Cherry Ridge Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Emmett, Idaho.
- Location
- 501 West Idaho Boulevard, Emmett, Idaho 83617
- CMS Provider Number
- 135095
- Inspections on file
- 20
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Cherry Ridge Of Cascadia during CMS and state inspections, most recent first.
A resident with chronic kidney disease, morbid obesity, mobility limitations, and multiple active wound care needs was discharged to a homeless shelter without the facility verifying the shelter’s ability to meet ADL and wound care requirements or documenting the receiving setting’s capacity to provide needed care. The resident required supervision/touching assistance for several ADLs and substantial/maximal assistance for bathing, and had documented MASD and a chronic leg ulcer with exposed subcutaneous tissue. The shelter later reported it could not support individuals over 400 lbs, could not provide wound care or mobility assistance, and had not been contacted in advance as required by its medically fragile program. The transport company was informed on arrival that the shelter could not accept the resident, notified the facility, and the resident remained outside the shelter until transported to the ER, while facility staff had believed the resident could perform her own wound care despite the DON stating she could not apply cream to her buttocks without assistance.
A resident with chronic kidney disease, peripheral venous insufficiency, and morbid obesity had an MDS assessment documenting a foot infection and an open foot lesion, but the electronic medical record lacked documentation of wound treatment and the comprehensive care plan did not include any interventions or directions for care of the foot wound. Facility policy and CMS SOM Appendix PP require a person-centered comprehensive care plan to be developed by the IDT within a specified timeframe after assessment, yet the MDS nurse confirmed there was no care plan addressing the foot infection, despite acknowledging that one was required.
A resident with chronic kidney disease, peripheral venous insufficiency, and morbid severe obesity had a comprehensive care plan that documented a desire to remain long term but was not updated to reflect changing discharge planning goals, despite policy and CMS requirements that care plans be revised with changing needs and preferences. The MDS nurse acknowledged that the discharge plan had changed multiple times and admitted she chose not to update the care plan, resulting in a care plan that did not reflect the resident’s current discharge planning needs.
Surveyors identified that an erythromycin ophthalmic ointment and a Trelegy Ellipta inhaler on a medication cart were not labeled with an open date or date of discard. An LPN confirmed uncertainty about the duration of use for the ointment and acknowledged that both medications should have been labeled appropriately.
Surveyors found that the facility did not maintain a pest-free environment, with flies observed throughout the building, full and unemptied fly traps, and several pest control devices unplugged or non-functional. Residents reported being unable to effectively use fly swatters and expressed concern about flies, especially in the dining area. Staff and maintenance practices were inconsistent, and pest control service documentation was incomplete.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Deficiencies were identified in infection control practices, including unsanitary conditions in a shower room with missing grout and visible mold, as well as improper technique during medication administration when an LPN placed injection supplies directly on a sink ledge without a sanitary barrier.
A resident with complex medical and psychiatric conditions was provided THC gummies by two dietary aides after making a joking request. The facility's investigation confirmed the aides' actions through staff interviews, but failed to thoroughly question other residents about the specific incident or drug-related concerns, resulting in an incomplete investigation.
A resident with multiple mental health diagnoses and a documented PASRR Level II was inaccurately coded on the MDS assessment as not having a serious mental illness or intellectual disability. This error was confirmed by facility leadership during the survey.
The facility did not ensure that PASRR Level I screenings accurately documented mental health diagnoses or initiate required Level II evaluations for three residents with conditions such as depression, anxiety, and major depressive disorder. Staff confirmed that screenings were incomplete and referrals to the state-designated authority were not made as required.
The facility did not accurately post daily nurse staffing information, omitting the number of hours worked per shift for RNs, LPNs, and CNAs. This was confirmed by observation and staff interview, with the Staffing Coordinator acknowledging that required hours were not included in the daily postings.
Three residents experienced significant medication errors when an LPN failed to administer or document scheduled doses of morphine, oxycodone, and sliding scale insulin. The errors occurred due to staff oversight and workload, resulting in missed pain and diabetes medications for residents with chronic pain, osteoarthritis, osteoporosis, and type 2 diabetes.
Two CNAs did not have documentation of completing the required 12 hours of annual in-service education, including training in dementia care and abuse prevention. Facility leadership confirmed the absence of these records during the survey.
