Eagle Rock Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Idaho Falls, Idaho.
- Location
- 840 East Elva Street, Idaho Falls, Idaho 83401
- CMS Provider Number
- 135092
- Inspections on file
- 20
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Eagle Rock Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that the facility failed to document that required pertinent health information, including care plan goals and advance directive details, was provided to hospitals when multiple residents were transferred for issues such as falls with head injuries, lacerations, respiratory problems, altered mental status, chest pain, and gastrointestinal symptoms. Although eINTERACT transfer forms were completed in the EHR, the residents’ records did not show that this critical information accompanied them to the receiving facilities, contrary to the facility’s discharge and transfer policy.
The facility did not complete and lock baseline care plans within 48 hours of admission for two residents with conditions including chronic respiratory failure, dementia, diabetes, and need for assistance with personal care, contrary to facility policy. In addition, the facility did not document that baseline care plans were provided and discussed with five cognitively intact or medically complex residents, including those with COPD, CKD, bipolar disorder, anxiety, interstitial lung disease, heart failure, and obstructive sleep apnea, or with their representatives. The CNO acknowledged that required baseline care plans were either not completed timely or not documented as shared with residents or their representatives.
Surveyors found that medications and treatment supplies on two medication carts and one treatment cart were not properly labeled, dated, or secured. On one cart, eye drops had illegible labels with old open dates and glucose test strips lacked an open date, while staff stated these items should only be used for 30 days after opening. A treatment cart containing medicated creams was observed unlocked in a hallway, and another cart contained undated glucose test strips, with an RN acknowledging they should have been dated and being unsure of their post-opening usability period.
The facility failed to follow infection control policies for oxygen and respiratory equipment and for disinfection of a shared glucometer. Multiple residents’ CPAP/BIPAP/VPAP masks, nebulizer masks, and oxygen tubing were observed uncovered on dressers, walkers, wheelchairs, and on the floor, rather than cleaned and stored in labeled bags as required. In one case, an RN placed oxygen tubing that had been on the floor directly into a storage bag without cleaning. A resident with COPD, depression, and cardiomegaly, ordered to receive continuous oxygen via nasal cannula, had the cannula picked up from the floor and reapplied by a CNA instead of being replaced. An LPN used a glucometer on a resident and wiped it with a disinfecting wipe but did not ensure the device remained wet for the full required contact time before returning it to its case, despite acknowledging the stated 2-minute dry time.
Surveyors found that staff failed to maintain resident dignity during personal care and catheter management. In one case, a CNA removed a resident’s shirt without closing the privacy curtain while the roommate was present. In another case, a resident’s urinary catheter bag was left uncovered and visible from the hallway with the room door open, despite facility policy requiring catheter bags to be covered to promote dignity.
A resident with COPD, depression, and cardiomegaly was started on Aripiprazole 5 mg daily without informed consent being obtained prior to initiation. Review of records showed that the psychoactive medication informed consent form, which included Aripiprazole along with Bupropion and Fluoxetine, was signed only after the medication had already been started. The CEO confirmed that a psychotropic medication acknowledgement consent should have been signed before Aripiprazole was administered but was not.
A resident with paraplegia and depression was found with two ophthalmic medications (artificial tears and prednisolone acetate) stored at the bedside, despite facility policy requiring an assessment and physician order before self-administration and bedside storage. An LPN and the CNO both stated the resident should not have had eye drops at the bedside, and the IDT self-administration assessment documented that the ability to correctly administer eye drops was marked as not applicable. The resident’s record contained active physician orders for both eye medications, but there was no approval by the IDT for self-administration of eye medications, resulting in a failure to follow the facility’s self-administration policy.
The facility failed to assist a resident in exercising the right to formulate an advance directive. A resident with quadriplegia and depression had a POST form in the medical record but no documented advance directive and no documentation that the facility informed the resident or provided written information about the right to create one. The Administrator confirmed that only POST documents were on file for this resident, with no evidence of required advance directive information being provided.
