Coeur D Alene Health Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Coeur D'alene, Idaho.
- Location
- 2514 North Seventh Street, Coeur D'alene, Idaho 83814
- CMS Provider Number
- 135052
- Inspections on file
- 16
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Coeur D Alene Health Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow proper hand hygiene, did not use required beard coverings, and did not maintain adequate cleaning and sanitizing practices in the kitchen. These actions included handling food and utensils after touching the face or nose without washing hands, using a sanitizer at insufficient concentration, and storing clean equipment with food residue. Dust was also observed on surfaces where clean dishes were stored, indicating lapses in cleaning routines.
The facility did not ensure residents were free from abuse and neglect, as evidenced by two residents being left in soiled briefs for extended periods without timely incontinence care, and another resident with cognitive impairment being subjected to loud, condescending remarks from a CNA. Staff interviews and grievance reviews confirmed delays in care and inappropriate staff interactions, but the facility failed to properly investigate these grievances as neglect or abuse.
A resident with mobility impairments experienced two unwitnessed falls in one day due to inadequate supervision and lack of updated care plans. The first fall resulted in a minor skin tear, while the second caused a head laceration and severe pain, requiring hospital transfer. The facility failed to train staff to update care plans and implement interventions on weekends.
The facility failed to maintain infection control practices, as a CNA and LPN did not clean a resident lift between uses, and an LPN did not follow hand hygiene or PPE protocols while administering medications, including to a resident on droplet precautions. The DON confirmed a lack of specific training and observations for compliance.
The facility failed to provide physical therapy services as ordered for several residents, leading to a deficiency in care. Residents with various diagnoses, including muscle weakness and mobility issues, did not receive the prescribed number of therapy sessions. The Physical Therapy Director cited insufficient staffing as the reason for the lack of services.
A facility failed to notify a resident's family when the resident, who had a tracheostomy and was respirator-dependent, experienced a change in condition. The resident was found decannulated, and the respiratory therapist could not reinsert the trach. Although the physician was informed, the family was not notified, as confirmed by the DON.
The facility failed to ensure accurate MDS assessments for three residents, incorrectly indicating they did not have serious mental illnesses despite PASRR Level II documentation showing diagnoses such as schizophrenia, depression, and bipolar disorder. The MDS Coordinator confirmed these inaccuracies, which could lead to negative outcomes if residents are not properly assessed and monitored.
The facility failed to update care plans for three residents, leading to potential risks. A resident with congestive heart failure had no updated interventions in his care plan. Another resident's care plan lacked documentation of his smoking needs despite a nicotine dependency diagnosis. A third resident, with a tracheostomy, was found decannulated, but the care plan was not revised to reflect the removal of the trach. These deficiencies were acknowledged by facility staff.
A resident with muscle weakness and difficulty walking did not receive scheduled bathing assistance as required. The resident's records showed multiple instances of missing documentation for offered or refused showers over a period of several weeks. The DON confirmed the resident missed scheduled shower opportunities, and no documentation was provided for refusals.
A resident with quadriplegia and a history of constipation did not receive bowel management medications as ordered by the physician, resulting in significant gaps between recorded bowel movements. The DON confirmed the failure to administer the medications but could not explain why this occurred.
A resident with stomach cancer and cognitive communication deficit experienced severe abdominal pain without timely intervention. Despite a physician's order for pain medication, the resident did not receive any pain management until the afternoon, resulting in prolonged unrelieved pain. The DON confirmed that a scheduled pain medication order was not reinstated after the resident's hospital readmission.
The facility failed to ensure an RN was on-site for 8 consecutive hours a day, 7 days a week, as required. A review of nursing staff hours revealed that on two occasions, the facility did not have an RN on-site for the required hours, which was confirmed by the Administrator. This deficiency placed all residents at risk for harm if their routine and/or emergency needs could not be met without the care of a registered nurse.
The facility failed to accurately complete, post daily, and maintain nurse staffing data for at least 18 months. A review of records from October to March revealed numerous missing and incomplete data entries. An observation on March 16 showed outdated staffing data, and the Administrator was unsure why the data was not managed as required.
