Creekside Transitional Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Idaho.
- Location
- 1351 West Pine Avenue, Meridian, Idaho 83642
- CMS Provider Number
- 135125
- Inspections on file
- 20
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Creekside Transitional Care And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that potatoes and onions stored in the kitchen were spoiled, with potatoes being mushy and sprouting, and onions being green and soft. The CDM acknowledged these items were not fresh and should have been discarded, indicating a failure to maintain safe and sanitary food storage for all residents consuming facility-prepared food.
Surveyors found that the facility did not consistently protect resident privacy, as a computer displaying a resident's medical information was left unattended and visible, and multiple residents received mail and packages that had already been opened. Staff interviews confirmed that mail was sometimes opened based on judgment calls, particularly for insurance documents, contrary to residents' rights to privacy and confidentiality.
Two residents sharing a room experienced persistent foul urine odors and unclean conditions due to one resident's refusal of care and the other's occasional refusal, with staff only cleaning when the room was unoccupied. The cognitively intact resident expressed dissatisfaction with the odor, and staff confirmed that both residents' behaviors contributed to the environment, but no alternative arrangements were offered.
Two residents with significant mental health diagnoses had inaccurate MDS assessments, with documentation failing to reflect updated PASRR Level II determinations and current diagnoses. The MDS Coordinator confirmed that assessments did not include correct information regarding serious mental illness status, despite supporting documentation in the medical records.
A resident with existing neurological and cognitive conditions was diagnosed with delusional disorder and alcohol-induced dementia, but the facility did not complete a new PASRR Level I screening as required. This omission was confirmed by staff and identified during record review and interview.
A nurse failed to prime an insulin pen and did not hold the needle in place for the recommended time during administration to a resident with diabetes. This did not follow professional standards or manufacturer instructions, as confirmed by staff interviews.
A resident with muscle weakness and unsteadiness was not provided assistance with toenail care despite multiple requests to staff. Observations and staff interviews confirmed that the resident's toenails were excessively long and had not been trimmed since admission.
A resident with multiple chronic conditions did not receive prescribed as-needed bowel care medications according to physician orders, resulting in a five-day period without a bowel movement. Medication administration records showed that interventions were not provided as required, and this lapse was confirmed by the ADON.
A resident with obstructive sleep apnea had a CPAP machine with a water chamber that was found dry and containing a whitish residue, indicating it had not been properly cleaned as required by physician orders. An RN, when asked about the residue, did not provide an explanation and only cleaned the chamber after the issue was identified during a survey.
A resident with PTSD, paraplegia, anxiety, and major depressive disorder was not assessed for trauma triggers, and their care plan only included medication administration without interventions for PTSD triggers. The ADON confirmed a lack of knowledge regarding the resident's triggers and acknowledged the absence of appropriate care plan interventions.
A resident requiring personal care assistance and with a pressure ulcer was found with a Pure Wick catheter canister full of foul-smelling, cloudy urine, and tubing containing urine resting on the nightstand. The canister and tubing were not emptied, rinsed, or stored in a clean bag after use, and an LPN confirmed these infection control practices were not followed.
Two residents experienced falls during mechanical lift transfers due to inadequate safety measures. One resident sustained significant injuries, while the other was unharmed. Despite current competencies of the CNAs involved, the facility's investigation found no deficiencies in staff actions or equipment.
The facility failed to ensure proper sanitation and PPE use in food preparation areas. Staff with facial hair did not wear coverings, and chemical testing supplies for sanitization were unavailable. Additionally, pans were stored wet, contrary to air-drying procedures, increasing the risk of bacterial growth.
The facility failed to properly contain and dispose of garbage, as observed when two dumpsters were found with open lids, exposing the garbage inside. This was contrary to the facility's policy requiring dumpsters to be closed and free of litter. A staff member was reminded to close the dumpster lid, and the Administrator confirmed the expectation for lids to be closed, indicating a lapse in policy adherence.
The facility failed to provide bed hold notices to two residents upon their transfer to the hospital, as required by policy. One resident with dementia, diabetes, and metabolic encephalopathy, and another with hypertension and congestive heart failure, were transferred without receiving the necessary documentation. The ADON was unaware of the requirement to issue a written bed hold notice during these transfers.
A resident with a fluid restriction due to medical conditions expressed a preference to have a water pitcher in their room to avoid frequent requests for water. Despite being cognitively intact and aware of their fluid restriction, the water pitcher was removed by a CNA at the direction of an LPN, who was concerned about the resident's water intake. Another LPN and the ADON stated that the resident's choice should be honored, and education on fluid restrictions could be provided.
