Cove Of Cascadia, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellevue, Idaho.
- Location
- 620 North Sixth Street, Bellevue, Idaho 83313
- CMS Provider Number
- 135069
- Inspections on file
- 18
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Cove Of Cascadia, The during CMS and state inspections, most recent first.
Four residents with complex medical histories did not receive or have documented administration of prescribed bowel care medications after extended periods without a BM, despite clear physician orders. Nursing staff did not document interventions, and the CNO confirmed that these actions should have occurred.
Surveyors found expired medications and biologicals, unclear or missing open dates on medication bottles, and loose pills in medication carts. Controlled medications were not stored in permanently affixed, separately locked compartments, and staff confirmed these storage and labeling failures.
The facility did not accurately post daily nurse staffing information, as required, with posted lists missing actual hours worked for RNs, LPNs, and CNAs, and one daily staffing sheet left incomplete. The CEO confirmed that both scheduled and actual hours should have been posted, but this was not done.
Controlled medications were not properly tracked or secured due to incomplete documentation on narcotic accountability sheets for a medication cart. Audits revealed that required signatures from two licensed nurses were missing on multiple occasions, and staff confirmed that the protocol for signing the sheets when accepting or releasing the cart was not followed.
A registered nurse administered insulin to a resident with diabetes and heart failure without priming the insulin pen as required, resulting in a medication administration error. The nurse was unaware of the need to prime the pen before use, as confirmed by facility leadership.
Surveyors identified multiple deficiencies in food storage, labeling, and handling, including opened food items without required dates, unlabeled containers, improper sealing, and inadequate cleaning of storage areas. A cook was also observed failing to change gloves or wash hands between tasks. The Culinary Manager acknowledged that items without proper dates should have been discarded.
A resident with dementia and a history of wandering exited the facility through a side door with a non-functioning alarm, resulting in a fall and injuries. The resident's care plan included a Wander Alert device, but the side door alarm was not set, allowing the resident to leave unsupervised.
The facility failed to maintain a clean kitchen environment, with raw chicken defrosting above ready-to-eat eggs, dust on refrigerator fans, and expired spices stored improperly. These issues risked cross-contamination and affected 69 residents.
A facility failed to prevent abuse between two residents sharing a suite, resulting in multiple incidents of physical and verbal altercations. Despite having a policy to protect residents, the facility did not effectively prevent the abuse, as the residents continued to share adjacent rooms, leading to ongoing conflict.
The facility failed to update care plans for two residents, leading to potential harm. One resident's care plan inaccurately required cigarette extenders, while another's care plan did not reflect a change from full code to DNR, despite documentation and guardian's request.
A resident with dysphagia was not provided with the physician-ordered mechanical soft diet, leading to a coughing incident during a meal. The meal card lacked the correct diet information, and the mushrooms were not processed to the required texture, as confirmed by the CDM and CNO.
A resident with multiple diagnoses was observed with his head tilted to the right side while sitting in a wheelchair, despite having a neck cushion. The resident expressed discomfort, and the Acting DOR admitted that no other devices were tried to maintain a neutral head position. The deficiency was identified due to the lack of appropriate intervention and assessment for the resident's neck positioning.
Failure to Administer and Document Bowel Care per Physician Orders
Penalty
Summary
The facility failed to follow physician orders for bowel care management for four residents with multiple diagnoses, including post-surgical amputation, obesity, dementia, anxiety, Alzheimer's disease, chronic kidney disease, and transient cerebral ischemic attack. For each resident, physician orders specified a stepwise administration of medications such as Bisacodyl tablets, Dulcolax suppositories, Fleet enemas, and Polyethylene Glycol to be given if a bowel movement (BM) did not occur within a specified number of days. Despite these orders, documentation showed that each resident went over 100 hours without a BM, and there was no record of the required medications being administered during these periods. Staff interviews confirmed that nurses had not documented any bowel medication interventions for these residents during the relevant timeframes, despite the absence of BMs and the presence of standing orders. The Chief Nursing Officer (CNO) acknowledged that the nurses should have documented and administered the prescribed interventions according to the physician's orders. This lack of adherence to physician orders and failure to document interventions was observed for all four residents reviewed for bowel and bladder care.