A resident with multiple sclerosis and Alzheimer's disease suffered fractures after falling from her bed due to staff failing to follow her care plan. The care plan required total assistance for transfers and specific interventions like fall mats and a low bed position. However, the bed was not in the lowest position, and the fall mat was missing, leading to the fall. The facility's investigation found that the CNAs involved did not provide honest or accurate reports and failed to adhere to the care plan.
The facility did not have a registered nurse (RN) on-site for 8 consecutive hours a day, 7 days a week, as required by their policy. This was discovered during a review of the nursing schedule, which showed that on five days, no RN was present for the required duration. The Director of Nursing (DON) was unaware of the need for an RN to be physically on-site, believing that being on-call was sufficient. This oversight potentially affected all 33 residents by leaving their nursing needs unmet.
The facility failed to provide clean equipment for resident care, with observations revealing dusty and soiled Hoyer lifts and mobile blood pressure machines. A CNA acknowledged the presence of dust and dirt, cleaning the equipment upon inspection. The DON confirmed that nursing staff are responsible for cleaning these items after each use.
The facility failed to provide a dignified dining experience for three residents, who were not served their meals or beverages promptly. Despite requests, a resident received a warm Pepsi without ice, which was later rectified by another resident and the Staffing Coordinator. The DON acknowledged staffing issues during mealtime.
A facility failed to provide necessary records during the transfer of a resident with multiple health issues, including diabetes and congestive heart failure, to a hospital. Despite a policy requiring specific information to be sent, there was no documentation of what records were provided. A nursing note indicated a report was given to EMTs and the receiving nurse, but the Clinical Resource Nurse could not find documentation of the records sent.
A resident with moderate persistent asthma was not instructed to rinse her mouth after using a fluticasone propionate inhaler, as observed during a medication pass by an LPN. The physician's order lacked this instruction, which was confirmed by the Clinical Resource Nurse and a pharmacist, creating a potential risk for a mouth infection.
A resident with chronic kidney disease and morbid obesity had a care plan requiring daily weight monitoring and physician notification for significant weight gain. The facility only recorded monthly weights, missing significant increases, and did not notify the physician. The DON considered the care plan a PRN order, leading to non-compliance with the care plan.
The facility failed to conduct necessary AIMS evaluations for two residents on antipsychotic medications, as required every six months. One resident, with schizoaffective disorder, had no AIMS assessments after September 2023, despite being on Depakote and Zyprexa. Another resident, also with schizoaffective disorder, had no assessments after July 2023, while on Zyprexa. This oversight created a potential for harm due to unmonitored adverse side effects.
Failure to Assess and Coordinate Safe Discharge to Homeless Shelter
Penalty
Summary
The deficiency involves the facility’s failure to consider the availability, capacity, and capability of a caregiver/support setting to meet a resident’s care needs prior to discharge. The facility’s policy required that information necessary to meet a resident’s needs be provided upon transfer, but for one resident with chronic kidney disease, morbid obesity (BMI >70), muscle weakness, difficulty walking, anxiety/adjustment disorders, and multiple active wound care orders, this did not occur. A Discharge MDS documented the resident was cognitively intact but required supervision/touching assistance for eating, hygiene, dressing, toileting, and footwear, and substantial/maximal assistance for bathing. The TAR and wound care note showed ongoing wound care needs, including a chronic ulcer with exposed subcutaneous tissue and MASD requiring topical treatment, and documented that refusal of care and garments could lead to unhealable wounds, sepsis, and death. The discharge evaluation noted a follow-up medical appointment but the record lacked a referral to a wound care clinic, documentation that the receiving setting could meet ADL or wound care needs, and a signed discharge plan. The resident was discharged to a homeless shelter without prior contact from the facility to verify the shelter’s ability to meet her care needs. The homeless shelter’s case manager reported their cots could not support individuals over 400 lbs and that they could not provide wound care or mobility assistance, and confirmed the facility had not contacted them before dropping off the resident. The shelter’s medically fragile program requirements specified that individuals must be independent with ADLs, that LTC facilities must provide advance notification to verify bed availability and care capability, and that an in-person assessment is required prior to acceptance. Transportation records showed the resident was offloaded at the shelter, which then informed the driver they could not accept her; the transport company left a message for the facility and later informed the facility that the shelter could not accept the resident, but the facility did not request the resident be returned. The resident remained outside the shelter until transported to the ER. The Social Services Director stated she did not notify the shelter because it was a homeless shelter and did not refer the resident to a wound clinic because she believed the resident could perform her own care, while the DON stated the resident could not apply cream to bilateral buttocks without assistance. Cross-references were made to F656 and F657.
