Cascadia Of Lewiston
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Idaho.
- Location
- 2852 Juniper Drive, Lewiston, Idaho 83501
- CMS Provider Number
- 135145
- Inspections on file
- 14
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Cascadia Of Lewiston during CMS and state inspections, most recent first.
Two residents experienced significant medication errors when staff failed to follow established medication administration protocols. One resident received medications through a J-tube instead of by mouth, resulting in a clogged tube that required surgical replacement. Another resident was found with two Fentanyl patches applied instead of one, after a nurse failed to remove the previous patch before applying a new one. Both incidents involved failures to verify medication orders and adhere to the eight rights of medication administration.
Surveyors found that kitchen staff failed to consistently label, date, and properly seal opened food items in both the walk-in freezer and refrigerator. Thick ice buildup, undated and unsealed foods, and expired items were observed, with staff confirming that labeling was sometimes skipped and the freezer door was not always fully closed, resulting in freezer burn and potential food safety issues.
Staff did not consistently rinse and store nebulizer mouthpieces after use for multiple residents with respiratory conditions, leaving the equipment on bedside tables or machines instead of following proper cleaning and storage procedures. Interviews with staff confirmed that the required process was not followed, despite physician orders for inhaled medications and established facility policy.
Several residents reported that meals lacked flavor, were sometimes too salty or bland, and were served at improper temperatures or with unappetizing appearance. A test tray review by surveyors, a CNA, and the CEO confirmed issues with cold, hard bread, mushy and discolored broccoli, and a dessert served too warm. The Kitchen Manager attributed some problems to the use of frozen vegetables and extended holding times.
Two residents with COPD were found to be self-administering inhalers without documented assessments by the interdisciplinary team, as required by facility policy. Staff confirmed that neither resident had been evaluated for their ability to safely self-administer medication, and physician orders did not specify that inhalers could be kept at bedside.
A resident with impaired vision and nutritional deficiency was not provided effective assistance in making meal selections, resulting in her receiving the same unwanted breakfast daily despite repeated requests for alternatives. Staff failed to document her dietary preferences or ensure she could participate in menu choices, and key personnel were unaware of the issue.
A resident with COPD and heart failure reported missing cash, but the facility did not fully document its investigation, omitting staff interviews, the police report, and a summary of findings. Although other residents were interviewed and police were involved, the investigation remained incomplete due to missing documentation and an inconclusive outcome.
The facility failed to ensure a licensed pharmacist reviewed each resident's medications monthly and that the physician addressed medication irregularities. Two residents' records lacked documentation of Drug Regimen Reviews for March and April 2024, and there was no evidence of physician review of the Pharmacy Consultant's recommendations. Staff interviews revealed a lack of a system to ensure physician follow-up and a miscommunication regarding the new CNO.
The facility failed to securely store diabetic kits in residents' rooms, left a medication cart unlocked and unattended, and inconsistently documented medication refrigerator temperatures. Staff acknowledged issues with locking the kits and maintaining consistent temperature logs.
The facility failed to maintain infection control practices for nine residents requiring Enhanced Barrier Precautions (EBP). Despite physician orders, there were no signs or PPE available in or near the residents' rooms. Staff were unaware or inadequately trained on EBP, and the necessary information was not listed in the residents' electronic medical records. The CNO and CRN confirmed the lack of implementation of EBP measures.
The facility failed to provide necessary education about the pneumococcal vaccine to newly admitted residents before they refused the vaccine. Five residents signed the Vaccine Information Acknowledgement form without receiving the required Vaccine Information Sheet (VIS), as confirmed by staff interviews.
The facility failed to properly investigate and resolve grievances from two residents, leading to incomplete documentation and unresolved concerns about medication errors and inappropriate staff behavior.
The facility failed to report allegations of abuse to the State Survey Agency within the required timeframe. A resident reported multiple grievances against an LPN, including verbal abuse and medication errors, but these were not properly investigated or reported, creating the potential for ongoing abuse.
The facility failed to recognize, report, and investigate abuse allegations documented on grievance forms by a resident. The resident reported incidents involving an LPN being rude, dismissive, and potentially retaliatory, including dismissing concerns about a swollen incision and attempting to give the wrong medication. These grievances were not investigated for abuse, contrary to the facility's policy.