A resident with a history of stroke was inaccurately assessed in their MDS, which documented them as cognitively intact and without extremity impairments. However, the Therapy Program Manager confirmed the resident had bilateral extremity impairments, and the MDS Coordinator admitted the assessment was incorrectly coded.
Improper Storage of Spoiled Produce in Kitchen
Penalty
Summary
During a kitchen inspection, surveyors observed a sack of potatoes and a sack of onions stored on a wire rack. The potatoes were found to be mushy with bulging sprouts, and the onions were green, soft, and mushy. The Certified Dietary Manager (CDM) confirmed that the potatoes and onions were not fresh and should have been disposed of. This failure to properly store and dispose of spoiled food items constituted a deficiency in maintaining safe and sanitary food storage practices for the facility's 129 residents who consumed food prepared by the facility.
Failure to Protect Resident Privacy and Confidentiality of Records and Mail
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as well as the security of their mail and packages. On one occasion, a computer screen displaying a resident's medical information was left open and unattended on a medication cart, making sensitive information visible. The responsible LPN acknowledged not logging off the computer before leaving the area. Additionally, the facility's process for handling resident mail and packages resulted in multiple instances where residents received mail and packages that had already been opened. Residents reported receiving opened packages and mail, with one resident stating this occurred regularly and another noting a specific incident and subsequent staff behavior that made her feel uncomfortable. Staff interviews revealed that the receptionist/accounts payable staff would sometimes open resident mail, particularly if it was believed to contain insurance cards, to make copies for the billing department before delivering the mail to residents. The administrator confirmed that staff made judgment calls about opening mail based on the return address and the feel of the envelope. These actions were inconsistent with the facility's documented resident rights, which guarantee personal privacy, confidentiality of records, and the right to receive unopened mail and packages.
Failure to Maintain Clean and Homelike Environment in Shared Room
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents sharing a room, resulting in persistent foul urine odors and unclean living conditions. One resident, who was severely cognitively impaired and had a history of refusing care, was observed with a half-full, uncapped urinal and an open bedside commode containing urine and splatters across the seat. Multiple observations over several days documented a strong foul urine odor emanating from the room and into the hallway. Staff interviews confirmed that the resident's behaviors often prevented timely cleaning, and staff would only clean the area when the resident was not present. The other resident in the shared room, who was cognitively intact but had a history of major depressive disorder and occasional refusal of care, expressed dissatisfaction with the persistent odor but felt unable to address the issue. Staff acknowledged that both residents' refusals of care contributed to the unclean environment and that relocating the affected resident had not been considered. The ongoing odor and lack of cleanliness were directly observed and corroborated by staff and resident interviews.
Inaccurate MDS Assessments Related to PASRR Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation regarding their mental health status and PASRR (Preadmission Screening and Resident Review) determinations. One resident, with diagnoses including Wernicke's encephalopathy, cognitive communication deficit, delusional disorder, and alcohol-induced dementia, had an annual MDS assessment that did not reflect updated mental health diagnoses. The assessment incorrectly indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness, despite documentation of an active psychotic disorder diagnosis. The MDS Coordinator confirmed that the PASRR Level I and II had not been updated following the new diagnoses. Another resident, admitted and readmitted with diagnoses such as PTSD, major depressive disorder, and anxiety, also had an annual MDS assessment that inaccurately documented the absence of a PASRR Level II determination. However, a PASRR Level II was present in the resident's electronic medical record. The MDS Coordinator acknowledged that the assessment should have indicated the presence of a PASRR Level II. These inaccuracies were identified through record review and staff interviews, demonstrating a failure to ensure that MDS assessments included correct and current information for residents with serious mental illness or related conditions.
Failure to Complete PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR) was accurately completed when new mental health diagnoses were identified for a resident. Specifically, the resident was admitted with multiple diagnoses, including Wernicke's encephalopathy and a cognitive communication deficit. On 3/14/24, the resident received two new mental health diagnoses: delusional disorder and alcohol-induced dementia. Despite these new diagnoses, the facility did not conduct a new PASRR Level I screening as required. This was confirmed by staff interview, where the ADON acknowledged that a new PASRR should have been completed at the time the new diagnoses were made. The deficiency was identified through record review and staff interview, and it was noted that the failure to complete the required PASRR screening could have resulted in the resident not being referred for necessary specialized mental health services.