Medication and Biological Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in medication and biological storage and labeling practices across two units. Expired medications, such as Mucus Relief and Albuterol inhalers, were found in medication storage cabinets, and some bottles had unclear or missing open dates. Additionally, biologicals like glucose test solutions and strips were found to be expired and had not been removed from storage. Staff interviews confirmed that these expired items should have been removed but were not. Medication cart audits revealed loose pills of various types at the bottom of drawers, and one organizer tray contained dried sediment. Staff acknowledged that loose pills should not have been present and should have been destroyed. Furthermore, controlled medications, specifically lorazepam, were stored in removable plastic containers within medication refrigerators rather than in permanently affixed, separately locked compartments as required. Staff confirmed that the storage method for controlled medications did not meet regulatory requirements.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted daily for each shift, as required. On one occasion, the posted daily licensed and CNA staffing list displayed only the scheduled hours for day and night shifts, but did not include the actual hours worked by RNs, LPNs, and CNAs. Additionally, the daily staffing sheet for another date was found to be incomplete, with no staffing information recorded at all. During an interview, the CEO confirmed that the posted staffing list should have included both scheduled and actual hours worked for each nursing category, but this was not done.
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 incomplete documentation on narcotic accountability sheets for one of two medication carts reviewed. During audits of the medication cart on the [NAME] Unit, it was observed that the narcotic accountability sheets covering multiple dates were missing the required signatures of two licensed nurses, as per facility protocol, when accepting or releasing the medication cart. Staff interviews confirmed that both an LPN and an RN did not sign the narcotic accountability sheets as required, and the Chief Nursing Officer acknowledged that two nurse signatures were necessary for proper documentation.
Insulin Administration Error Due to Failure to Prime Pen
Penalty
Summary
A deficiency occurred when a registered nurse failed to properly prepare and administer insulin to a resident with diabetes and heart failure. The resident had physician orders for Novolog insulin, including a scheduled dose and a sliding scale based on blood glucose readings. During medication administration, the nurse dialed the insulin pen to the correct total dose but did not prime the pen with 2 units as required before administering the insulin. The nurse later stated he was unaware of the need to prime the pen prior to use. The facility's Chief Nursing Officer confirmed that insulin pens should be primed with 2 units before administration.
Deficient Food Storage, Labeling, and Handling Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and handling practices within the facility's kitchen. Opened food items, such as syrups, rice, broccoli, onions, lettuce, pancake mix, and cranberry juice, were found without required opened dates or use-by dates. Some containers and squeeze bottles containing food items like melted butter were not labeled with contents or use-by dates. Additionally, an opened bag of rice was not properly sealed, resulting in spillage. Large cooking pots were stored upside down on top of a refrigerator that had visible dirt and food particles, indicating inadequate cleaning and storage practices. During food preparation, a cook was seen handling bell peppers with gloved hands, then using the same gloves to put on oven mitts, remove items from the oven, and return to food preparation without changing gloves or washing hands. The Culinary Manager confirmed that food items without opened or use-by dates should have been discarded but were not. These observations were made in the presence of the Culinary Manager, and the facility's own policies, as well as the Idaho Food Code, require proper labeling, dating, and storage of food items to prevent contamination and ensure food safety.
Failure to Prevent Elopement and Falls Due to Non-Functioning Alarms
Penalty
Summary
The facility failed to provide adequate supervision and functioning devices to prevent elopement and falls for a resident with multiple diagnoses, including dementia, fractures, and cancer. The resident was severely cognitively impaired and had a care plan indicating a risk for wandering and elopement. Despite having a Wander Alert device on his wheelchair, the resident managed to exit the facility through a side door with a non-functioning alarm. This led to the resident being found in the parking lot with injuries, including a laceration to the right temporal area and abrasions, after his wheelchair wheels fell off the curb, causing him to fall. The facility's investigation revealed that the side door alarms were not set, allowing the resident to exit without alerting staff. The resident had been wandering for several days prior to the incident, and the emergency exit alarm was turned off at the time of the event. The lack of a functioning alarm system and adequate supervision contributed to the resident's ability to leave the facility unsupervised, resulting in physical harm.