Countryside Care & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Rupert, Idaho.
- Location
- 1224 Eighth Street, Rupert, Idaho 83350
- CMS Provider Number
- 135064
- Inspections on file
- 17
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Countryside Care & Rehabilitation during CMS and state inspections, most recent first.
Kitchen staff did not wear required beard nets, and food items in storage were not properly labeled with expiration or use-by dates. A cook was observed touching his face and hair with gloved hands before handling food, and the food service manager was unaware of the beard net requirement. These actions did not comply with food safety standards.
Garbage cans in the kitchen food prep areas were found uncovered and not in use, with staff unaware that lids were required when not actively filling the cans. This failure to keep garbage containers properly closed did not comply with state and federal regulations intended to minimize pest and rodent attraction.
A resident with significant neurological impairment and a legal guardian did not have an Advance Directive documented in the medical record. Facility staff did not offer or document assistance to the guardian in formulating an Advance Directive, as confirmed by both the DON and Administrator.
A resident with a history of stroke and hypertension was not given the required Advance Beneficiary Notice (CMS-10055) when discharged from Medicare Part A Skilled Nursing and admitted to LTC. The administrator confirmed the notice was not provided as required.
The facility did not follow its bowel care protocol for several residents with complex medical conditions, resulting in missed or delayed administration of prescribed interventions such as prune juice, milk of magnesia, and suppositories. The DON confirmed that nursing staff failed to implement the required steps according to physician orders and facility policy.
Several residents with complex medical conditions did not have their oxygen tubing changed as ordered by their physicians or per facility policy. Observations showed overdue and discolored tubing, and documentation confirmed that scheduled changes were missed. The DON acknowledged the lapses in following the required schedule for respiratory care.
The facility did not document attempts at alternatives or the intended purpose for bed rail use for several residents with complex medical conditions, despite policy requirements. Both the DON and Administrator acknowledged the absence of required documentation in the medical records.
Controlled medications were not properly tracked or secured due to missing licensed nurse signatures on narcotic accountability sheets for a medication cart. An LPN and the Administrator confirmed that two nurses should have signed the sheets when accepting or releasing the cart, but this was not done, creating the potential for undetected misuse or diversion.
The facility failed to properly sanitize a food thermometer, increasing the risk of foodborne illnesses. Cook1 was observed using the thermometer without sanitizing it before use and reused an alcohol swab between items. The Food Service Supervisor confirmed the need for proper cleaning before and after each use.
A resident with Alzheimer's Disease and severe cognitive impairment was found with bruising on her hand, an injury of unknown origin. The facility's incident report was incomplete, and no investigation was conducted, contrary to the facility's policy. The Administrator in Training confirmed the lack of investigation during an interview.
A resident with a G-Tube did not receive medications according to professional standards, as the facility lacked a policy for G-Tube medication administration. An LPN administered medications improperly by crushing them together and not checking tube placement correctly, while the resident's head was not elevated as required. The AIT confirmed the expected procedures were not followed.
A facility failed to assess a resident for bed rail use, discuss risks and benefits with the representative, and obtain informed consent. The resident, with anoxic brain damage and quadriplegia, was observed with side rails despite being unable to move independently. The Administrator in Training confirmed there was no rationale for the rails, highlighting a deficiency in following the facility's policy.
Failure to Follow Food Safety and Hygiene Standards in Kitchen
Penalty
Summary
Surveyors observed that kitchen staff failed to comply with food safety and hygiene standards as outlined in the Idaho Food Code and the facility's own Food and Nutrition Services Policy. Specifically, a male cook with a beard was seen working in the kitchen without a required beard net or cover, and he touched his face and hair with gloved hands before handling an open container of food without changing gloves or washing his hands. The food service manager was unaware of the requirement for beard nets for staff with facial hair. Additionally, multiple food storage and labeling deficiencies were identified. In the dry food storage room, containers of cracker crumbs and chocolate chips were found without any labeling indicating expiration or use-by dates. In the walk-in freezer, an opened package of egg rolls was not labeled with an opened date or expiration date. The food service manager confirmed that these items should have been properly labeled and dated, but they were not.