The facility failed to maintain sanitation in the nutrition room and equipment, as observed during an inspection. An ice bin had a thick, slimy layer, and food containers lacked use-by dates. The Dietary Manager was unsure about cleaning responsibilities, increasing the risk of foodborne illnesses for residents.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food safety and sanitation practices within the facility's kitchen, affecting 57 of 76 residents who received food prepared there. Staff were seen not performing proper hand hygiene, including instances where a kitchen aide wiped his nose with his fingers and then handled clean silverware and napkins for resident trays without washing his hands. The same aide was also observed putting on gloves without prior hand hygiene and repeatedly touching his face and arms without washing hands between tasks. Staff interviews confirmed a lack of understanding and adherence to hand hygiene protocols during meal service. Additional deficiencies included the absence of required beard coverings for food preparation staff, as both the dietary manager and a kitchen aide were observed preparing food without beard restraints. The sanitizing solution used for cleaning food thermometers was found to be at half the required concentration, and food-contact equipment was not properly cleaned, as evidenced by a food particle left in a supposedly clean immersion blender container. Furthermore, the kitchen environment was not maintained in a sanitary condition, with dust observed on shelves and pipes above food preparation areas, despite claims of daily and weekly cleaning schedules.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect by not properly investigating grievances and ensuring timely care. One resident with quadriplegia and total dependence on staff for activities of daily living reported being left in a wet brief for four hours after requesting incontinence care. The resident also reported that a CNA repeatedly turned off his call light and failed to return in a timely manner, with similar incidents occurring in the past. Staff interviews confirmed the delay in care, and facility leadership acknowledged the incident should have been investigated as neglect. Another resident with severe cognitive impairment was the subject of a grievance after a CNA was heard yelling and making condescending remarks, such as telling the resident to go to her room and accusing her of seeking attention. Multiple staff reported the CNA used a stern or loud tone, which was disruptive and could be perceived as scolding, though the facility's investigation did not substantiate abuse. Additionally, a third resident with cognitive and physical impairments was left in a stool-filled brief for an extended period after unsuccessfully seeking assistance from a CNA. The facility did not determine why the resident was not changed as requested, and the resident expressed increased sadness and frustration related to care provided.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in two falls with injuries. The resident, who was admitted with diagnoses including muscle weakness and abnormalities of gait and mobility, was assessed to be at risk for falls and required extensive assistance with transfers and direct supervision while toileting. Despite these assessments, the resident experienced two unwitnessed falls on the same day. The first fall occurred while transferring from the toilet to a wheelchair, resulting in a skin tear and a reported pain level of 1 out of 10. The care plan did not include any interventions to prevent further falls after this incident. Later that day, the resident suffered a second unwitnessed fall while transferring, leading to a laceration on the back of the head and a reported pain level of 10 out of 10. The resident exhibited severe pain and a rapid decline in vital signs, necessitating a transfer to the hospital for further evaluation and treatment. The post-fall investigation did not document the severity of the injuries after the hospital transfer. The Director of Nursing acknowledged that the facility failed to train staff to update care plans and implement interventions post-falls on weekends.
