the DON confirmed that the carrot splint should have been in use as ordered.
Failure to Update Care Plan With Required Dining Room Supervision After Fall
Penalty
Summary
The facility failed to ensure a resident’s fall-prevention intervention was timely incorporated into the care plan, resulting in the resident being left unsupervised in the dining room and experiencing repeat falls. The resident was admitted with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking. On 12/1/25, an IDT fall investigation documented that the resident had fallen from her wheelchair while unattended in the dining room and concluded that she was to be always supervised while in the dining room to avoid future falls. However, this supervision intervention was not added to the resident’s care plan at that time. On 1/23/26, the resident again fell from her wheelchair when a staff member left her unsupervised in the dining room, as documented in a 1/26/26 fall investigation report. The care plan was not revised to include constant supervision in the dining room until 1/27/26, and the DON confirmed that the supervision intervention should have been added in December 2025 but was not. The deficiency centers on the facility’s failure to update the resident’s care plan after the first documented fall and identified intervention, leaving staff without a formalized directive to provide constant supervision in the dining room between early December 2025 and late January 2026. During an interview on 3/4/26, the DON acknowledged that the care plan related to staff supervision for this resident was not added until 1/27/26, despite the IDT’s earlier determination on 12/1/25. When asked if the fall on 1/23/26 could have been prevented had the care plan been updated in December 2025, the DON declined to answer.
Failure to Complete Recommended Antipsychotic Movement-Disorder Monitoring
Penalty
Summary
The facility failed to ensure recommended monitoring for adverse effects of antipsychotic medication was completed for one resident receiving psychoactive medication. The resident was readmitted with multiple diagnoses, including bipolar disorder, anxiety disorder, and traumatic brain injury, and had a care plan directing staff to monitor and report side effects and adverse reactions related to psychoactive medications. A physician’s order documented that the resident was to receive Seroquel 300 mg by mouth once daily for traumatic brain injury. A pharmacy review noted that antipsychotic medications can cause tardive dyskinesia and other movement disorders and recommended that a movement-disorder assessment, such as an AIMS or DISCUS test, be completed at least every six months while the resident remained on antipsychotic therapy. Record review showed the last AIMS assessment was completed more than six months before the pharmacy recommendation and outside the recommended monitoring interval, and the DON confirmed that the pharmacy recommendation had not been acted upon and the record did not contain a current AIMS assessment.
Failure to Monitor and Document Anticonvulsant Side Effects
Penalty
Summary
Surveyors identified a failure to ensure residents’ drug regimens were free from unnecessary drugs by not monitoring for side effects of anticonvulsant medications as required by the residents’ care plans. One resident with major depressive disorder, anxiety disorder, and alcohol dependence had a physician order for Depakote 250 mg by mouth three times a day for alcohol dependence. The resident’s comprehensive person-centered care plan, revised 8/6/25, directed staff to monitor, notify the provider, and document specific anticonvulsant side effects, including over-sedation or lethargy, restless agitation, increased confusion or poor concentration, mental status change, visual disturbance, change in gait, behavioral changes, and weight change. Record review showed no documentation that staff were monitoring for these anticonvulsant side effects. Another resident with borderline personality disorder, Alzheimer’s disease, and suicidal ideations had a physician order for Depakote sprinkles 750 mg by mouth two times a day for borderline personality disorder. This resident’s care plan, revised 10/14/24, contained the same directives for staff to monitor, notify the provider, and document anticonvulsant side effects, listing the same potential symptoms. Record review similarly showed no documentation that staff were monitoring for these side effects. On 3/5/26 at 8:32 AM, the DON confirmed that the records for both residents did not include anticonvulsant monitoring, and the report stated this failure created the potential for harm if side effects were undetected.