Uncovered Garbage Cans in Kitchen Food Prep Areas
Penalty
Summary
Surveyors observed that garbage cans in the kitchen food preparation areas were not properly closed with lids as required by Idaho Administrative Rules and the U.S. Food and Drug Administration Food Code. Specifically, a 55-gallon garbage can was found half full and uncovered while not in use, with the lid placed on the ground under a table. Additionally, two more 55-gallon garbage cans were observed without lids in the kitchen food prep areas. Interviews with the contractor food service manager and worker revealed that they were not aware that lids needed to be on the garbage cans when not actively being filled. These actions and inactions resulted in the facility failing to ensure garbage cans were properly closed to minimize attracting pests and rodents into the kitchen.
Failure to Assist with Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that a resident and their representative were provided with assistance to exercise the right to formulate an Advance Directive. Upon review of the medical record for a resident admitted with anoxic brain damage and quadriplegia, it was found that while the record included a POST and a Letter of Guardianship, there was no documentation of an Advance Directive. Additionally, there was no evidence that the facility had offered to assist the resident's guardian in formulating an Advance Directive, as required by regulation. Interviews with the Director of Nursing and the Administrator confirmed that the resident had not created an Advance Directive prior to admission, and the guardian had not completed one either. Furthermore, the resident's record did not contain documentation that Advance Directive information had been offered to the guardian. This lack of documentation and assistance constituted a failure to comply with federal requirements regarding advance care planning.
Failure to Provide Advance Beneficiary Notice Upon Change in Coverage
Penalty
Summary
The facility failed to provide an Advance Beneficiary Notice (CMS-10055 form) to a resident whose medical records were reviewed for beneficiary protection notification. The resident, who had multiple diagnoses including stroke and hypertension, was admitted to the facility and later discharged from Medicare Part A Skilled Nursing before being admitted to the long-term care unit. Upon review, it was found that the required notice was not given to the resident at the time of discharge from Medicare Part A and admission to long-term care. The administrator confirmed that the resident should have received the notice but did not.
Failure to Follow Bowel Care Protocol for Multiple Residents
Penalty
Summary
The facility failed to follow its established bowel care standing orders for four residents whose records were reviewed for bowel and bladder care. According to the facility's protocol, specific interventions and medications were to be administered at 24, 48, 72, and subsequent hours without a bowel movement. However, documentation revealed that these steps were missed or delayed for multiple residents. For example, one resident with a history of stroke and hypertension did not receive the required interventions from day one through day five of no bowel movement. Another resident with polyosteoarthritis and respiratory failure had missed steps in the protocol during two separate periods of constipation. Additional residents with diagnoses such as epileptic seizures, hypertension, chronic kidney disease, and COPD also experienced missed or delayed administration of bowel protocol steps. The missed interventions included failure to provide prune juice, milk of magnesia, bisacodyl suppositories, or to notify the primary care provider as outlined in the protocol. The Director of Nursing confirmed that nursing staff had not followed the bowel protocol as required for these residents. The failure to administer medications and interventions according to physician orders and facility policy was identified through record review and staff interviews.
Failure to Provide Physician-Ordered Respiratory Services
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for four out of five residents reviewed for respiratory care. Specifically, the facility's policy required oxygen tubing and masks/cannulas to be changed monthly and as needed if soiled or contaminated. However, multiple residents with significant medical histories, including dementia, anxiety disorder, hypertensive heart disease, chronic kidney disease, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease, did not have their oxygen tubing changed according to physician orders or facility policy. For example, one resident's tubing was last changed over a month prior and was not replaced on the scheduled date. Another resident's tubing was only changed after the issue was brought to the attention of the DON by the surveyor. Observations revealed that several residents' oxygen tubing was overdue for replacement, with one instance of tubing appearing yellowed. Documentation and interviews confirmed that the required monthly changes were not completed as scheduled for these residents. The DON acknowledged that the tubing had not been changed according to the established schedule, confirming the facility's failure to follow physician orders and its own policy regarding respiratory care.
Failure to Document Alternatives and Rationale for Bed Rail Use
Penalty
Summary
The facility failed to ensure that, prior to the placement of bed rails, alternatives were attempted and documented as unsuccessful in meeting residents' assessed needs. For four out of six residents reviewed for bed rail use, there was no documentation in the medical records regarding the evaluation of alternatives or the intended purpose for the use of bed rails. The facility's policy requires that the assessment include an evaluation of alternatives and documentation of their failure to meet the resident's needs before bed rails are installed. Specifically, residents with various diagnoses such as hemiparesis, diabetes, encephalopathy, respiratory failure, heart failure, osteomyelitis, and atherosclerosis were observed with bilateral upper side rails in place. In each case, the medical records lacked evidence of attempted alternatives or the rationale for bed rail use. Both the DON and the Administrator confirmed that this documentation was missing and should have been present in the residents' records.