Failure to Follow Professional Standards in Insulin Administration
Penalty
Summary
A deficiency was identified when a nurse failed to administer insulin according to professional standards and manufacturer instructions for a resident with diabetes. The nurse prepared the insulin pen by removing the cap, sanitizing the tip, attaching a new needle, and dialing the prescribed dose, but did not prime the pen before administration. The nurse then administered the insulin to the resident's left upper arm without holding the pen in place for the recommended duration, withdrawing the needle after approximately three seconds instead of the required ten seconds. Interviews confirmed that the nurse did not prime the insulin pen and did not adhere to the recommended injection time. The Assistant Director of Nursing stated that the facility's practice is to follow the manufacturer's instructions, which include priming the pen and holding the needle in place for ten seconds. The failure to follow these procedures was observed during the administration of insulin to a resident with multiple diagnoses, including diabetes, as ordered by the physician.
Failure to Assist with Personal Care Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a resident who was unable to perform these tasks independently. The resident, who had diagnoses including muscle weakness and unsteadiness, reported that she had repeatedly asked nurses, doctors, and CNAs to trim her toenails, but no one had assisted her. Observations confirmed that both of her great toenails were long, thick, and yellow, with measurements of a quarter inch in length. Staff interviews corroborated that the toenails were excessively long and should have been trimmed, indicating that the resident's needs for personal care were not met.
Failure to Administer Bowel Care Medications as Ordered
Penalty
Summary
The facility failed to follow professional standards of practice for bowel and bladder care for one resident with multiple diagnoses, including multiple sclerosis, malnutrition, and dementia. According to the physician's orders, the resident was to receive Miralax as needed if no bowel movement occurred for three days, followed by Dulcolax suppository and then a Fleets enema if there was no response to the previous interventions. Record review showed that the resident did not have a bowel movement for five consecutive days, from 6/1/25 through 6/5/25. Medication administration records indicated that none of the prescribed as-needed bowel care medications were administered during the first four days without a bowel movement, and the first intervention was not given until the fifth day. This was confirmed by the ADON, who acknowledged that the resident should have received medication on the fourth day but did not.
Failure to Maintain Clean CPAP Water Chamber
Penalty
Summary
The facility failed to ensure that the CPAP water chamber for a resident with obstructive sleep apnea was kept clean, as required by physician orders. The resident's care plan included nightly use of a CPAP machine with specific instructions to wash the tubing and reusable filter weekly. During observation, the CPAP machine was found on the resident's bedside table, and the resident reported last using it about a week prior. Upon inspection, the water chamber was found to be very dry with a whitish residue at the bottom. When questioned, the RN did not provide an explanation for the residue and proceeded to wash the chamber. The RN acknowledged that if the CPAP had been used the previous night, night shift staff should have noticed and cleaned the residue before setting up the machine.
Failure to Assess and Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to assess, monitor, and identify potential triggers for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), as required for trauma-informed care. Record review showed that the resident had multiple diagnoses, including PTSD, paraplegia, anxiety, and major depressive disorder, and was taking antianxiety and antidepressant medications daily. The resident's care plan only included medication administration for PTSD and did not address specific triggers. During staff interview, the Assistant Director of Nursing (ADON) confirmed she was unaware of the resident's PTSD triggers and acknowledged that the care plan lacked interventions for these triggers, despite the requirement to do so.
Failure to Maintain Sanitary Conditions for Pure Wick Catheter System
Penalty
Summary
The facility failed to implement proper infection control practices for a resident who used a Pure Wick female external catheter system. The resident, who required assistance with personal care and had a pressure ulcer on the left buttocks, was observed with her Pure Wick canister full of foul-smelling, dark, cloudy urine, and the tubing containing visible urine was resting on her nightstand. The canister and tubing were not emptied or rinsed after use, and the tubing was not stored in a clean bag as required. An LPN confirmed that the room smelled like urine and acknowledged that the canister and tubing should have been properly maintained to prevent cross contamination.
Deficiency in Resident Safety During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure the safety of residents during mechanical lift transfers, resulting in harm to two residents. Resident #1, who was severely cognitively impaired and dependent on staff for transfers due to hemiplegia and hemiparesis, fell during a transfer from her bed to a chair. Despite the mechanical lift competencies of the CNAs involved being current and complete, Resident #1 slid out of the sling, sustaining a facial contusion and fractures to her lumbar vertebrae and left leg. The facility's investigation did not identify any deficiencies in staff actions or equipment. Similarly, Resident #2, who was also severely cognitively impaired and required assistance for transfers due to Alzheimer's, muscle weakness, and knee contractures, fell during a transfer from a chair to her bed. The resident slid feet first from the sling, landing on the floor, but fortunately, no injuries were reported. The mechanical lift competencies of the CNAs involved were also current and complete, and the facility's investigation did not find any causative factors related to staff actions or equipment failure.