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during inspections. Raw chicken was found defrosting above packaged ready-to-eat hardboiled eggs in the refrigerator, which poses a risk of cross-contamination. Additionally, there was a significant build-up of dust particles on the ceiling fans in the kitchen refrigerators, indicating a lack of proper cleaning and maintenance. The facility's cleaning schedule showed that the main refrigerator and freezer were not cleaned on several documented dates. Expired spices were found in the kitchen cabinet, with some lacking expiration dates, and the temperature in the spice cabinet was recorded at 81 degrees Fahrenheit, which is not ideal for spice storage. The CDM confirmed that the spices should have been discarded by their expiration dates and acknowledged that the refrigerators should be cleaned at the end of each shift by the cooks. However, the CDM was unsure why there was a dust build-up on the ventilation cooling fans. These deficiencies had the potential to affect the 69 residents who consumed food prepared by the facility, placing them at risk for potential contamination and adverse health outcomes.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically involving two residents who shared a suite. One resident, who was cognitively intact, experienced physical and verbal abuse from another resident who was severely cognitively impaired. The incidents included physical altercations where one resident was hit with a cup, had juice thrown on them, and was punched in the shoulder. These interactions were documented in nursing progress notes and investigative summaries, highlighting the ongoing conflict between the two residents. The facility's policy on abuse, revised in August 2023, emphasized the importance of protecting residents from abuse and neglect, particularly those with dementia or behavioral dysfunctions. Despite this policy, the facility did not effectively prevent the abusive interactions between the two residents. The incidents were reported to the State LTC portal, and the facility conducted investigations, but the residents continued to share adjacent rooms, which contributed to the ongoing conflict. The facility's investigation revealed that the two residents had multiple interactions involving abuse. Although the facility offered a room change to the resident who was abused and adjusted medications for both residents, the incidents continued to occur. The facility's actions were insufficient in preventing further abuse, as the residents remained in close proximity, leading to repeated altercations.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents' care plans were revised and updated as required, which was identified for two residents. Resident #6, who had a history of traumatic brain injury and dysphagia, was noted to have a care plan that required supervision while smoking and the use of cigarette extenders. However, observations revealed that Resident #6 was smoking without an extender, and the Chief Nursing Officer (CNO) confirmed that the care plan was not updated to reflect that the resident no longer needed the extender. Resident #32, with diagnoses including major depressive disorder, dementia, and parkinsonism, had a care plan indicating a full code status. However, a review of the resident's records showed a change in code status to Do Not Resuscitate (DNR) as documented in a Physician Orders for Scope of Treatment (POST) form. The CNO verified that the care plan was not updated to reflect this change, despite the guardian's request and the physician's documentation. This oversight in updating the care plans created the potential for harm due to inaccurate information.
Failure to Provide Physician-Ordered Nutrition
Penalty
Summary
The facility failed to provide nutrition as ordered by the physician for a resident with a history of traumatic brain injury and dysphagia. The resident was prescribed a dental/mechanical soft texture diet with thin consistency, extra sauce, and gravy on meals. However, during a meal observation, the resident was served ground chicken with mushrooms cut into slices, green beans, and pasta. The mushrooms were not processed to the required texture, leading to the resident coughing while eating. This incident highlighted a failure in adhering to the prescribed dietary modifications. Further investigation revealed that the resident's meal card did not indicate the correct diet, which contributed to the oversight. The Certified Dietary Manager (CDM) acknowledged that the meal card should have specified the mechanical soft diet. Additionally, the CDM and another staff member admitted that the mushrooms were not processed correctly, as they should have been put into the food processor with the chicken. The Chief Nursing Officer (CNO) also confirmed the diet information was missing from the meal card, indicating a lapse in communication and documentation within the facility.
Failure to Provide Appropriate Positioning Devices for Resident
Penalty
Summary
The facility failed to provide appropriate devices to support a resident's body positioning while sitting in a wheelchair, specifically for a resident with multiple diagnoses including schizoaffective disorder, anemia, and benign prostatic hyperplasia. The resident was observed multiple times with his head tilted to the right side while sitting in various locations within the facility, such as the dining room and common area, and during activities like listening to the Activity Director and participating in a Resident Council meeting. Despite having a neck cushion, the resident's head remained tilted, and he expressed discomfort, describing his neck as 'bad' and 'rotten.' The Acting Director of Rehabilitation (DOR) acknowledged that the resident was provided with a u-shaped pillow, which he refused to use, and admitted that no other devices were tried to maintain the resident's head in a neutral position. The DOR also stated that the resident had been assessed for physical therapy from June to August, but the neck positioning was not specifically addressed since the resident was reportedly doing well with neck exercises. The lack of appropriate intervention and assessment for the resident's neck positioning led to the deficiency identified by the surveyors.
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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