Staff failed to maintain a safe, clean, and homelike environment in multiple areas, including two resident rooms and several shower rooms. One room had torn door frame molding with sharp, jagged edges, and another had a broken electrical outlet with jagged edges. Shower rooms had broken and missing floor tiles, rusted and broken wall heaters (including one with exposed wiring and another partially detached from the floor), dark black residue in grout and around drains, and large amounts of hair on a shower stall floor. A CNA reported the shower rooms did not appear to have been cleaned, and the Maintenance Director stated he was unaware of the needed repairs and the poor condition of the shower rooms.
Surveyors found that the facility did not review and implement hospital discharge instructions for two residents who used respiratory support devices. One resident with chronic respiratory failure and sleep apnea had a CPAP machine in the room and reported using it at night, but there was no corresponding physician order, care plan entry, or MDS documentation. Another resident with COPD and chronic kidney disease had an AVAP machine with detailed hospital transfer orders specifying pressure settings, respiratory rate, tidal volume, and O2 bleed-in parameters, yet no physician orders for AVAP use were entered in the medical record. The CNO confirmed that orders for both devices were missing, placing these residents at risk of delayed respiratory care and assessments.
A resident with chronic respiratory failure with hypoxia and dementia was started on hospice care per physician order and care plan documentation, but the facility did not complete the required significant change in condition/status MDS assessment within 14 days of this change. The MDS coordinator and CNO both acknowledged that the significant change MDS should have been completed but was not, resulting in the resident’s status not being accurately reflected in the assessment.
The facility failed to correctly complete a PASARR Level I screening for a resident with documented chronic PTSD and anxiety disorders, as required by facility policy. The resident’s Level I screenings did not include these mental health diagnoses, which should have triggered a PASARR Level II evaluation by the state-designated authority prior to admission. Review of the medical record showed that, despite the documented PTSD diagnosis, there was no evidence that a Level II PASARR had been completed by the time of surveyor review, indicating that the required in-depth evaluation and determination letter were not obtained as mandated.
A resident with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, did not have their PTSD addressed in the comprehensive person-centered care plan, despite facility policy requiring that all individual conditions and needs be reflected with measurable goals and interventions. Review of the care plan showed no focus, interventions, or tasks related to PTSD, and the CNO acknowledged that the PTSD diagnosis should have been included in the care plan but was not.
Surveyors found that the facility did not revise care plans to include new physician orders for two residents. One resident with a right leg fracture and edema had an order for a Tubi grip for edema management, but this intervention was not added to the care plan or TAR, and the resident was repeatedly observed without the Tubi grip in place despite reporting ongoing swelling. Another resident with COPD, depression, and cardiomegaly had a new order for continuous O2 at 3 LPM via NC, but the care plan still listed only older O2 orders at different settings and was not updated to reflect the current prescription.
Two residents experienced deficiencies in care when physician orders and facility protocols were not followed. One resident with Parkinson's disease and chronic kidney disease went more than four days between documented BMs without bowel protocol medications being administered or physician notification documented, despite standing orders outlining stepwise interventions. Another resident with interstitial lung disease and heart failure had a PICC line with an undated, loose dressing and unsecured tubing, and nursing staff could not locate current orders for the line after IV antibiotic therapy had ended, nor confirm whether it should still be in use or removed.
A resident with paraplegia and dysphagia, who received medications via an enteral tube, had a physician order requiring tube placement to be checked by auscultation before medication administration. An RN administered water and liquid hydroxyzine HCl through the tube and flushed it without verifying tube placement. The facility’s policy referenced following professional standards and verifying tube placement per protocol, but the RN reported not knowing the policy on checking placement or residual, and the CNO stated the G-tube policy did not require checking placement or residual before medications or feedings, relying only on x-ray at insertion. This resulted in a deficiency related to inadequate care and treatment for enteral tube use.