Expired Acetaminophen Suppositories Found in Medication Storage Room
Penalty
Summary
Surveyors identified a failure to ensure drugs and biologicals were properly managed and stored when expired medications were found in the facility’s medication storage room. During an inspection of the medication room refrigerator with the ADON, five acetaminophen suppositories with an expiration date of 10/2025 were observed still stored inside. The ADON acknowledged that the acetaminophen suppositories were expired and confirmed they should not have been kept in the refrigerator. This deficiency involved the medication storage area only; no specific residents or administrations of the expired medications were described in the report. The report stated that this failed practice created the potential for adverse effects if residents received expired medications with decreased efficacy.
Failure to Follow Antibiotic Stewardship and McGeer’s Criteria for UTI Treatment
Penalty
Summary
The deficiency involves failure to follow the facility’s Antibiotic Stewardship Policy and McGeer’s Criteria when initiating antibiotic therapy for a suspected urinary tract infection (UTI). The policy, revised 8/10/25, states the facility focuses on improving antibiotic use through an Antibiotic Stewardship Program, utilizes McGeer’s Criteria to validate infections, and routinely reviews culture and sensitivity reports as part of infection surveillance. McGeer’s Criteria for UTI without an indwelling catheter require at least one specified clinical sign or symptom and at least one qualifying microbiologic criterion. Despite these requirements, the facility initiated antibiotic treatment before culture and sensitivity results were available and in a situation later confirmed by the DON not to meet McGeer’s criteria for UTI. The resident involved was readmitted with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care. The resident’s care plan, revised 3/27/25, directed staff to encourage fluids and monitor for specific urinary and systemic symptoms such as urinary frequency, malaise, foul-smelling urine, dysuria, fever, nausea, vomiting, flank pain, suprapubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and behavioral changes. On 3/27/25 at 4:43 PM, the resident was observed to be increasingly lethargic with decreased muscle function, and the provider was notified. New orders were obtained for a CBC, CMP, urinalysis with culture and sensitivity, and cefdinir 300 mg by mouth twice daily for 5 days for a diagnosis of UTI. The urine specimen was collected earlier that day, and the culture and sensitivity were not completed until 3/29/25, three days after antibiotics were started. On 3/5/26 at 4:12 PM, the DON confirmed the resident did not meet McGeer’s criteria for antibiotics for a UTI.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to honor resident rights by not making the past three years of state survey results and plans of correction readily accessible to residents and their representatives. On multiple days of observation, a binder labeled “State Survey Results” was located in a pocket folder on the wall of a corridor leading to the courtyard, but access to the binder was blocked by a stuffed chair with large equipment stacked on it, two vital signs towers, and an extra-large padded specialized wheelchair. During a Resident Council group discussion with surveyors, residents reported they were not aware that the facility was responsible for making the past three years of survey results readily accessible, nor were they aware of their right to review these results and plans of correction, and they stated they did not know where the survey results were posted. The Administrator later confirmed that the survey results were not accessible because they were blocked by stored equipment. No specific resident medical histories or clinical conditions were described in relation to this deficiency.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours per day, 7 days a week, as required. This deficiency was identified during a review of the facility's staffing records and staff interviews, which revealed that on one of the 38 days reviewed, specifically on 9/1/24, there was no RN on duty for the required duration. Instead, the RN duties were covered by a Licensed Practical Nurse (LPN) on that day. This lapse in staffing created the potential for harm if routine and/or emergency nursing needs went unmet, potentially affecting all residents living in the facility.