Discovery Rehabilitation And Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Salmon, Idaho.
- Location
- 600 Shanafelt Street, Salmon, Idaho 83467
- CMS Provider Number
- 135129
- Inspections on file
- 18
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Discovery Rehabilitation And Living during CMS and state inspections, most recent first.
Surveyors identified multiple failures in food storage, labeling, and temperature monitoring, including unlabeled opened food items, undercooked meat loaf, and milk served at improper temperatures. Dietary staff and the DON confirmed that required labeling and temperature checks were not performed, resulting in non-compliance with food safety standards.
A resident with complex medical needs, including cauda equina syndrome and COPD, was admitted and did not have a baseline care plan completed and signed by an RN within the required 48 hours. Instead, the care plan was finalized four days after admission, as confirmed by the DON, which did not meet the facility's policy for timely care planning.
Two residents with physician orders for as-needed oxygen therapy did not have proper documentation in nursing progress notes regarding the initiation of oxygen or physician notification, despite records showing oxygen was administered. The DON later identified these as documentation errors.
Surveyors found that medication and treatment carts were left unlocked and unattended, allowing access to medications and medicated creams. A narcotic box in the medication refrigerator was not permanently affixed, and an open bottle of saline nasal spray with no expiration date, as well as loose pills, were found in the medication cart. The DON and an LPN confirmed these items should not have been present or unsecured, indicating failures in medication storage and labeling practices.
A trash can in the kitchen food prep area was found with a hole cut in the top, making it impossible to close and leaving it open to the air. The dietary supervisor was unaware that a closable lid was required for the trash can, resulting in noncompliance with FDA Food Code requirements for covering refuse containers containing food residue.
A medication cart was observed with a blue mug and an energy drink on top, which an LPN confirmed were her personal drinks. This action violated infection control regulations prohibiting food and drink in areas where occupational exposure to blood or infectious materials may occur.
The facility failed to store food safely and sanitarily, with uncovered and undated items found in the refrigerator and dry storage. Observations included undated salad, cheese, sour cream, and milk, as well as expired Brussels sprouts and sour cream. The Dietary Manager acknowledged the need for proper labeling and rotation of food items.
The facility failed to maintain a safe and clean environment in a shower/tub room, which had multiple areas with missing floor tiles posing a fall hazard and risk of cross-contamination. The Maintenance Supervisor and Administrator acknowledged the issue and mentioned efforts to address it.
A facility failed to maintain and store respiratory equipment properly for a resident with COPD and kidney disease. Observations showed outdated oxygen tubing and undated nebulizer tubing improperly stored. The DON confirmed the equipment should be cleaned, dried, and stored correctly, with tubing changed weekly and dated, creating a potential risk for respiratory infections.
The facility failed to maintain resident meals at the correct temperature and ensure they were palatable, affecting several residents. Observations showed hot foods were not kept at 135 degrees F or above, and cold foods were not maintained at 41 degrees F or below. Residents reported dissatisfaction with the food, describing it as cold and tasteless. Despite claims of using garnishes to improve appeal, staff were unaware of ongoing complaints.
The facility failed to adhere to infection control practices, including improper cleaning of equipment, inadequate hand hygiene, improper glove changes, and non-compliance with hairnet and glove use in the kitchen. An LPN used incorrect wipes for a glucometer, CNAs did not offer hand hygiene to residents before meals, and a kitchen staff member did not wear a hairnet or change gloves between tasks.
A facility failed to provide necessary health information to a hospital during a resident's transfer. The policy required staff to send documents like the face sheet, advance directive, and current physician's orders, and to document the process in Nursing Notes. However, for a resident with COPD and hypertension, there was no record of these documents being sent. The DON confirmed the oversight.
A facility failed to provide a required bed hold notice to a resident with COPD and hypertension upon transfer to the ER. The facility's policy requires written notification of a 7-day bed hold right upon admission and before hospital transfer, with documentation in the resident's health record. However, no such documentation was found, and the DON confirmed its absence.