Failure to Develop Comprehensive Care Plan for Foot Infection
Penalty
Summary
Surveyors found that the facility failed to ensure a resident-centered, comprehensive care plan was written to address an identified foot infection and open foot lesion. CMS SOM Appendix PP requires each resident to have a person-centered comprehensive care plan that addresses medical, physical, mental, and psychosocial needs, and the facility’s RAI & Comprehensive Care Plans policy requires the IDT to develop such a plan within 7 days of completing the comprehensive assessment. Resident #1, who had multiple diagnoses including chronic kidney disease, peripheral venous insufficiency, and morbid obesity, had a Quarterly MDS assessment documenting an infection of the foot and another open lesion on the foot. Despite this, the resident’s electronic medical record did not contain documentation indicating treatment for wounds, and the care plan initiated and later revised did not include any directions for care of the foot wound or infection. During interview, the MDS nurse confirmed that the resident did not have a care plan for the foot infection and acknowledged that there should have been one. This deficient practice was cited for 1 of 3 residents whose care plans were reviewed and was noted by surveyors as creating the risk of adverse outcomes if comprehensive care plans did not reflect the necessary care for each resident.
Failure to Update Care Plan for Changing Discharge Planning Needs
Penalty
Summary
The facility failed to ensure a resident’s comprehensive care plan was revised to reflect current discharge planning needs and goals as required by CMS SOM Appendix PP and the facility’s RAI & Comprehensive Care Plans Policy and Procedure. The policy, revised on 9/3/25, required that the care plan reflect discharge planning goals, and CMS guidance required review and revision of the care plan after each assessment based on changing goals, preferences, and needs. Resident #1, initially admitted and later readmitted with multiple diagnoses including chronic kidney disease, peripheral venous insufficiency, and morbid severe obesity, had a care plan initiated on 3/1/24 and revised on 9/29/25 that documented the resident wanted to stay at the facility long term. However, the care plan was not updated to include current discharge planning that reflected the resident’s evolving goals, preferences, and care needs. During an interview on 2/3/25 at 2:00 PM, the MDS Nurse acknowledged that there was no updated care plan reflecting discharge planning and stated that because the resident’s discharge plan kept changing, she chose not to update the care plan. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents’ needs changed.
Medications Not Properly Labeled or Dated on Medication Cart
Penalty
Summary
During a medication cart inspection, surveyors found that certain medications available for residents were not labeled or dated as required. Specifically, an erythromycin ophthalmic ointment and a Trelegy Ellipta inhaler were discovered without an open date or date of discard. When interviewed, an LPN stated she was unsure how long the ophthalmic ointment was good for and acknowledged that both medications should have been labeled with the open date. This issue was identified on one of two medication carts inspected.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain a pest-free environment and implement an effective pest control program, as evidenced by multiple observations of flies throughout the building and inadequate maintenance of pest control devices. Surveyors observed full fly traps hanging outside the facility, fly swatters in most resident rooms, and flies landing on residents' food in the dining room. Several pest control devices, such as air curtains and insect catchers, were found unplugged, turned off, or non-functional, with some traps full and not emptied for several weeks. The Director of Maintenance confirmed that some devices had not been operational for an extended period and that exterior fly traps had not been emptied in 6-8 weeks. Documentation of pest control services was incomplete, with no record for one of the months reviewed. Residents reported being offered fly swatters, but many were unable to use them effectively and expressed concern about the presence of flies, particularly in the dining area. During a Resident Council meeting, residents indicated they were unaware of the facility's pest control measures and noted that outdoor fly traps appeared full. Staff were observed entering and exiting the facility without ensuring air curtains were functioning, further contributing to the pest issue. The deficiency was identified through direct observation, record review, and interviews with residents and staff.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Infection Control Deficiencies in Shower Room Sanitation and Medication Administration
Penalty
Summary
The facility failed to implement effective infection control practices in two key areas: shower room sanitation and medication administration. During an inspection of a shower room with the Director of Maintenance, it was observed that the shower floor lacked grout between the tiles, creating uneven and potentially unsanitary conditions. Black mold-like substances were visible along the bottom edges of the shower walls, and an adhesive trim on the lower portion of the shower walls was peeling away, with additional black mold-like material found underneath. The Director of Maintenance confirmed the lack of grouting contributed to the unsanitary environment. Additionally, the CEO stated there was no log of who was responsible for cleaning the shower rooms, although they should be cleaned daily. During a medication administration observation, an LPN was seen preparing a subcutaneous injection. After performing hand hygiene and gathering supplies, the LPN placed the injectable pen and alcohol wipes directly on the sink ledge without using a sanitary barrier. She then washed and dried her hands, applied gloves, and administered the injection. The LPN later acknowledged that a paper towel should have been used as a barrier instead of placing the supplies directly on the sink. These actions demonstrate lapses in infection control protocols during both environmental cleaning and direct resident care.