Sanitation and PPE Deficiencies in Food Preparation Areas
Penalty
Summary
The facility failed to adhere to sanitary standards in the food preparation areas, as observed during a survey. Staff members with facial hair were not wearing appropriate coverings, such as hair nets or beard nets, while working in food preparation areas. This was contrary to the facility's policy, which mandates that all dietary personnel must wear hair restraints at all times in these areas. The Certified Dietary Manager (CDM) confirmed that kitchen staff with facial hair are required to have their facial hair covered, yet observations showed non-compliance with this policy. Additionally, the facility did not have the necessary supplies to test the chemical levels in the sanitization compartment of a three-compartment sink, as required by their policy. A staff member was unable to demonstrate the monitoring of sanitization chemical levels due to the unavailability of testing supplies. Furthermore, the facility did not follow proper procedures for air-drying dishes, as observed with seven pans that were stacked and stored while still wet, which could encourage bacterial growth. The CDM acknowledged the oversight and noted that the pans needed to be re-washed and air-dried before storage.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper containment and disposal of garbage, as observed during a survey. The facility's policy, dated October 2023, requires that garbage be stored in a manner inaccessible to vermin, with dumpsters kept closed and free of surrounding litter. However, on June 24, 2024, at 8:37 AM, two dumpsters outside the facility were found with open lids, exposing the garbage inside. Dumpster #2 had bags of garbage preventing the lid from closing. A staff member was seen placing cardboard into this dumpster and was reminded by another staff member to close the lid, indicating a lapse in adherence to the policy. Later that day, at 3:26 PM, the Administrator confirmed that the dumpsters were supposed to have their lids closed, further highlighting the failure to comply with the facility's garbage disposal policy. This oversight increased the risk of pests and rodents, potentially endangering residents, staff, and guests.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to residents and/or their representatives upon transfer to a hospital, as required by their Admission/Discharge/Transfer policy. This deficiency was identified for two residents who were transferred to the hospital. The policy, revised in October 2023, mandates that residents or their representatives be informed in writing of their right to exercise the bed hold provision during a transfer to a hospital or for therapeutic leave. Resident #81, who had multiple diagnoses including dementia, diabetes, and metabolic encephalopathy, was transferred to the hospital on May 14, 2024, but there was no documentation of a bed hold notice being provided. Similarly, Resident #99, with diagnoses including hypertension and congestive heart failure, was transferred on May 12, 2024, without a bed hold notice being documented. The Assistant Director of Nursing (ADON) admitted to being unaware of the requirement to provide a written bed hold notice during such transfers, resulting in the failure to inform the residents or their representatives of their rights.
Failure to Honor Resident's Choice for Water Pitcher
Penalty
Summary
The facility failed to honor a resident's choice to have a water pitcher on the bedside table, which was a preference expressed by the resident. The resident, who was cognitively intact and had a physician's order for a 1,200 ml daily fluid restriction due to end-stage renal disease and congestive heart failure, reported that a water pitcher was placed on his bedside table by a nursing assistant but was later removed without his knowledge. The resident expressed that he preferred having the pitcher in his room to avoid frequently using the call light to request water. The removal of the water pitcher was directed by an LPN, who instructed a CNA to take it away while the resident was sleeping, citing the fluid restriction as the reason. The LPN acknowledged the resident's choice but was concerned about the resident requesting a lot of water over the weekend. Another LPN and the ADON stated that residents have the right to have a water pitcher in their room and that staff should honor their choices, suggesting that the resident could be educated on the risks and benefits of exceeding the fluid restriction.
Inaccurate MDS Assessment for Resident with Stroke History
Penalty
Summary
The facility failed to ensure accurate MDS assessments for its residents, as evidenced by the case of a resident with multiple diagnoses, including a history of stroke. A quarterly MDS assessment inaccurately documented the resident as cognitively intact and without upper or lower body impairments. However, the Therapy Program Manager later confirmed that the resident had both upper and lower bilateral extremity impairments. The MDS Coordinator also acknowledged that the MDS assessment was coded inaccurately, indicating a discrepancy between the resident's actual condition and the documented assessment.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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