The facility failed to follow physician orders and manufacturer instructions for oxygen and PAP therapy for three residents. One resident with COPD and cardiomegaly had an order for continuous O2 at 3 LPM via nasal cannula but was repeatedly observed without the cannula in place. Another resident with PTSD and obstructive sleep apnea had orders for CPAP with supplemental O2 at HS and O2 every shift, yet was observed not using O2 during the day, and oxygen was allowed to bleed into a CPAP device that was turned off without the required pressure valve installed. A third resident with osteomyelitis and a lumbar fracture had an order and care plan for continuous 2 LPM O2 to maintain SpO2 ≥ 90%, but was observed off oxygen and had documented SpO2 readings of 88% on room air. The CNO acknowledged staff had not ensured ordered oxygen use and was unaware of the required pressure valve for PAP devices.
A resident with acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture had a care plan calling for non-pharmacological pain interventions in addition to PRN Hydrocodone-Acetaminophen. Review of the MAR showed that staff administered the PRN opioid on multiple occasions without any documented attempt to use non-pharmacological pain management beforehand, contrary to facility policy and the resident’s care plan. The CNO acknowledged that non-pharmacological interventions should have been offered prior to giving the hydrocodone but were not, resulting in inadequate pain management.
The facility failed to ensure staff competency in medication administration when an LPN administered Metoprolol to a resident with interstitial lung disease, heart failure, and hypertension without obtaining required vital signs beforehand, despite a physician order to hold the drug for SBP < 100 or HR < 50 and a facility policy and completed competency indicating vital signs must be taken prior to preparing parameter-based medications. This issue was identified in 1 of 5 nurses observed and was determined to have the potential to affect all residents and increase the risk of harm.
The facility failed to accurately complete and post daily nurse staffing information for all shifts, resulting in multiple days where RN, LPN, or CNA staffing data were missing or entire staffing sheets were not available. On several occasions, posted information lacked RN or LPN data for specific shifts, omitted CNA data for all shifts, or showed only one RN for part of a shift with no other licensed nurses listed. The Staffing Coordinator later acknowledged that these staffing sheets and data should not have been missing but were, affecting the ability of residents, their representatives, visitors, and others to review accurate staffing levels.
A resident with COPD and diabetes was moved to a different room without receiving the required prior written notice explaining the nature and date of the transfer. Review of the medical record and staff interviews confirmed that no written documentation was provided to the resident regarding the room change.
The facility did not send required discharge or transfer notices to the State LTC Ombudsman for three residents with complex medical needs who were transferred to the emergency department or discharged to another care setting. This failure occurred over several months when the Social Worker position was vacant, and no documentation of notification was found in the residents' records.
A resident with documented allergies to tomatoes and melon was served a meal containing a tomato-based sauce, despite these allergies being clearly noted in the medical record and on the meal ticket. The food service manager confirmed the error after investigation, indicating a failure to follow the facility's nutrition policy regarding accommodation of dietary needs.
The facility failed to maintain kitchen sanitation and proper food storage, with food items stored only 4.5 inches above the floor and a pink slimy substance found in the ice machine. Kitchen cookware had black residue despite being cleaned, and dust particles were observed in the walk-in refrigerator. These issues were confirmed by the Culinary Director and Registered Dietitian.
The facility failed to develop comprehensive care plans for four residents, leading to deficiencies in their care. A resident with dementia did not have care directions for her condition, while another with a foley catheter lacked care instructions in his plan. A third resident's activity preferences were not addressed, and a fourth resident's care plan did not reflect new orders for a foley catheter. The CEO confirmed these omissions.
A facility failed to update a resident's care plan after changes in medication orders, despite the resident having multiple diagnoses including bipolar and psychotic disorders. The care plan still documented the use of antidepressant medications even after they were discontinued, as confirmed by the CEO. This oversight risked adverse outcomes due to the care plan not reflecting the resident's current needs.