The facility failed to provide a written transfer notice to a resident, their representative, and the Office of the State Long-Term Care Ombudsman prior to transferring the resident to the hospital for a cardiac evaluation. Interviews confirmed that the facility was not following its policy for sending such notices.
The facility failed to provide a bed hold notice to a resident or their representative upon transfer to the hospital for a cardiac evaluation. Staff interviews confirmed that the facility was not following its policy to issue written bed hold notices for hospital transfers.
The facility failed to develop baseline care plans within 48 hours of admission for two residents with End Stage Renal Disease, omitting necessary dialysis care. This was confirmed by staff reviews and interviews, highlighting a significant lapse in ensuring immediate care needs were addressed.
The facility failed to develop and implement a comprehensive care plan for a resident requiring dialysis, despite specific physician's orders. Interviews with staff confirmed the absence of a dialysis care plan, which is against the facility's policy.
The facility failed to follow physician orders for bowel care for a resident, resulting in a six-day delay in bowel movement management. Despite the resident's reports and the facility's protocol, the prescribed interventions were not administered timely, leading to prolonged discomfort and potential complications.
The facility failed to maintain accurate and complete clinical records for a resident with multiple diagnoses, including syncope and systemic lupus erythematosus. Medications were documented as administered by an LPN who did not enter the resident's room, while another nurse actually administered the medications, violating the facility's medication administration policy.
Significant Medication Errors Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with a history of stomach cancer and a surgically placed J-tube was admitted with orders specifying that medications should be given by mouth. Despite this, nursing staff administered medications through the J-tube, which led to the tube becoming clogged. The resident required transfer to the emergency room, where it was confirmed that the medications had been given via the incorrect route, necessitating surgical replacement of the J-tube. The facility's review found that the admission orders were not properly clarified, and staff did not verify the correct route of administration as required by the facility's medication administration procedure. In the second incident, another resident with multiple diagnoses, including fractures and lymphoma, was found to be wearing two Fentanyl transdermal patches instead of the ordered single patch. The error was discovered during a review, and it was determined that an agency nurse had applied a second patch without removing the first, failing to follow the facility's protocol for medication administration. The physician was notified, and the resident was monitored for signs of oversedation. Both incidents demonstrate failures by nursing staff to adhere to the facility's established procedures for verifying medication orders and following the eight rights of medication administration.
Improper Food Storage, Labeling, and Sealing in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, and sealing of food items. During a kitchen tour, thick layers of ice and ice crystals were found on food racks and boxes in the walk-in freezer, with the ceiling also showing ice buildup. Several food items, including jam, blueberries, dinner bread, carrots, tater tots, and chicken patties, were found opened, not sealed properly, and lacking date labels. In the walk-in refrigerator, opened and plastic-wrapped stacks of cheese, salad dressings, broccoli, mayonnaise, ranch dressing, and milk were also found either past their use-by dates, opened and undated, or not sealed correctly. Additionally, a box of diced potatoes with visible freezer burn was found in the freezer, and the kitchen manager acknowledged that food should be labeled and sealed after opening. Staff interviews revealed that dates were sometimes not written on opened packages if they were expected to be used the same day. The kitchen manager also confirmed that the freezer door may not always be closed properly, leading to thawing and refreezing of foods near the door. These observations and staff statements indicate that the facility did not consistently follow its own policies or the Idaho Food Code requirements for labeling, dating, and properly storing food items.
Failure to Properly Clean and Store Nebulizer Mouthpieces
Penalty
Summary
Facility staff failed to properly rinse and store nebulizer mouthpieces after each use for five residents with various respiratory conditions, including COPD, emphysema, and acute respiratory failure. Observations revealed that nebulizer mouthpieces were left on top of nebulizer machines or bedside tables, rather than being rinsed, air dried, and stored in a clean plastic bag as required by facility policy and best practice guidelines. In several instances, staff confirmed during interviews that the correct procedure was not followed. Residents affected had physician orders for inhaled medications via nebulizer, and staff, including LPNs, CNAs, and the Infection Preventionist, acknowledged that the mouthpieces should have been rinsed and stored appropriately after each use. Documentation and interviews indicated that the failure to follow proper cleaning and storage procedures was consistent across all observed cases, placing residents at risk for respiratory infection due to potential pathogen growth in the equipment.