Incomplete Investigation of Abuse Allegation Involving Psychoactive Substance
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with multiple diagnoses, including schizophrenia, auditory hallucinations, and chronic pain syndrome. The incident involved two dietary aides who provided the resident with THC gummies on two separate occasions after the resident had jokingly requested them. The facility's investigation included interviews with the involved resident and two unidentified dietary staff, both of whom confirmed the aides' actions. Additionally, three other residents were interviewed, but they were only asked general safety questions and not specifically about the incident or drug-related concerns. The investigation substantiated the allegation, as evidenced by the termination of the two dietary aides. However, the investigative process was incomplete because resident interviews did not address the specific incident or related drug concerns, limiting the scope and thoroughness of the inquiry. This incomplete approach created the potential for undetected harm due to the lack of comprehensive investigative procedures.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment, specifically in Section A1500 regarding PASRR (Preadmission Screening and Resident Review) status. A resident admitted with diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence had a PASRR Level II documented in the electronic medical record. However, the admission MDS assessment incorrectly indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. This inaccuracy was confirmed by the Director of Clinical Services, who acknowledged the MDS was coded incorrectly. The deficiency was identified through review of the RAI Manual, record review, and staff interview, and was found to be true for one of three residents whose records were reviewed for assessment accuracy.
Failure to Complete Accurate PASRR Screenings and Referrals for Mental Health Diagnoses
Penalty
Summary
The facility failed to refer residents with diagnosed mental disorders to the appropriate state-designated authority for evaluation and determination, as required by PASRR (Preadmission Screening and Resident Review) regulations. For three residents reviewed, the facility did not ensure that PASRR Level I screenings accurately reflected their mental health diagnoses, nor did they initiate PASRR Level II evaluations when indicated. Specifically, one resident with multiple sclerosis, Alzheimer’s disease, and depression was admitted without a PASRR Level II, and their Level I screening did not document the depressive disorder despite the use of an antidepressant. Another resident with quadriplegia, depression, and anxiety was admitted and readmitted without a PASRR Level II, and their Level I screening omitted documentation of depression and anxiety. Additionally, a third resident with major depressive disorder, anxiety disorder, and alcohol dependence had a Level I screening that only noted mild or situational depression, omitting the major depression and anxiety diagnoses. Staff interviews confirmed that the PASRR Level I screenings were incomplete or inaccurate and that Level II evaluations were not completed when required. The Social Services Director acknowledged that the screenings should have included all relevant diagnoses and that Level II evaluations were necessary but not performed. These findings were based on record reviews and staff interviews, demonstrating a pattern of failure to properly identify and refer residents with mental health needs for appropriate evaluation.