A resident with COPD was found receiving oxygen therapy at two liters per minute, contrary to the physician's order of one liter per minute. This discrepancy was confirmed by an RN, highlighting a failure to adhere to prescribed oxygen therapy, potentially compromising the resident's respiratory care.
Two residents in an LTC facility experienced significant medication errors. One resident received incorrect doses of oxycodone due to a transcription error in the MAR, while another received a lower dose of Lyrica than prescribed. These errors were confirmed by the CEO, indicating a failure in ensuring accurate medication administration.
Two residents in a facility experienced significant medication errors. One resident was hospitalized after receiving another resident's medications due to an LPN's confusion over room assignments and similar first names. Another resident was potentially given the wrong insulin type, but did not require further medical intervention. The errors were confirmed by the DNS and Regional Clinical RN.
A resident's medications were crushed and mixed with food without a physician's order, and Levothyroxine was administered at night instead of the prescribed 5:30 AM. The LPN altered the administration time to avoid waking the resident early, and the facility's DNS and Regional Clinical RN were unaware of these practices until informed by surveyors.
A facility failed to remove discontinued hydrocodone from a medication cart, affecting a resident with multiple diagnoses, including metabolic acidosis, diabetes, and hypertension. The medication was discontinued but remained in the cart, posing a risk for medication errors and diversion. An LPN acknowledged the oversight, and the CRN confirmed that such medications should be removed by the next working day.
A medication labeling deficiency was identified when a resident's blister pack for oxycodone 5 mg did not reflect the updated order of four times a day (every 6 hours) and instead stated every 4 hours as needed. This was discovered during a medication cart inspection with an LPN present. The resident had multiple diagnoses, including a left arm fracture, heart failure, hypertension, and pain, and had their medication order changed, but the label was not updated accordingly.
Failure to Document Transmission of Pertinent Health Information During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pertinent health information, including care plan goals and advance directive information, was provided to receiving hospitals when residents were transferred. Policy review showed that the facility’s “Discharge or Transfer” policy, revised on 8/30/25, required that information conveyed to receiving providers for residents being transferred or discharged be provided in accordance with federal guidance. Despite this policy, surveyors found multiple instances where the medical records did not contain documentation that the required information was sent with the residents at the time of transfer. For one resident with progressive supranuclear ophthalmoplegia and a history of pulmonary embolism, eINTERACT Transfer Forms documented several discharges to the hospital for head pain and falls on multiple dates. However, for each of these transfers, the resident’s medical record lacked documentation that care plan goals and advance directive information were provided to the hospital. Another resident with Parkinson’s disease and chronic kidney disease was transferred to the hospital for lacerations on two separate occasions, and in both cases, the medical record did not show that the required pertinent medical information, including care plan goals and advance directives, was sent to the receiving facility. Additional residents with diagnoses such as bipolar disorder, anxiety, COPD, obstructive sleep apnea, heart failure, and COPD were also transferred to the hospital on multiple occasions for issues including shortness of breath, pain, diarrhea, elevated heart rate, altered mental status, chest pain, and other conditions. For each of these transfers, the medical records similarly lacked documentation that care plan goals and advance directive information were provided to the receiving hospitals. During an interview, the CNO stated that nurses had completed the eINTERACT charting in Point Click Care but had not documented which forms were sent to the hospital, acknowledging that this documentation should have been completed.