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to appropriately store, label, and serve foods, as observed during a survey. The Idaho Food Code requires that refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours must be clearly marked with a date by which the food should be consumed, sold, or discarded. The facility's policy also mandates labeling of opened food products with contents and use-by dates. However, during the survey, three outdated yogurts with a date of 10/2/24 were found in the walk-in refrigerator on 10/7/24. Additionally, an ice cream container with an open date of 9/2/24 and a use-by date of 10/2/24 was observed in the resident snack freezer on 10/9/24. The Certified Dietary Manager (CDM) acknowledged that these items should have been removed by their respective use-by dates.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, as evidenced by incomplete physician orders and improper oxygen administration. Resident #5, diagnosed with panic disorder and dementia, was observed without his oxygen nasal cannula after being transferred to bed. A CNA admitted that the oxygen should have been in use at all times, as per a physician's order for 2 liters per minute via nasal cannula, but it was not replaced after the transfer. Resident #32, with diagnoses including hemiplegia and end-stage renal disease, had an incomplete medical order for oxygen usage that lacked the duration of use. Similarly, Resident #47, who had acute respiratory failure with hypoxia and chronic obstructive pulmonary disease, was observed with a nasal cannula attached to a portable oxygen unit set at zero liters per minute, contrary to the physician's order for 2 liters per minute. The medical record for Resident #47 also had an incomplete order lacking the duration of use, which was confirmed by a CRN.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide a resident with written notice prior to a room change, which is a violation of the resident's rights. The deficiency involved a resident who was initially admitted to the facility with multiple diagnoses, including schizoaffective disorder, borderline personality disorder, COPD, and diabetes. The resident was transferred from a single-bed room to a four-bed room on January 3, 2024, without receiving the required written notice. During an interview, a Clinical Registered Nurse (CRN) confirmed that there was no documentation in the resident's record indicating that the resident had been notified in advance of the room change.
Peeling Paint in Shower Room Compromises Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, specifically in one of the three shower rooms observed. On October 8, 2024, at 9:22 AM, it was observed that the paint was peeling away from the ceiling in various areas of the east shower room. A Certified Nursing Assistant (CNA) mentioned that the paint had started peeling a few months ago. Upon reviewing the facility's maintenance work orders for the past six months, no work order was found for the peeling paint issue. Later that day, at 3:30 PM, the Maintenance Director stated that he was not aware of the peeling paint in the east hall shower room and acknowledged that it needed to be fixed. This oversight created the potential for a diminished quality of life for all residents using the east shower room.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by an incident involving two residents. Resident #111, who had a history of dementia and hypertension, exhibited aggressive behavior towards Resident #32, who was diagnosed with hemiplegia and end-stage renal disease. On one occasion, Resident #111 approached Resident #32 from behind and placed him in a chokehold, threatening to kill him. This incident was part of a pattern of aggressive behavior by Resident #111, who had previously yelled at another resident and lunged at their neck, as well as pushed Resident #32 in his wheelchair, causing him to bump his knee into a cabinet. The facility's investigation into the incident on 3/9/24 revealed that the administrator believed Resident #111 intended to harm Resident #32. Despite the aggressive behavior exhibited by Resident #111, the facility did not take adequate measures to prevent further incidents, thereby failing to ensure the safety and protection of its residents. The lack of timely intervention and effective management of Resident #111's behavior placed all residents at risk of ongoing abuse and potential harm.
Failure to Provide Bed-Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives upon transfer to the hospital, as evidenced by the case of a resident with multiple diagnoses including schizoaffective disorder, borderline personality disorder, COPD, and diabetes. This resident was initially admitted to the facility and later readmitted, with a documented transfer to the hospital for evaluation and treatment of worsening respiratory symptoms. However, there was no documentation in the resident's record indicating that a bed-hold notice was provided at the time of transfer. During an interview, the Director of Nursing confirmed the absence of documentation for the bed-hold notice, highlighting a deficiency in the facility's process for informing residents or their representatives of their right to return to their former bed within a specified time frame.
