Cascadia Of Boise
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 6000 W Denton St, Boise, Idaho 83704
- CMS Provider Number
- 135146
- Inspections on file
- 20
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cascadia Of Boise during CMS and state inspections, most recent first.
Surveyors found that food items in a resident freezer were not labeled or dated, and a therapy ice pack wrapped in a pillowcase was stored alongside food, leading to contamination. Additionally, ice machines in the kitchen and resident area had visible dark residue, with staff unable to confirm recent cleaning. These deficiencies reflect failures in food storage, labeling, and equipment sanitation.
Three residents with documented serious mental illness or intellectual disability had inaccurate MDS assessments, as staff failed to correctly reflect PASRR findings in the MDS records. The MDS nurse acknowledged the errors after review and interview.
A resident with dementia and mobility issues experienced a fall, after which a fall mat was implemented as an intervention. Although the fall mat was in use and observed by staff, it was not added to the resident's care plan, indicating the care plan was not revised to reflect post-fall interventions.
A nurse administered Insulin Lispro to a resident with diabetes without priming the insulin pen, contrary to manufacturer instructions and professional standards. The nurse believed priming was only necessary for new pens, while facility leadership confirmed it should be done before each use.
Staff did not follow physician's orders for two residents: one with diabetes did not have a repeat blood glucose check after a low reading as required by protocol, and another with ALS and respiratory failure had a urinary catheter in place without a physician's order due to orders not being updated after readmission.
A resident with a seizure disorder and other complex conditions had two rescue seizure medications ordered with unclear and overlapping instructions for use. The orders did not specify which medication should be administered in specific situations, and the Acting DON acknowledged the lack of clarity, increasing the risk of medication errors.
A resident with end stage renal disease and a left arm fistula had a physician's order prohibiting blood pressure measurements on that arm. Despite this, records showed blood pressure was documented as being taken on the left arm multiple times. An RN stated that staff may have inaccurately recorded the site, leading to incorrect documentation in the medical record.
Staff failed to follow infection prevention protocols, including not performing hand hygiene before donning PPE, not changing gloves or performing hand hygiene between peri and wound care, and not wearing a gown during high-contact procedures, as observed during care of multiple residents with complex medical needs.
A resident with paraplegia and diabetes was diagnosed with pneumonitis, but the facility failed to update the care plan to reflect new medical orders for intravenous fluids and antibiotics. Despite the resident's cognitive intactness and a negative urinalysis for UTI, the care plan did not address the resident's fever, elevated heart rate, and cough, as confirmed by the MDS Nurse and DON.
Two residents in an LTC facility were affected by medication order errors. One resident, with a tracheostomy and gastrostomy, received Depakote sprinkles via PEG tube despite an oral order, due to a lack of clarification by an LPN. Another resident received an incorrect Vitamin D dosage due to a physician order entry error, which was not caught by the pharmacist during the monthly review. The DON later clarified the errors.
A resident with multiple diagnoses, including stroke and left hemiparesis, was found without a dressing on an open rash on the left arm, contrary to a physician's order. The order required cleansing and covering the rash with border gauze, to be changed twice a week and as needed. Staff interviews confirmed the oversight, highlighting a failure to follow the prescribed care plan.
A resident with paraplegia and cerebral palsy did not receive a Comprehensive Metabolic Panel (CMP) due to a sample collection error. The facility failed to follow up on the missing test results, despite having a process to track pending laboratory results.
The facility failed to maintain accurate clinical records for two residents, leading to potential communication issues. One resident's record lacked documentation for the discontinuation of an antibiotic, while another resident's record inaccurately noted a dressing change that was not performed. The DON and an LPN acknowledged these documentation errors.
A resident with a stage 4 pressure ulcer was at risk of infection due to improper wound cleaning by an LPN, who deviated from infection control guidelines by patting the wound in a random pattern. The facility's standards required cleaning from the center outward, which was not followed, as confirmed by the DON and SDC/IP.