Failure to Properly Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing signatures on narcotic accountability sheets for one medication cart. During a medication cart audit, it was observed that the narcotic accountability sheets, covering a period from February to September, were missing three required licensed nurse signatures. Both an LPN and the Administrator confirmed that two nurses should have signed the narcotic accountability sheet when accepting or releasing the medication cart. This lapse in documentation created the potential for undetected misuse or diversion of controlled medications for all residents receiving such medications.
Improper Sanitization of Food Thermometer
Penalty
Summary
The facility failed to properly sanitize the thermometer used for taking food temperatures, which could potentially increase the risk of foodborne illnesses and infections for all residents receiving food from the facility kitchen. The facility's policy on taking accurate temperatures requires that the thermometer probe be cleaned, rinsed, sanitized, and air-dried before and after taking the temperature of each food item. However, during an observation of the tray line, Cook1 was seen taking the thermometer out of her pocket and using it to measure food temperatures without sanitizing it beforehand. After taking the temperature of the first item, Cook1 used an alcohol swab to clean the thermometer but reused the same swab for the next two items, and then placed the thermometer back into her pocket. Cook1 continued to take temperatures of additional food items without sanitizing the thermometer first and used the same alcohol swab between items. During interviews, Cook1 acknowledged that her pocket could contaminate the thermometer and admitted she should have cleaned it before use. The Food Service Supervisor confirmed that thermometers need to be cleaned before and after each use and expected staff to adhere to the sanitizing requirements. This failure to follow proper sanitization procedures was observed and confirmed through interviews with the staff involved.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as R20, who was part of a sample of 14 residents reviewed for abuse. R20, who was admitted with Alzheimer's Disease, was found to have scattered bruising on the back of her right hand on 08/29/24. The resident was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of three out of 15, and was unable to explain how the bruising occurred. The incident was recorded as an injury of unknown origin in the facility's Incident/Accident Log. The facility's incident report for R20's injury was incomplete, with sections on Level of Pain, Mental Status, and Predisposing Factors left blank. No investigation was conducted into the injury, as confirmed by the Administrator in Training (AIT) during an interview on 09/17/24. The AIT acknowledged that a thorough investigation should have been conducted for any injury of unknown origin experienced by residents, as per the facility's Abuse, Neglect, and Exploitation Policy.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to meet professional standards of care for a resident receiving medication through a gastrostomy (G) tube. The survey team found that the facility did not have a policy for administering medication via G-Tube. During an observation, a Licensed Practical Nurse (LPN) was seen administering medications to a resident with a G-Tube without following proper procedures. The resident, who had anoxic brain damage and quadriplegia, received all nutrition and medication through the G-Tube. The LPN crushed all medications together, mixed them with water, and administered them simultaneously without checking the tube's placement properly or elevating the resident's head to the recommended degree. The LPN admitted to not being instructed to crush and administer medications separately with water flushes in between. The Administrator in Training (AIT), who was the former Director of Nursing (DON), confirmed that the facility's expected procedure was to administer medications separately with water flushes, check G-Tube placement by checking residuals without pushing water first, and administer medications via gravity with the resident's head elevated at least 30 degrees. The lack of adherence to these procedures created the potential for complications in the resident's care.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of bed rails, did not discuss the risks and benefits with the resident's representative, and did not obtain informed consent for the use of side rails. The facility's policy requires a person-centered approach, including evaluating alternatives before using bed rails, assessing the resident's risk, and obtaining informed consent. However, for this resident, who was admitted with anoxic brain damage and quadriplegia, these steps were not followed. The resident's records indicated the use of side rails, but there was no documentation of a Bed Rail Evaluation, risks and benefits discussion, or signed informed consent. The resident was observed with bilateral half side rails in the raised position on multiple occasions, despite being unable to move independently or grasp the side rails due to severely contracted upper extremities. During interviews, the Administrator in Training confirmed that the resident should not have had bed rails, as there was no rationale for their use. This oversight created the potential for the resident to experience negative effects or risks associated with unnecessary use of the rails.
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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