Failure to Accurately Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted each day, specifically omitting the number of hours worked per shift for registered nurses, licensed practical nurses, and certified nursing assistants. Observations conducted from 8/4/25 through 8/6/25 revealed that the daily postings did not include the required hours for each shift. During an interview on 8/6/25, the Staffing Coordinator confirmed that the hours worked for nursing staff were not posted as required for the number of covered positions on the daily staff postings.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for three residents, as evidenced by missed or undocumented administration of prescribed medications. One resident with chronic pain and a history of left hip joint absence and shoulder deformity did not receive a scheduled dose of morphine sulfate because the LPN forgot to retrieve the medication while assisting another resident. Documentation indicated the resident was alert and able to verbalize pain, and the error was discovered during a narcotic count at the end of the shift. Another resident with back pain, osteoarthritis, and osteoporosis did not receive a scheduled dose of oxycodone due to the LPN being overwhelmed by the number of residents waiting for medication. The resident's pain level increased during this period, and the incident was documented as a medication error. A third resident with type 2 diabetes and morbid obesity did not have documentation of receiving prescribed sliding scale insulin after a blood sugar reading that required administration. Review of the Medication Administration Record confirmed the absence of documentation for the insulin dose. In all three cases, the medication errors were attributed to staff oversight or workload, and the facility's policy on medication errors was not followed as required.
Failure to Provide Required Annual In-Service Education for CNAs
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of in-service education per year for two of three Certified Nursing Assistants (CNAs) reviewed for sufficient and competent staffing. Record reviews showed that both CNAs had been employed at the facility for over 12 months, but their training records did not document completion of the required annual in-service hours for the evaluation period. During staff interviews, facility leadership confirmed that they were unable to produce any records showing that these CNAs had completed the mandated training for the specified period. This lack of documented in-service education included essential topics such as dementia care and abuse prevention, as required for CNA competency. The absence of these records was identified during the review of staff files and confirmed by the CEO during the survey process.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a resident's care plan was followed to prevent falls, resulting in harm to the resident. The resident, who had multiple sclerosis and Alzheimer's disease, required total assistance for transfers with two staff and a mechanical lift, as documented in her care plan. Additionally, interventions such as using fall mats and keeping the bed in the lowest position were specified. However, on the day of the incident, the resident fell from her bed, resulting in fractures to her right lower leg. The facility's investigation revealed that the bed was not in the lowest position, and the fall mat was not in place at the time of the fall. The incident occurred when CNA #1 and #2 were involved in transferring the resident. After placing a sling under the resident, CNA #1 lowered the bed and left the room to retrieve the mechanical lift and CNA #2. Upon returning, they found the resident had rolled over the bolster and fallen to the floor. The facility later determined that the reports provided by the CNAs were not honest or accurate, and they did not follow the resident's care plan, leading to the fall and subsequent injury.
Failure to Ensure RN On-Site 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on-site for 8 consecutive hours a day, 7 days a week, as required by their policy. This deficiency was identified during a review of the nursing schedule for a three-week period, where it was found that on five specific days, there was no RN present for the required duration. The Director of Nursing (DON) admitted to being unaware of the requirement for an RN to be physically on-site and believed that being on-call was sufficient. This oversight had the potential to affect all 33 residents in the facility by leaving their routine and emergency nursing needs unmet.
Deficiency in Equipment Cleanliness
Penalty
Summary
The facility failed to ensure that residents were provided with clean equipment for obtaining vital signs and performing transfers, which could potentially lead to psychosocial harm. Observations made on two separate occasions revealed that two Hoyer lifts were visibly dusty, with a clear dried brown substance on their bases and thick white or gray material, resembling hairs, wrapped around the wheels. Additionally, the control wand for electric lifting on one of the Hoyer lifts was smeared with a light brown substance. Three mobile blood pressure machines were also found to be noticeably dusty on their reading screens, tops, legs, and bases, with one blood pressure cuff smeared with a light brown substance. During an interview, a CNA stated that he cleans the mobile blood pressure machines after each resident use, focusing on parts that touch the resident, such as the blood pressure cuff. However, he acknowledged the presence of dust and dirt on the machines and proceeded to clean them with a disinfectant wipe. The CNA also identified the material on the Hoyer lift wheels as hairs and removed them. The DON confirmed that nursing staff are responsible for cleaning the mobile blood pressure machines and Hoyer lifts after each use, indicating a lapse in adherence to the facility's cleaning protocols.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime, as observed on August 19, 2024. Three residents were affected by this deficiency. Resident #24 was seated alone at a table in the back corner, while Residents #26 and #29 were seated at the end of the main table with two other residents. Despite the facility's Dining Policy, which emphasizes a pleasant dining atmosphere and adequate staffing, these residents were not served their meals or beverages promptly. The meal service began at 12:25 PM, but by 12:31 PM, the tray cart was removed without serving these residents. Resident #26 requested a cold Pepsi three times between 12:35 PM and 12:41 PM, but CNA #3, who was assisting another resident, deferred the request. Eventually, the Staffing Coordinator brought a warm can of Pepsi at 12:41 PM, which was opened by Resident #29. The Staffing Coordinator returned with a cup of ice at 12:46 PM and poured the Pepsi for Resident #26. The meal trays for Residents #24, #26, and #29 were finally served at 12:48 PM. The Director of Nursing (DON) acknowledged that sometimes there is insufficient staff to assist with meals, as staff may be redirected to pass out hall trays.