Failure to Complete PASARR Level 2 Evaluations for Residents with Major Mental Illness
Penalty
Summary
The facility failed to refer residents for further evaluation when diagnosed with a major mental illness, as required by the Pre-Admission Screening and Resident Review (PASARR) program. This deficiency was identified for two residents who were reviewed for PASARR level 2 evaluations. The facility's policy mandates that positive level 1 PASARR screenings, indicating a major mental illness, must be forwarded to the state-designated authority for a level 2 evaluation. However, this procedure was not followed for the residents in question. One resident was admitted with multiple diagnoses, including bipolar disease, and was prescribed antianxiety and antipsychotic medications. Despite the diagnosis of bipolar disease, the resident's medical record lacked a completed PASARR level 1 screening or a level 2 evaluation. Another resident, admitted with schizophrenia and non-Alzheimer's dementia, had a PASARR level 1 screening completed 36 days post-admission, which identified schizophrenia as a major mental illness. The screening instructed that it be forwarded for a level 2 evaluation, but the resident's medical record did not document the completion of this evaluation. The facility's Clinical Resource Nurse confirmed the absence of PASARR level 2 evaluations for both residents.
Failure to Complete Timely PASARR Screenings
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) was completed within the required timeframe for two residents. According to the facility's policy, a PASARR Level 1 should be completed prior to admission. However, for Resident #42, who was admitted with diagnoses including bipolar disease, there was no documentation of a PASARR Level 1 being completed. This resident's care plan and admission MDS indicated the presence of a mental disorder, yet the necessary screening was not conducted as required. Similarly, Resident #46, admitted with schizophrenia and non-Alzheimer's dementia, did not have a PASARR Level 1 completed prior to admission. The screening was only completed 36 days after admission, revealing a major mental illness and necessitating a PASARR Level 2 evaluation. The absence of timely PASARR screenings for these residents indicates a failure to comply with regulatory requirements, potentially impacting the provision of specialized mental health services.
Failure to Revise Care Plan for Fall Intervention
Penalty
Summary
The facility failed to revise a comprehensive person-centered care plan for a resident who required 30-minute checks following a fall. The resident, who had been admitted with diagnoses including Parkinson's disease and bipolar disorder, had a care plan that documented the need for 30-minute checks due to a fall on June 9, 2024. An interdisciplinary team progress note dated June 15, 2024, confirmed the plan for continuous 30-minute checks for increased safety. However, the resident's medical record did not document that these checks were performed. On October 10, 2024, the Director of Nursing acknowledged that the care plan should have been updated and the 30-minute checks should have been removed.
Deficiencies in Resident Transfer and Weight Monitoring
Penalty
Summary
The facility failed to adhere to standard practices during resident transfers and did not follow a comprehensive person-centered care plan to maintain resident body weight. For one resident with major depressive disorder and dementia, a CNA used the resident's belt loop instead of a gait belt during a bed to wheelchair transfer, contrary to the facility's policy that mandates the use of gait belts for safety. Another resident with dementia and diabetes experienced a 5.84% weight loss over a month, but there was no documentation that the medical director was notified of this significant change, as required by the care plan. These deficiencies created the potential for harm or adverse outcomes.
Failure to Provide Call Light Access
Penalty
Summary
The facility failed to ensure that all residents had access to their call lights while in bed, as observed in the case of Resident #5. Resident #5, who was admitted with multiple diagnoses including panic disorder and dementia, had a care plan initiated on 3/17/23 directing staff to keep his call light button within reach. On 10/8/24, it was observed that Resident #5 was in bed without access to his call light, which was placed across the room on his dresser. Resident #5 reported yelling for help due to pain but was not heard by staff. CNA #3 admitted to forgetting to provide Resident #5 with his call light. The Director of Nursing confirmed that staff should ensure all residents have access to their call lights while in bed.
Deficient Shower Floor Safety
Penalty
Summary
The facility failed to provide safe shower floors for residents using the east shower room, which had the potential to cause harm due to slips or falls. Resident #51, who was admitted with multiple diagnoses including stroke and diabetes, reported that the shower floor was very slippery and he had almost fallen because the anti-slip pads were missing. On observation, it was confirmed that the non-slip strips in the east hall shower room had peeled up and were missing. CNA #2 stated that the non-slip strips had been missing for about two months, and a work order had been submitted, but no action had been taken. The Maintenance Director acknowledged the need to replace the missing non-slip strips. A work order for the non-slip strips was created on 8/15/24, but the strips were not replaced until 10/8/24.
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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