Improper Food Storage and Ice Machine Sanitation
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of food items in a resident freezer, as well as the cleanliness of ice machines. In the Alpine Resident freezer, undated lemon ices, a frozen yogurt, and a frozen entrée meal were found without resident names or dates. Additionally, a therapy ice pack wrapped in a pillowcase was stored on the top shelf of the freezer, which staff acknowledged should not have been present and resulted in contamination of the food items. The Certified Dietary Manager (CDM) was unaware that non-food items were being stored in the resident freezer, despite a policy in place regarding food storage. Further observations revealed that ice machines in both the kitchen and the Alpine ice room had a dark residue on the interior portion of the white plastic ice separator. Both the Registered Dietitian (RD) and a Registered Nurse (RN) confirmed the presence of the residue and stated that the machines are supposed to be cleaned regularly, but were unsure of the last cleaning date. These findings indicate lapses in food safety practices, including improper food labeling, storage of non-food items with food, and inadequate cleaning of food-contact equipment.
Inaccurate MDS Assessments Related to PASRR Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, as determined through record review and staff interviews. For one resident with chronic respiratory failure, anxiety, panic disorder, and depression, both PASRR Level I and II assessments documented serious mental illness, but the Annual MDS assessment incorrectly indicated that the resident was not considered to have a serious mental illness or intellectual disability. The MDS nurse acknowledged the assessment was inaccurate after reviewing the documentation. Another resident with spastic quadriplegic cerebral palsy, chronic respiratory failure, and epilepsy had a PASRR Level I indicating an intellectual disability, but the Admissions MDS assessment incorrectly answered 'no' to the presence of a serious mental illness or intellectual disability. Similarly, a third resident with quadriplegia, depression, and anxiety had a PASRR Level II documenting severe mental illness, but the comprehensive MDS assessment did not reflect this. In each case, the MDS nurse confirmed the assessments were completed inaccurately due to misunderstanding of PASRR documentation requirements.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect post-fall needs. A resident with multiple diagnoses, including a broken leg, muscle weakness, and dementia, experienced an unwitnessed fall from bed. Following the incident, a fall assessment and interdisciplinary review were completed, and interventions such as a fall mat and keeping the bed in the lowest position were implemented. However, although the fall mat was observed in use and was identified as an intervention in the fall assessment, it was not documented in the resident's care plan. Staff interviews confirmed that the fall mat, while present in the resident's room, was not included in the care plan as required. The care plan did include other fall risk precautions, such as keeping the door open, locking bed brakes, and ensuring the resident was out of the room when in a wheelchair, but failed to reflect the addition of the fall mat. This omission indicated that the care plan was not properly updated to address the resident's post-fall needs.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to prime an insulin pen prior to administering Insulin Lispro to a resident with diabetes, as observed during medication administration. The resident had a physician's order for Insulin Lispro 100 unit/ml, with instructions to inject two units subcutaneously before meals. During the observed administration, the nurse replaced the needle and sanitized the pen but did not prime it, stating that priming was only necessary for new pens. The Acting Director of Nursing later clarified that the insulin pen should be primed before each use. According to the Insulin Lispro manufacturer’s instructions, priming is required before every injection to ensure accurate dosing.
Failure to Follow Physician's Orders for Blood Glucose Monitoring and Catheter Use
Penalty
Summary
The facility failed to follow professional standards of practice by not adhering to physician's orders for three residents. For one resident with diabetes, there was a physician's order to check blood glucose levels for hypoglycemic or hyperglycemic symptoms and to follow a specific hypoglycemic protocol if blood glucose was less than 70 mg/dL. The resident's medical record showed a blood glucose reading of 50 mg/dL, but staff did not retake the blood glucose 15 minutes later as required by the protocol. A staff member confirmed that the hypoglycemic protocol was not followed in this instance. Another resident with multiple diagnoses, including amyotrophic lateral sclerosis and respiratory failure, was observed to have a urinary catheter on several occasions. However, a review of the resident's physician's orders did not show any order for a urinary catheter. The Acting DON stated that the physician's orders were not updated upon the resident's readmission due to multiple admissions and unforeseen circumstances, resulting in the resident having a catheter without a corresponding physician's order.