Failure to Provide Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature, as required by its Food Preparation policy. Multiple residents reported dissatisfaction with the food, citing issues such as lack of flavor, excessive saltiness, bland taste, and unappetizing appearance. Some residents noted that food intended to be hot was sometimes served cold, and one resident's family member began taking him home for meals due to dissatisfaction. Another resident stated that while the food tasted good, its appearance was so poor it would be unappetizing to others. A test tray evaluation conducted by surveyors, a CNA, and the CEO revealed that while the main dish was at an appropriate temperature, the French bread was cold and hard, the broccoli was mushy, discolored, and unpalatable, and the chocolate pie was too warm and melting. The CEO confirmed the poor quality of the broccoli. The Kitchen Manager stated he had not received grievances regarding food temperature or palatability but acknowledged that the use of frozen broccoli and prolonged time in the heating table likely contributed to the poor quality.
Failure to Assess Residents for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their ability to safely self-administer medications, as required by facility policy. For two residents with chronic pulmonary disease, both were found to have inhalers at their bedside and were self-administering these medications without a documented assessment by the interdisciplinary team to determine if this practice was safe. In one instance, a medication assistant was about to administer an inhaler when the resident stated she had already used it, and the staff member acknowledged forgetting that the resident had the inhaler at her bedside. Review of the resident's record confirmed that no assessment for self-administration had been completed. In another case, a resident was observed with an inhaler on his overbed table and reported using it twice daily. Upon review, staff confirmed that the physician's order did not specify that the resident could keep the inhaler in his room, and there was no assessment on file to support self-administration. Both the nurse manager and the chief nursing officer confirmed that neither resident had been assessed for their ability to self-administer medication, contrary to facility policy and procedure.
Failure to Accommodate Visually Impaired Resident's Food Choices
Penalty
Summary
The facility failed to promote and facilitate a resident's ability to make food choices, as required by resident rights policies. A resident with macular degeneration and nutritional deficiency, who was cognitively intact but visually impaired, was not provided effective assistance in selecting meals. Although the resident was given a menu, she could not read it due to her blindness and reported that no one offered to help her fill it out. She stated she had been served eggs every morning since admission despite requesting alternatives multiple times. There was no documentation in her medical record regarding her dietary preferences. Interviews with facility staff revealed that the Registered Dietician was unaware that the resident's meal choices had not been assessed, and the Dietary Manager could not locate the resident's menu choices for the week. The facility's process relied on residents, family, or staff to assist with menu selection, but in this case, the process failed, and the resident's preferences were not accommodated. The lack of assistance and documentation led to the resident repeatedly receiving unwanted meals.
Failure to Document Thorough Investigation of Resident Grievance
Penalty
Summary
The facility failed to thoroughly investigate a grievance regarding missing cash belonging to a resident with chronic pulmonary disease and congestive heart failure. The resident's representative reported the missing money, but neither the resident nor the representative could specify the amount lost. The facility conducted a search for the money and interviewed other residents, none of whom reported missing items. The resident's representative requested police involvement, and law enforcement conducted interviews. However, the facility's documentation of the investigation was incomplete, lacking staff interview records, the police report, and a summary of the investigation's conclusion. During interviews, facility leadership acknowledged that staff interviews were conducted but not documented, and they did not have a copy of the police report at the time of the survey. The police report, later obtained, indicated that determining the whereabouts of the missing money was unlikely due to the number of visitors and absence of cameras. The investigation was left inconclusive, and the resident did not wish to pursue the matter further. The facility's failure to document all investigative steps and provide a summary of findings constituted a deficiency in responding to the grievance.
Failure to Ensure Monthly Drug Regimen Reviews and Physician Follow-Up
Penalty
Summary
The facility failed to ensure a licensed pharmacist reviewed each resident's medications at least monthly, and the physician/prescriber addressed the medication irregularities identified by the pharmacist. This deficiency was observed in two residents, one with Alzheimer's Disease and another with multiple diagnoses including a craniotomy, major depressive disorder, and anxiety disorder. Both residents' records lacked documentation of a Drug Regimen Review (DRR) by the Pharmacy Consultant for the months of March and April 2024. Additionally, the Medication Regimen Reviews (MRRs) that included recommendations from the Pharmacy Consultant did not show evidence of review by the physician. Interviews with staff revealed that the facility's process involved notifying the Pharmacy Consultant of new admissions, especially those on psychoactive medications, for an Interim Drug Regimen Review within 24 hours. However, the facility did not have a system in place to ensure the physician reviewed the recommendations made by the Pharmacy Consultant. Furthermore, the Clinical Pharmacist indicated that the pharmacist responsible for the MRRs was unaware of a change in the Chief Nursing Officer (CNO) and sent the reviews to the wrong CNO, contributing to the oversight.