Failure to Provide Resident Records During Hospital Transfer
Penalty
Summary
The facility failed to ensure that necessary resident records were provided to the hospital upon the transfer of a resident, identified as Resident #16. This deficiency was identified through a review of records, policies, and staff interviews. According to the facility's Transfer and Discharge policy, specific information should be provided to the receiving provider, including contact information for the resident's practitioner, resident representative information, advanced directive information, special instructions for ongoing care, the resident's comprehensive care plan goals, and all information necessary to meet the resident's needs. However, there was no documentation indicating what records were sent to the hospital when Resident #16 was transferred. Resident #16, who had multiple diagnoses including diabetes, legal blindness, congestive heart failure, and chronic respiratory failure with hypoxia, was transferred to the emergency room after being found hard to arouse. A nursing progress note documented that a report was given to the EMT and the nurse at the receiving facility, but there was no documentation of the specific records sent. The Clinical Resource Nurse confirmed the absence of documentation and noted that a checklist should have been used to document what was sent, but it was not found.
Failure to Instruct Resident on Proper Medication Administration
Penalty
Summary
The facility failed to ensure medication was administered according to professional standards of practice for one resident. During an observation of medication administration, a resident with a diagnosis of moderate persistent asthma was given fluticasone propionate inhalation without being instructed to rinse her mouth afterward. This omission was noted during a medication pass by an LPN, who did not provide the resident with instructions to rinse and spit after using the inhaler. The Clinical Resource Nurse confirmed that the physician's order for the medication did not include instructions to rinse and spit, which should have been included. Additionally, a pharmacist confirmed that residents should be instructed to rinse their mouths after taking fluticasone propionate to prevent mouth infections. The lack of proper instruction created the potential for the resident to develop a yeast infection.
Failure to Follow Care Plan for Weight Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident with chronic kidney disease and morbid obesity. The resident's care plan required staff to monitor and report specific signs and symptoms, including a weight gain of over 2 pounds per day, to the physician. However, the resident's weight was only recorded monthly, showing significant increases of 13.2 pounds from June to July and 10.4 pounds from July to August. There was no documentation that the physician was notified of these weight gains, nor was there evidence that daily weight checks were conducted to monitor for a 2-pound daily increase as directed by the care plan. During an interview, the Director of Nursing (DON) indicated that the care plan was considered a PRN order, to be activated only if there was a problem, and confirmed that the resident was not weighed daily. An email from the Administrator further clarified that the checks were to be performed when the patient exhibited general signs of illness or clinical changes, which would then trigger further assessment. This approach led to a failure in following the care plan as directed, creating a potential for harm to the resident.
Failure to Conduct AIMS Evaluations for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents taking antipsychotic medications received the necessary Abnormal Involuntary Movement Scale (AIMS) evaluations, as recommended by the American Psychiatric Association. This deficiency was identified for two residents who were reviewed for unnecessary medications. Resident #5, who was admitted with multiple diagnoses including schizoaffective disorder, was prescribed Depakote and Zyprexa. Although his care plan required AIMS evaluations every six months, the last documented assessment was in September 2023, with no evaluations conducted in March 2024. Clinical Resource Nurse #1 confirmed the absence of the required assessments. Similarly, Resident #16, also diagnosed with schizoaffective disorder, was prescribed Zyprexa. His care plan also mandated AIMS evaluations every six months. However, the last recorded AIMS assessment was in July 2023, with no subsequent evaluations in January and July 2024. Clinical Resource Nurse #1 was unable to locate any AIMS assessments for Resident #16 after July 2023. The lack of these evaluations created a potential for harm as residents were not monitored for adverse side effects of antipsychotic medications.
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.
Trusted by long-term care providers and associations.