Failure to Clarify Rescue Seizure Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders were properly clarified for a resident with multiple complex diagnoses, including spastic quadriplegic cerebral palsy, seizure disorder, and congenital hydrocephalus. Record review revealed that the resident had two physician orders for rescue seizure medications—Nayzilam (midazolam) and Valtoco (diazepam)—with overlapping but not clearly differentiated instructions regarding when each should be administered. The orders did not specify which medication to use under specific seizure circumstances, leading to unclear direction for staff. During staff interview, the Acting DON confirmed that the directions for administering these medications were not clear and required clarification to prevent medication errors or overmedication.
Inaccurate Documentation of Blood Pressure Site for Dialysis Patient
Penalty
Summary
The facility failed to ensure that a resident's medical records contained accurate documentation regarding vital signs. Specifically, a resident with multiple diagnoses, including high blood pressure and end stage renal disease requiring dialysis, had a physician's order stating that blood pressure should not be taken on the left arm, which had a fistula. Despite this order, documentation showed that blood pressure was recorded as being taken on the left arm on multiple occasions. During an interview, a registered nurse acknowledged that while nurses are aware not to take blood pressure from a fistula arm, they may have inaccurately documented the site, recording the left arm when they actually used the right arm. This resulted in inaccurate documentation in the resident's medical record.
Failure to Implement Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices as observed during care provided to multiple residents. In one instance, a respiratory therapist entered a resident's room, donned personal protective equipment (PPE) without performing hand hygiene beforehand, and then proceeded to provide care involving cleaning and suctioning. The therapist acknowledged afterward that hand hygiene should have been performed prior to donning PPE. In another case, a licensed nurse performed peri care and then transitioned to wound care for a resident without changing gloves or performing hand hygiene between the two tasks. The nurse later confirmed that gloves should have been changed and hand hygiene performed when moving between different body sites and after peri care. Additionally, a respiratory therapist was observed providing endotracheal suctioning to a resident under Enhanced Barrier Precautions without wearing a gown, despite signage indicating that both gloves and a gown were required for such high-contact activities. The therapist admitted that a gown should have been worn during the procedure. These lapses in infection control practices were identified through direct observation and staff interviews, and were not in accordance with CDC guidance for hand hygiene and use of PPE.
Failure to Update Care Plan for Resident with Pneumonitis
Penalty
Summary
The facility failed to develop a comprehensive resident-centered care plan for a resident diagnosed with pneumonitis. The resident, who was admitted with multiple diagnoses including paraplegia and diabetes mellitus, was cognitively intact according to a quarterly MDS assessment. On a specific date, a physician's assistant noted a diagnosis of pneumonitis versus urinary tract infection, and the resident's urinalysis result was negative for a urinary tract infection. Despite these findings, the resident's care plan did not reflect the new orders for intravenous fluids and Rocephin, an antibiotic, which were documented in the nursing progress notes. Interviews with the MDS Nurse and the Director of Nursing confirmed that the care plan should have been updated to reflect the resident's change in condition, which included fever, elevated heart rate, and cough. The absence of an updated care plan placed the resident at risk of unmet care needs, as the care plan did not address the resident's current medical condition and treatment requirements.
Medication Order Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medication orders were written accurately per current standards of practice, affecting two residents. Resident #71, who had multiple diagnoses including tracheostomy, dementia, and gastrostomy, was ordered to receive Depakote sprinkles orally, despite being NPO and requiring medications to be administered via a PEG tube. The LPN administering the medication did not clarify the route with the physician, and the RCM acknowledged the error upon review. The DON confirmed that the nurse should have verified the order before administration. Resident #52, with diagnoses including fibromyalgia and dysphasia, was affected by an incorrect medication order for Vitamin D. The order incorrectly stated a dosage of 2,000 mg instead of the correct 50 mcg/2,000 IU. The LPN administered the incorrect dosage based on the erroneous order, and the DON later clarified the mistake. Additionally, the pharmacist failed to identify the error during the monthly medication regimen review, and the expired order for Vitamin D was not discontinued as it should have been.