Failure to Secure Diabetic Kits and Medication Cart, and Inconsistent Temperature Documentation
Penalty
Summary
The facility failed to ensure that diabetic kits containing insulin injector pens, needles, glucometers, alcohol wipes, and cotton balls were securely stored in the rooms of five diabetic residents. These kits were observed to be unlocked, contrary to the facility's policy that required them to be locked and maintained in the residents' rooms. Staff interviews revealed that there was an issue with securely locking these kits, and it was decided to remove all sharps from the kits to ensure resident safety. Additionally, a medication cart was found unlocked and unattended in front of a resident's room, which was acknowledged by the responsible nurse as an oversight due to being in a hurry to administer medication. The Chief Nursing Officer (CNO) confirmed that it was an expectation for the medication cart to always be locked when not in use by the nurse. Furthermore, the facility failed to consistently document the daily temperatures of the medication refrigerator in the central medication room. The temperature logs showed significant gaps in recording for several months, with temperatures recorded on only a fraction of the days in each month. The Clinical Resource Nurse (CRN) stated that night nurses were responsible for checking and documenting the refrigerator temperatures daily, but this was not consistently done. The CRN confirmed that no medications were stored in the freezer, so freezer temperatures were not recorded.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was observed in nine residents who required Enhanced Barrier Precautions (EBP) due to conditions such as wounds, indwelling medical devices, and multidrug-resistant organism (MDRO) colonization. Despite physician orders and care plans indicating the need for EBP, there were no signs on the residents' doors to alert staff and visitors, and no personal protective equipment (PPE) was available in or near the residents' rooms. This failure was noted for residents with conditions including Type 2 Diabetes with a Foot Ulcer, Acute Cystitis with Hematuria, End Stage Renal Failure, MRSA Infection, and infection due to an internal right hip prosthesis, among others. During observations, it was found that staff were not adhering to the facility's policy on EBP. For instance, Resident #133, who had a diabetic foot ulcer and a history of MRSA, did not have the required signage or PPE available. Similar deficiencies were noted for other residents with various medical conditions requiring EBP. Interviews with staff revealed a lack of awareness and training regarding EBP. LPN #1 and RN #1 were either unaware of the residents on EBP or unsure of what EBP entailed. The Infection Preventionist (IP) confirmed that the necessary information was not listed in the residents' electronic medical records (EMR), and the required signs and PPE were not in place. The Chief Nursing Officer (CNO) and the Clinical Resource Nurse (CRN) acknowledged that staff were supposed to initiate EBP for residents meeting the criteria. They confirmed that PPE supplies should be located in or near the resident rooms and that appropriate signage should be posted. However, these measures were not implemented, and staff were not adequately informed about the updated transmission-based precautions policy. This lack of adherence to infection control protocols had the potential to impact all residents in the facility by placing them at risk for cross-contamination and infection.
Failure to Provide Pneumococcal Vaccine Education
Penalty
Summary
The facility failed to ensure newly admitted residents were provided education for pneumococcal vaccines prior to refusing the vaccine. This deficiency was identified for five residents who did not receive the necessary Vaccine Information Sheet (VIS) before signing the Vaccine Information Acknowledgement form. The facility's policy, revised on 5/31/23, required that residents or their advocates be educated about the pneumococcal vaccination, including its benefits, potential side effects, and general safety, and be provided with a copy of the VIS. However, the review found that the VIS was not provided to the residents during the admission process, leading to uninformed refusals of the vaccine by the residents involved. Specific instances included residents who were admitted or readmitted to the facility and subsequently signed the Vaccine Information Acknowledgement form without receiving the VIS. The Infection Preventionist (IP) and other staff confirmed during interviews that the VIS was not provided to residents at the time of signing the form. This oversight was acknowledged by the Chief Nursing Officer (CNO) and the Clinical Resource Nurse (CRN), who confirmed that the VIS should have been provided prior to the residents signing the form. This failure to provide necessary vaccine education created the potential for harm should residents contract pneumococcal pneumonia and experience illness from pneumonia.