A facility failed to follow physician's orders for a resident requiring OT, PT, and SP. The resident, admitted with conditions like subarachnoid hemorrhage and dysphagia, had orders for therapy evaluations and treatments that were not executed. The DON confirmed that referrals to Therapy were not made, creating potential harm and adverse outcomes.
The facility failed to update care plans for two residents, leading to discrepancies in care directives. One resident's care plan was not updated to reflect the resolution of a wound, while another resident's care plan contained conflicting resuscitation preferences. These oversights were acknowledged by facility staff.
A facility failed to obtain physician's orders for diabetic nail care and did not follow the wound care plan for a resident with multiple diagnoses, including diabetes. The resident was observed with unkempt toenails and no documented podiatrist referral, despite an existing order. Additionally, wound care was not documented on specified dates and areas. The DON acknowledged the absence of a podiatrist and the lack of care planning for diabetic nail care, as well as missed wound care documentation by nursing staff.
An inspection of a medication cart revealed deficiencies in medication storage and labeling, including an unlabeled Atrovent inhaler, expired normal saline vials, and loose pills. The facility's policies require proper labeling and disposal of expired medications, but these were not followed, as confirmed by an LPN present during the inspection.
A resident with multiple medical conditions was unable to reach the call light after falling in the bathroom due to the call light string being wrapped around the grab bar, shortening its length. The facility's policy requires accessible call systems, but this was not ensured in the resident's room.
A resident with multiple medical conditions, including a right shoulder joint fracture and confined to a wheelchair, was unable to access her closet due to the handles being positioned 58 inches high. The resident attempted to open the closet by prying the doors apart, highlighting the facility's failure to provide accessible closet door handles. The DON acknowledged the issue and the need for correction.
Deficient Food Storage, Labeling, and Temperature Monitoring
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and labeling practices. During a kitchen tour, it was found that dishwashing machine temperatures were not checked or recorded before use, and several opened food items in both dry storage and refrigeration areas lacked required date labels. Specifically, opened containers of rice, Hollandaise sauce mix, milk, apple juice, and cheese were either missing opened dates or use-by dates. Additionally, a lunch test tray included meat loaf that was undercooked and measured at 88 degrees F, and milk served at 50 degrees F, both outside of safe temperature ranges. The dietary supervisor and registered dietitian acknowledged these lapses, noting that required checks and labeling had not been performed. Further inspection revealed additional unlabeled opened milk containers and resident food items in the refrigerator, such as homemade soup and a half sandwich, which were not properly dated. The DON confirmed that these items should have been labeled according to policy but were not. These findings demonstrate a pattern of non-compliance with food safety standards, specifically regarding date marking, temperature monitoring, and labeling of ready-to-eat and resident food items.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed within 48 hours of admission for one of three residents reviewed. According to the facility's policy, a baseline care plan should be created and implemented within 48 hours to provide effective and person-centered care. In the case reviewed, a resident with multiple diagnoses, including cauda equina syndrome and chronic obstructive pulmonary disease, was admitted and the baseline care plan was not completed and signed by an RN until four days after admission. The Director of Nursing confirmed that the RN did not lock the initial baseline care plan in the medical record until four days post-admission, instead of within the required 48-hour timeframe.
Failure to Document and Notify Physician for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents who required oxygen therapy. For one resident with Alzheimer's disease and dementia, the physician's order specified to start oxygen as needed to maintain oxygen saturation above 90% and to notify the physician upon implementation. The resident's medical record showed multiple instances where oxygen was administered, but there was no documentation in the nursing progress notes indicating that oxygen therapy had been started or that the physician had been notified as required by the order. Similarly, another resident with a left femur fracture and orthopedic aftercare had a physician's order for oxygen therapy under similar conditions. The medical record documented the use of oxygen, but there was no corresponding documentation in the nursing progress notes regarding the initiation of oxygen therapy or physician notification during the relevant period. The Director of Nursing later stated that the SpO2 documentation in both residents' records were documentation errors and should not have been made.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. On two separate occasions, both the medication cart and the treatment cart were found unlocked and unattended, with no nurse present. The medication cart contained medications accessible to unauthorized individuals, and the treatment cart contained medicated creams and wound dressings. Additionally, a narcotic box stored in the medication refrigerator was not permanently affixed, as required, and the Director of Nursing (DON) was unaware of this requirement. Further inspection of the medication cart revealed an open bottle of saline nasal spray with an open date exceeding one month and no manufacturer's expiration date, as well as loose pills found in the bottom drawer. The LPN present confirmed the nasal spray should not have been on the cart and that the loose pills should have been destroyed. The DON stated that the medication cart is checked monthly for loose pills, suggesting the pills had been dropped since the last check. These observations demonstrate a failure to ensure medications were properly labeled, stored securely, and not expired.