Failure to Follow Physician's Order for Dressing Changes
Penalty
Summary
The facility failed to follow a physician's order regarding dressing changes for a resident with a rash on the left arm. The resident, who was admitted with multiple diagnoses including stroke, acute respiratory failure with hypoxia, and left hemiparesis and hemiplegia, was documented as severely cognitively impaired. A physician's order dated August 6, 2024, required the staff to cleanse the resident's open rash with wound cleanser, cover it with border gauze, and change the dressing two times a week and as needed. However, observations on August 7, 2024, revealed that the resident did not have a dressing on the left arm at two different times during the day. Interviews with staff confirmed the deficiency. An LPN confirmed that the resident was supposed to have a dressing on the left arm, which should be changed as per the physician's order. The LPN also confirmed that if the dressing came off, it should be redressed. The Director of Nursing stated that if the dressing came off, it was to be redressed. Despite these acknowledgments, the resident was observed without a dressing, indicating a failure to adhere to the physician's order, which created the potential for infection to spread to the resident's open areas.
Failure to Obtain Physician-Ordered Laboratory Test
Penalty
Summary
The facility failed to obtain physician-ordered laboratory testing for a resident, specifically a Comprehensive Metabolic Panel (CMP). The resident, who was admitted with diagnoses including paraplegia and cerebral palsy, had physician orders for three laboratory tests: a Complete Blood Count (CBC), a Comprehensive Metabolic Panel (CMP), and a Urinalysis with Culture and Sensitivity (UA with C&S). While the results for the CBC and UA with C&S were present in the resident's record, the CMP results were missing. The deficiency was identified when the Director of Nursing (DON) was informed that the CMP results were not received. Upon investigation, it was discovered that the blood sample for the CMP was collected in the wrong type of tube, preventing the test from being conducted. The facility had a process in place to track pending laboratory results, discussed during morning clinical meetings, but failed to follow up on the missing CMP results, leading to the deficiency.
Inaccurate Clinical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, leading to potential communication failures among the interdisciplinary team. For one resident, the clinical record did not include documentation regarding the discontinuation of an antibiotic, daptomycin, which was initially prescribed for MRSA urosepsis. The Director of Nursing (DON) failed to document the infectious disease physician's order to discontinue the antibiotic after 48 hours, which was an oversight acknowledged by the DON. For another resident, the clinical record inaccurately documented that a dressing change had been completed when it had not. The resident, who was severely cognitively impaired, was observed without a dressing on his left arm, despite a progress note indicating that the dressing had been applied. The LPN responsible for the documentation admitted to not performing the dressing change and acknowledged the error. The DON emphasized the expectation for nurses to perform treatments as ordered and document them accurately after completion.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during a wound care dressing change for a resident with a stage 4 pressure ulcer. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure, dementia, and a stage 4 pressure ulcer on the sacral region, was dependent on a gastric tube for nutrition and had a tracheostomy. The physician's order required daily cleansing and dressing of the wound on the resident's right buttock. However, during an observation, an LPN was seen cleaning the wound by patting it with gauze in a random pattern, moving from areas outside the wound to inside the wound bed, which increased the risk of contamination. The facility's competency guidelines and Lippincott's nursing standards of practice both directed that wound cleaning should be performed from the center of the wound outward in concentric circles to prevent contamination. Despite these guidelines, the LPN did not follow the correct procedure, as confirmed by their statement of uncertainty about the cleaning method used. The DON and the SDC/IP both reiterated that the correct procedure was to clean from the inside of the wound to the outer region. This deviation from established infection control practices placed the resident at an increased risk of infection.
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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