Failure to Properly Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure grievance concerns and/or complaints were thoroughly investigated and resolved to the satisfaction of the complainant without fear of reprisal. Resident #7, who was cognitively intact, submitted a grievance on 3/24/24 regarding an incident where an LPN attempted to give her the wrong medication. The grievance was not included in the facility's Grievance Log, and the form was found incomplete in the LPN's personnel file. The Social Services representative and the Chief Nursing Officer (CNO) confirmed that the grievance was not followed up on, and no resolution was identified or documented. Resident #143, also cognitively intact, filed a grievance on 12/8/23 concerning inappropriate conversations by two LPNs regarding her use of pain medication. The grievance form documented that the Unit Manager, CNO, and CEO were notified, and the CNO summarized the incident but did not consider it abuse. The form indicated that staff education was provided, but it lacked the resident's signature confirming satisfaction with the resolution and the CEO's signature indicating the investigation was complete. Resident #143 expressed that the nurses' behavior made her reluctant to request pain medication and felt the incident was abusive. Interviews with the Social Services representative, CNO, Human Resources Director, and CEO revealed that the grievances were not properly followed up on, and the necessary documentation and resolution steps were incomplete. Both residents experienced a lack of thorough investigation and resolution of their grievances, which could lead to feelings of neglect and distress.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of resident abuse to the State Survey Agency within the required 2 to 24-hour timeframe. This deficiency affected one resident who reported multiple grievances against an LPN, including verbal abuse and medication errors. The facility's policy mandates immediate reporting of such allegations to the CEO and the state agency, but this was not followed. The resident, who was cognitively intact, expressed concerns about the LPN's behavior, describing instances of rudeness, dismissiveness, and a medication error that could have led to poisoning. The facility's grievance forms documented the resident's complaints but did not include proper follow-up or investigation for abuse. The CEO acknowledged that the grievances should have been investigated as potential abuse but were not. The failure to report and investigate these allegations as required by the facility's policy and state regulations created the potential for ongoing abuse without detection or protective measures being implemented.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure abuse allegations documented on grievance forms were recognized, reported, and investigated for one resident reviewed for abuse. Resident #7, who was cognitively intact and had multiple diagnoses including syncope and systemic lupus erythematosus, reported feeling that an LPN was rude, dismissive, and potentially retaliatory. The resident's grievance form dated 3/10/24 detailed an incident where the LPN dismissed concerns about a swollen and discolored incision, which later burst. The grievance resolution included follow-up by medical staff and communication education for the LPN, but did not address the potential abuse allegations. Another grievance form dated 3/24/24 from the same resident described an incident where the LPN attempted to give the resident the wrong medication, which the resident recognized before ingestion. The form indicated that the LPN's actions could have led to poisoning, but it was not investigated as abuse. Interviews with the CEO confirmed that the grievances were not investigated for abuse as required by the facility's policy, and the CEO was unaware of the second grievance until the survey. The failure to investigate these grievances as potential abuse created the risk of ongoing abuse without detection or protective measures.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice to a resident, their representative, and the Office of the State Long-Term Care Ombudsman prior to transferring the resident to the hospital. This deficiency was identified for a resident who was admitted with multiple diagnoses, including post-surgical care for a total joint replacement. On a specific date, the resident was transferred to the hospital for a cardiac evaluation due to epigastric pain and a positive troponin level, indicating potential heart damage. However, the resident's record did not include documentation of the required written notification of the transfer. During interviews, the Social Services representative and the Clinical Resource Nurse (CRN) confirmed that the facility was not sending discharge/transfer notices to residents and their representatives for facility-initiated transfers to the hospital. The Social Services representative also stated that the ombudsman was only notified when a resident was discharged from the facility, not when they were sent to the hospital. The CRN acknowledged that the facility was not following its policy, which mandates sending notices for hospital transfers, including notification to the ombudsman.