Improperly Covered Trash Can in Kitchen Food Prep Area
Penalty
Summary
Surveyors observed that a trash can in the kitchen food preparation area had a hole cut in the top, preventing it from being properly closed and leaving it continuously open to the air. This observation was made in the presence of the dietary supervisor, who stated he was not aware that the trash can in the food prep area needed to have a closable lid. The facility failed to ensure that garbage cans were properly closed with lids, as required by the U.S. Food and Drug Administration 2022 Food Code, which mandates that receptacles containing food residue be kept covered when not in continuous use or after being filled. This deficient practice had the potential to affect all residents and staff in the facility.
Improper Storage of Personal Drinks on Medication Cart
Penalty
Summary
The facility failed to maintain proper infection control prevention practices as required by OSHA Bloodborne Pathogens regulations. During observation, a medication cart located by the nurse's station was found with a blue mug and an energy drink placed on top. Upon interview, an LPN confirmed that the personal drinks belonged to her and acknowledged they should not have been on the medication cart. This practice is not in compliance with regulations that prohibit food and drink in areas where there is a reasonable likelihood of occupational exposure to blood or other potentially infectious materials.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner, as observed during a kitchen inspection. In the walk-in refrigerator, a large stainless-steel bowl of salad was found uncovered and undated, along with sliced cheese wrapped in saran wrap and eight individual containers of sour cream, all lacking use-by dates. The dry storage closet contained open packages of cocoa, vanilla pudding, and gelatin without use-by dates. During a lunch meal observation, an open gallon of milk was also found without a date, with the Dietary Manager (DM) acknowledging the oversight due to the facility's high milk consumption rate. A follow-up inspection revealed further issues with food storage practices. A box of Brussels sprouts had a best-by date of over a month prior, and an opened container of sour cream was past its use-by date. The DM admitted that the food should have been properly rotated using the first-in, first-out method. These deficiencies in food storage practices had the potential to affect the 31 residents consuming food prepared by the facility, placing them at risk for potential contamination and adverse health outcomes.
Deficient Shower Room Conditions Pose Safety Risks
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by the condition of the shower/tub room observed during a survey. The room, located across from the nurses' station, had multiple areas with missing floor tiles, including three different areas to the left of the entrance and two significant areas in the shower area near the drain. These deficiencies were noted to pose a fall hazard and a risk of cross-contamination from the spread of microorganisms. The Maintenance Supervisor acknowledged the floor as a fall hazard and mentioned ongoing efforts to fix the tiles. The Administrator also confirmed the need for repairs and stated that remodeling approval was being sought.
Failure to Maintain and Store Respiratory Equipment Properly
Penalty
Summary
The facility failed to ensure proper maintenance and storage of respiratory equipment for a resident with COPD and kidney disease. The resident was admitted with orders for oxygen therapy and nebulizer treatments. Observations revealed that the resident's oxygen tubing was dated over three weeks prior, and the nebulizer tubing was undated and improperly stored on the nightstand. The Director of Nursing confirmed that the nebulizer should have been cleaned, dried, and stored correctly, and that both the oxygen and nebulizer tubing should be changed weekly and dated. This oversight created the potential for respiratory infections due to pathogen growth in the equipment.