Infection Control and Prevention Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as evidenced by observations and staff interviews. The facility's policy required that resident care items, such as lifts, be cleaned and disinfected between each use. However, on March 18, 2025, a CNA and an LPN were observed using a resident lift without cleaning or disinfecting it afterward. The CNA stated that they were not required to clean or disinfect the lifts between resident use, which was later confirmed as incorrect by the Infection Prevention Nurse and the Director of Nursing (DON). Additionally, hand hygiene and personal protective equipment (PPE) practices were not followed according to CDC guidelines. On March 19, 2025, an LPN was observed failing to perform hand hygiene before and after administering medications to residents, including one on droplet transmission precautions for influenza. The LPN also improperly handled PPE and did not disinfect the medication cart after use. The DON confirmed that the facility had not provided specific in-service training for PPE use during the current influenza outbreak and had not conducted staff observations to ensure compliance with hand hygiene and PPE protocols.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide physical therapy services as ordered by physicians for five residents, leading to a deficiency in care. Resident #19, who was readmitted for surgical aftercare with diagnoses including muscle weakness and difficulty walking, was ordered to receive physical therapy three times a week for eight weeks. However, only 2 out of 24 sessions were documented as provided, with no refusals noted. Similarly, Resident #33, with diagnoses of abnormal gait, muscle weakness, and lack of coordination, was ordered the same frequency of therapy but only received 7 out of 24 sessions, with three refusals documented. Resident #37, diagnosed with quadriplegia and muscle weakness, was to receive therapy six times a week for four weeks but received none, with no refusals documented. Resident #67, with muscle weakness and cognitive communication deficit, was ordered therapy five times a week for eight weeks but received only 16 out of 20 sessions before discharge. Resident #182, with difficulty walking and an amputation, was ordered therapy five times a week for eight weeks but received only 9 out of 19 sessions, with no refusals documented. The Physical Therapy Director acknowledged that residents were not receiving therapy services as per evaluations due to insufficient staffing, contributing to the deficiency in care.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's representative when the resident experienced a change in condition. This deficiency involved a resident who was admitted for care following a traumatic brain injury and had multiple diagnoses, including a tracheostomy, respirator dependence, and acute respiratory failure. On a specific date, a physician's verbal order was documented, stating that if the resident decannulates and the respiratory therapist cannot reinsert the trach, the resident should not be sent to the emergency room, and the trach may be left out. Subsequently, the resident was found decannulated, and the respiratory therapist was unable to reinsert the trach. Although the physician was notified, the resident's family was not informed of this change in condition, as confirmed by the Director of Nursing (DON).
Inaccurate MDS Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which is a standardized tool used to assess residents' health and functional status. Specifically, the assessments for these residents incorrectly indicated that they did not have serious mental illness or intellectual disabilities, despite documentation to the contrary in their Preadmission Screening and Resident Review (PASRR) Level II records. This discrepancy was identified for three residents who had diagnoses of serious mental illnesses such as schizophrenia, depression, and bipolar disorder, among others. Resident #11 had a PASRR Level II indicating diagnoses of depression, schizophrenia, and dementia, yet her MDS assessment incorrectly marked 'No' for having a serious mental illness. Similarly, Resident #20's MDS assessment did not reflect her PASRR Level II diagnoses of schizophrenia, OCD, bipolar disorder, and depression. Resident #44's MDS assessment also failed to acknowledge her PASRR Level II diagnoses of autism, schizophrenia, depression, and anxiety. The MDS Coordinator confirmed these inaccuracies, which could potentially lead to negative outcomes if residents are not properly assessed and monitored.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions, as evidenced by the cases of three residents. Resident #60, who was readmitted with congestive heart failure, had a care plan dated several months prior that did not include any updates or new interventions related to his condition. The Director of Nursing acknowledged the need for improvement in care planning. Resident #182, admitted with nicotine dependency, had a smoking evaluation indicating he could smoke independently, yet his care plan lacked documentation regarding his smoking needs. The Director of Nursing confirmed that the care plan did not reflect the resident's current smoking status. Resident #64, admitted following a traumatic brain injury and with a tracheostomy, experienced a significant event when he was found decannulated, and the respiratory therapist was unable to reinsert the trach. Despite this incident, the care plan was not updated to reflect the removal of the tracheostomy. The Staff Development Coordinator Nurse noted that the care plan should have been revised to account for this change. These deficiencies in care planning placed residents at risk for adverse outcomes due to the lack of updated interventions and documentation.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident who required assistance with bathing received the necessary care. The resident, admitted with diagnoses including generalized muscle weakness and difficulty walking, was scheduled to receive showers twice weekly. However, the resident's bathing records from February to March 2025 showed multiple instances where there was no documentation of a shower being offered or refused. Specifically, there were extended periods where no records indicated that a shower was offered, and on two occasions, the resident refused a shower. The Director of Nursing confirmed that the resident did not receive shower opportunities as scheduled, and no documentation was provided to account for bathing refusals.