Failure to Provide Bed Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to ensure a bed hold notice was provided to a resident or their representative upon transfer to the hospital. This was identified for one resident who was transferred to the hospital for a cardiac evaluation due to epigastric pain and elevated troponin levels. The resident's record did not include documentation of a written bed hold notice being provided at the time of transfer. Interviews with facility staff, including the Social Services representative, Resident Care Manager, and CRN, confirmed that bed hold notices were not being sent out for facility-initiated transfers to the hospital. The facility's policy required that a written notice of the bed-hold policy be given to the resident or their representative at the time of transfer, but this procedure was not being followed, indicating a lapse in adherence to the established policy.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours of admission for two residents, which created the potential for harm if the care plan failed to provide direction for care. Resident #84, admitted with multiple diagnoses including End Stage Renal Disease (ESRD), Hypertension, Sepsis, MRSA Infection, and Type 2 Diabetes Mellitus, had a physician order for hemodialysis on specific days. However, the baseline care plan initiated did not include the necessary dialysis care. This omission was confirmed by the MDS Coordinator during an interview, who acknowledged that the baseline care plan should have included dialysis treatment and interventions. Similarly, Resident #26, admitted with End Stage Renal Failure, had a physician order for dialysis every evening on specific days. The baseline care plan for this resident also failed to include dialysis care. This was confirmed by LPN #1 and further reviewed by the CNO and CRN, who acknowledged the absence of a focus or plan of care for dialysis in the 48-hour care plan. Both instances highlight the facility's failure to develop appropriate baseline care plans within the required timeframe, potentially compromising the residents' care.
Failure to Develop and Implement Comprehensive Care Plan for Dialysis
Penalty
Summary
The facility failed to ensure comprehensive resident-centered care plans were developed and implemented for Resident #26. This resident, who was admitted with multiple diagnoses including End Stage Renal Failure requiring dialysis, did not have a care plan that included a focus care area for her dialysis needs. Despite a physician's order detailing the specific requirements for her dialysis treatment, including transportation, meal provisions, and documentation procedures, these were not reflected in her care plan. During interviews, both an LPN and the Chief Nursing Officer (CNO) along with the Clinical Resource Nurse (CRN) confirmed the absence of a dialysis care plan for Resident #26. The facility's Care Plan policy, revised on 10/15/22, mandates the development and implementation of a comprehensive person-centered care plan for each resident, which was not adhered to in this case. This oversight placed Resident #26 at risk of negative outcomes due to the lack of a detailed and actionable care plan for her dialysis treatment.
Failure to Follow Physician Orders for Bowel Care
Penalty
Summary
The facility failed to ensure physician orders for bowel care were followed for a resident, leading to a significant delay in bowel movement management. The facility's protocol required the medication/charge nurse to review CNA flowsheet records for bowel regularity and follow specific physician orders if a resident had not had a bowel movement in 48 hours. Despite this protocol, Resident #7, who was cognitively intact and had multiple diagnoses including syncope and systemic lupus erythematosus, did not receive the prescribed bowel care interventions in a timely manner. The resident reported not having a bowel movement for more than three days and was not offered Milk of Magnesia as per the physician's orders. Instead, the resident was given MiraLAX daily, which was not part of the prescribed regimen for this situation. The resident finally started having bowel movements after six days without one, following the administration of a Dulcolax suppository, which was significantly delayed from the initial physician's orders and facility protocol requirements. The record review and staff interviews confirmed that the physician orders and the facility's bowel care protocol were not followed. The resident's Treatment Administration Record (TAR) and Medication Administration Record (MAR) documented the absence of bowel movements for six consecutive days and the lack of administration of Milk of Magnesia as ordered. The CRN acknowledged that the bowel protocol and physician orders were not implemented as required, leading to the resident's prolonged discomfort and potential risk for complications. This deficiency highlights a critical lapse in following established medical and facility protocols for bowel care management.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to ensure accurate and complete clinical records for Resident #7, who was admitted with multiple diagnoses including syncope and systemic lupus erythematosus. The facility's policy required that the medical record contain an accurate representation of the resident's experiences and responses to treatments. However, on 4/28/24, it was documented that medications were administered by LPN #2, despite Resident #7 stating that LPN #2 did not enter her room and a different nurse administered the medications. This discrepancy was confirmed during an interview with RN #1, who stated that LPN #2 prepared the medications but RN #1 administered them, which was against the facility's medication administration policy that required the same nurse to both administer and document the medication. Further interviews with the CNO and CRN confirmed that the staff did not follow the medication administration policy, which mandates that the nurse who documents the medication as given should be the same nurse who administers it. This failure to adhere to the policy created the potential for harm if inappropriate care and/or treatment was provided to Resident #7.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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