Deficiency in Food Service Quality
Penalty
Summary
The facility failed to ensure that resident meals were palatable and maintained at the correct temperature, impacting seven residents directly and potentially affecting all 31 residents who dined in the facility. Observations during meal services revealed that hot foods were not maintained at the required temperature of 135 degrees F or above, and cold foods were not kept at 41 degrees F or below, as per the 2022 FDA Food Code. Specific instances included dry pork chops, small cubed potatoes without garnishes or condiments, and various food items served at incorrect temperatures, such as canned pears at 71 degrees F, yogurt at 44 degrees F, mashed potatoes at 125 degrees F, and milk at 46 degrees F. Residents expressed dissatisfaction with the food, describing it as cold, tasteless, and unappetizing. Interviews with residents and staff highlighted ongoing issues with food quality and temperature. Several residents, including those with conditions such as COPD, kidney disease, stroke, anemia, diabetes, and malnutrition, reported that the food did not taste good, was often cold, and lacked nutritional value. Despite the Dietary Manager's claim of using garnishes and gravies to enhance food appeal, both the Administrator and the Dietary Manager were unaware of the residents' complaints. This lack of awareness and the failure to address the residents' concerns contributed to the deficiency in food service quality.
Infection Control and Prevention Deficiencies
Penalty
Summary
The facility failed to adhere to infection control and prevention practices, as evidenced by improper cleaning of resident equipment, inadequate hand hygiene, improper glove changes, and non-compliance with hairnet and glove use in the kitchen. Specifically, an LPN used a Sani-Hands instant hand sanitizing wipe instead of the appropriate disinfecting wipe to clean a glucometer after checking a resident's blood sugar. Additionally, the Director of Nursing (DON) was unable to confirm the cleaning of a Hoyer lift after use, as the container of disinfecting wipes was missing. Hand hygiene practices were not consistently followed, as observed with multiple residents. CNAs failed to offer hand hygiene to residents before serving meal trays, despite the facility's policy emphasizing the importance of hand hygiene in preventing the spread of infections. This oversight was acknowledged by the CNAs, who admitted to forgetting to offer hand hygiene to the residents. In the kitchen, a staff member was observed not wearing a hairnet while preparing meals and failed to change gloves between tasks. This non-compliance with the facility's policy on hairnet and glove use was confirmed by the Dietary Manager, who stated that all kitchen staff should wear hairnets and change gloves between tasks.
Failure to Provide Pertinent Health Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that pertinent health information was provided to the receiving hospital during the transfer of a resident. According to the facility's Transfer or Discharge policy, staff were required to complete transfer documentation and attach copies of the face sheet, advance directive, current physician's orders, history and physical (H&P), and pertinent lab/x-ray results. Additionally, staff were to document the entire process in the Nursing Notes. However, for a resident with multiple diagnoses including COPD and hypertension, who was transported to the ER, there was no documentation in the resident's record indicating that the necessary medical information was sent to the hospital. The Director of Nursing confirmed that the required documents should have been sent and documented in the progress note, but this was not done.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives upon transfer to a hospital, as required by their policy. This deficiency was identified during a review of the case of a resident with multiple diagnoses, including COPD and hypertension, who was transferred to the emergency room. The facility's Bed Hold policy, revised in December 2023, mandates that residents or their representatives be informed in writing of their right to a 7-day bed hold upon admission and again before a hospital transfer, with a copy of this notification included in the resident's health record. However, upon review of the resident's medical record, no documentation of a bed hold notice was found, and the Director of Nursing confirmed its absence.