Failure to Administer Bowel Management Medications as Ordered
Penalty
Summary
The facility failed to provide quality care to a resident by not following physician orders for bowel management. The resident, who was admitted with multiple diagnoses including quadriplegia, respirator dependence, and a history of constipation and gastrointestinal hemorrhage, had specific physician orders for bowel care. These orders included administering Milk of Magnesia if there was no bowel movement for two days, followed by a Dulcolax suppository if there was no result, and finally a Fleet Enema if needed. However, the resident's bowel movement records and medication administration records from February to March 2025 showed multiple instances where there were significant gaps between recorded bowel movements, and no as-needed medications were administered as per the physician's orders. The Director of Nursing (DON) confirmed that the resident did not receive the bowel management medications as ordered and was unable to provide an explanation for this failure. This oversight placed the resident at an increased risk for harm, as the necessary interventions to manage the resident's bowel care were not implemented. The report highlights a deficiency in the facility's adherence to physician orders, which is critical for ensuring the well-being of residents with complex medical needs.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident #60, who was readmitted after a hospital stay with diagnoses including stomach cancer and a cognitive communication deficit. On the morning of 3/17/25, Resident #60 reported severe abdominal pain, rating it 9 out of 10, and requested pain medication. Despite acknowledging the resident's pain, LPN #3 did not conduct an assessment or provide any pain management interventions. By the afternoon, the resident continued to experience significant pain, rating it 8 out of 10, and reported not receiving any pain management interventions since the morning. The resident's medical record indicated a physician's order for Hydrocodone-Acetaminophen to be administered every 8 hours as needed for pain, with non-pharmacological interventions to be attempted first. However, the resident did not receive any interventions until LPN #2 administered pain medication at 2:39 PM. The Director of Nursing later confirmed that a previously scheduled pain medication order was not reinstated upon the resident's return from the hospital. This oversight resulted in the resident experiencing prolonged periods of unrelieved pain.
Failure to Provide RN Coverage for 8 Consecutive Hours
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 to provide care to the residents. This deficiency was identified during a review of nursing staff hours worked from February 23, 2025, to March 15, 2025. It was found that on February 24, 2025, and March 3, 2025, the facility did not have an RN on-site for the required 8 consecutive hours. This lapse in staffing was confirmed by the Administrator on March 20, 2025, at 1:22 PM. The absence of an RN for the specified hours placed all residents at risk for harm if their routine and/or emergency needs could not be met without the care of a registered nurse.
Failure to Accurately Post and Maintain Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data was accurately completed, posted daily, and maintained for a minimum of 18 months. This deficiency was identified through observation, record review, and staff interviews. The review of the facility's daily nurse staffing data posting records from October 1, 2024, to March 20, 2025, revealed numerous missing dates and instances of incomplete data. Specific dates in October, November, December, January, February, and March were identified as either missing or incomplete. On March 16, 2025, it was observed that the facility's daily nurse staffing data posting was outdated, showing data from March 14, 2025. During an interview on March 20, 2025, the Administrator expressed uncertainty regarding why the nurse staffing data was not completed accurately, posted, and retained as required.
Sanitation Deficiency in Nutrition Room and Equipment
Penalty
Summary
The facility failed to ensure the sanitation of nutrition rooms and equipment, as observed during an inspection. One of the two ice bins in the nutrition room was found to have a thick, slimy layer with different shades of pink surrounding the ice dispensing tray. This indicates a lack of proper cleaning and sanitation, which is necessary to minimize the growth of microorganisms that may result in food contamination. Additionally, plastic containers of food were found without any indication of use-by dates, and thickened cocktail cranberry juice was observed with no indication of when it was opened or when it should be disposed of. During an interview, the Dietary Manager acknowledged that the ice bin was not in sanitary conditions and expressed uncertainty about who was responsible for cleaning it. The manager also admitted that the food items in the refrigerator were unclear regarding when they were opened or when they should be disposed of. This lack of clarity and responsibility in maintaining sanitation standards in the nutrition room and equipment could potentially affect all residents consuming food or ice from these areas, increasing the risk of transmission of foodborne illnesses.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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