Failure to Follow Physician's Orders for Therapy
Penalty
Summary
The facility failed to adhere to physician's orders for a resident requiring specialized therapy treatments, which included Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (SP). The resident, who was admitted with multiple diagnoses such as nontraumatic subarachnoid hemorrhage, dysphagia, a right shoulder joint fracture, and diabetes, had physician's orders dated 7/23/24 for these therapies to evaluate and treat as needed. However, upon review on 9/11/24, there was no documentation in the resident's medical record indicating that OT or SP had been notified to evaluate or treat the resident. The resident's care plan included interventions for OT, PT, and SP evaluation and treatment per physician orders, yet these were not executed. On 9/12/24, the Director of Nursing (DON) confirmed that the necessary referrals to Therapy had not been made and documented, which was a requirement. This oversight created the potential for harm and adverse outcomes for the resident by not providing the ordered specialized therapy treatment.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the current needs and interventions for two residents. Resident #5, who was admitted with multiple diagnoses including herpes zoster and COPD, had a care plan that required contact transmission-based precautions and wound dressing for a lesion on the left hand. However, observations revealed that the wound dressing was not applied, and the infection preventionist confirmed that the wound had resolved, and the care plan should have been updated to reflect this change. Resident #8, admitted with conditions such as nontraumatic subarachnoid hemorrhage and dysphagia, had conflicting directives in her care plan regarding resuscitation preferences. One part of the care plan indicated a desire for CPR and calling 911, while another part indicated a DNR status. The Director of Nursing acknowledged the inconsistency, stating that the care plans were in the process of being updated, and both directives should not have been present in the care plan.
Failure to Obtain Physician's Orders and Follow Wound Care Plan
Penalty
Summary
The facility failed to obtain physician's orders for diabetic toenail and fingernail checks and did not follow the care plan for wound care for one resident. The resident, who was admitted with multiple diagnoses including diabetes, was observed with red, slightly swollen legs and feet, and unkempt long toenails. Although there was a physician's order for a podiatrist evaluation dated several months prior, no referral was documented, and the care plan lacked interventions for diabetic nail care. The Director of Nursing (DON) acknowledged the absence of a podiatrist serving the rural facility and the lack of care planning for diabetic nail care. Additionally, the facility did not document wound care for the resident on specified dates and areas, including the right upper inner arm, right elbow, and left lower extremity. The DON admitted that sometimes nurses missed wound care, and if the day shift did not complete it, the next shift should have done so and documented it.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications available for residents were properly labeled and not expired, as observed during an inspection of a medication cart. The inspection revealed several issues: an Atrovent inhaler was found in the top drawer of the medication cart without a label, 22 normal saline vials were present with an expiration date of April 2024, a loose levothyroxine tablet was found in the top drawer, and an unidentified half of a white tablet was also loose in the top drawer. These findings indicate a lack of adherence to the facility's policies regarding the storage and labeling of medications. The facility's policies, revised in 2018 and 2020, require that medications be stored in containers that meet legal requirements and that expired or discontinued medications be removed and disposed of according to facility procedures. However, during the inspection, it was noted that these policies were not followed, as evidenced by the presence of expired and improperly stored medications. LPN #1, present during the inspection, acknowledged the issues, stating uncertainty about the Atrovent inhaler's packaging and confirming that expired saline and loose pills should not have been in the medication cart.
Inaccessible Call Light in Resident Bathroom
Penalty
Summary
The facility failed to ensure that all call light strings in resident restrooms were of proper length and easily accessible to residents, as observed in the case of one resident. This deficiency was identified when a resident, who had multiple diagnoses including nontraumatic subarachnoid hemorrhage, dysphagia, a right shoulder joint fracture, and diabetes, reported being unable to reach the call light after falling in the bathroom. The call light string was found wrapped around the grab bar, which shortened its length and made it inaccessible from the ground. The facility's Environmental Safety policy requires that a resident call system be provided at each resident's bed and toilet/bathing areas to allow residents to call for staff assistance. Despite the facility's practice of conducting rounds to ensure call lights are accessible, this issue was not corrected in the resident's room.
Inaccessible Closet Door Handles for Wheelchair-Bound Resident
Penalty
Summary
The facility failed to provide accessible closet door handles in all resident rooms, which did not meet the physical needs of residents confined to wheelchairs. This deficiency was observed in one resident, who was unable to reach the closet door handles that were positioned 58 inches high. The resident, who had multiple diagnoses including nontraumatic subarachnoid hemorrhage, dysphagia, a right shoulder joint fracture, and diabetes, was seen attempting to open the closet door by pushing her finger between the doors and trying to pry it open. The Director of Nursing acknowledged that the height of the closet door handles was an issue for residents in wheelchairs and should have been corrected.
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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