Failure to Complete and Share Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to complete and lock baseline care plans within 48 hours of admission for two residents and failed to provide and document provision of baseline care plan summaries to several other residents or their representatives. Policy revised 9/3/25 required initiation of a baseline care plan for each resident within 48 hours of admission, and that the facility review and provide the resident and/or representative with a summary of the baseline care plan and provider orders in an understandable language, with evidence of this in the medical record. Resident #4, admitted with chronic respiratory failure with hypoxia and dementia, had a baseline care plan that was not signed and locked until four days after admission, and the CNO confirmed it should have been completed and locked within 48 hours. Resident #70, initially admitted and later readmitted with diabetes and a need for assistance with personal care, had no baseline care plan documented in the medical record, which the CNO also confirmed. The facility also did not document that baseline care plans were provided and discussed with five residents or their representatives. Resident #7, with bipolar disorder and anxiety and assessed as cognitively intact on a quarterly MDS, had a 48-hour care plan form that did not document that she or her representative received a copy of the baseline care plan. Resident #9, with COPD and chronic kidney disease and documented as cognitively intact on a comprehensive MDS, had no documentation in the medical record that a baseline care plan was provided and discussed with her or her representative. Residents #11, #21, and #28, each with multiple diagnoses including COPD, obstructive sleep apnea, interstitial lung disease, heart failure, and COPD, similarly had no documentation that their baseline care plans were provided and discussed with them or their representatives. The CNO stated there was no documentation that these residents or their representatives had received copies of their baseline care plans.
Improper Medication Labeling, Dating, and Security on Medication and Treatment Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were properly labeled, dated, and securely stored in accordance with its own “Medication Storage In The Facility” policy. The policy required all medications to be stored in pharmacy-labeled containers, for outdated or deteriorated medications to be immediately removed and destroyed, and for certain products such as ophthalmic solutions and blood sugar testing supplies to be assigned shortened expiration dates once opened. During observation of the Yellowstone Hall medication cart, surveyors found a bottle of eye drops with an illegible label and an open date of 12/20/25, another bottle of eye drops with an illegible label and an open date of 2/20/26, and a bottle of glucose test strips with no open date. The LPN present stated that eye drops and glucometer strips were considered good for only 30 days after opening, acknowledged the eye drops should have been wasted, and that the undated strips should have been discarded. The CNO later stated that eye drop bottles should be dated with the open date and that he would need to check pharmacy policy for the exact duration of use. Additional observations showed failures in securing medication and treatment supplies. A treatment cart was observed unlocked in a hallway outside a resident room, and an LPN confirmed that the cart contained medicated creams and should have been locked. On a separate medication storage observation of the Mesa Falls Hall medication cart, surveyors again found an undated bottle of glucose test strips. The RN present acknowledged that the strips should have been dated when opened and was unsure how long they remained usable after opening. These findings demonstrated that medications and treatment supplies on multiple carts were not consistently dated, labeled legibly, or kept locked and inaccessible as required by facility policy.
Failure to Maintain Infection Control for Oxygen Equipment and Glucometer Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies for oxygen and respiratory equipment storage/handling and for disinfection of shared blood glucose meters. Facility policy required oxygen and respiratory supplies to be changed weekly and when visibly soiled, and to be stored in labeled bags when not in use. Observations showed multiple residents’ respiratory devices and oxygen supplies left uncovered and improperly stored: a CPAP lying uncovered on a dresser, a nebulizer mask hanging uncovered on a walker, oxygen nasal cannula tubing lying on the floor, a BIPAP mask on a dresser and oxygen tubing draped over a wheelchair uncovered, and a VPAP mask lying over the machine uncovered. In one instance, an RN acknowledged that oxygen tubing should not be on the floor and nebulizers should not be stored on walkers, but then placed tubing that had been on the floor directly into an oxygen bag without cleaning and placed a nebulizer mask on a dresser. The Infection Preventionist later stated that oxygen tubing should be bagged when not in use, nebulizer masks should be cleaned and dried after each use, and CPAP/BIPAP/VPAP equipment should be cleaned and set up for nighttime use. The facility also failed to follow manufacturer instructions for disinfecting a shared glucometer. The TRUE METRIX Pro Glucose Meter manual required use of PDI Super Sani Cloth (or equivalent EPA-registered product) with all external surfaces kept wet for 2 minutes to disinfect the device. An LPN checked a resident’s blood sugar, wiped the glucometer with a Sani wipe, and then immediately returned it to its case, later stating that although she knew the dry time was 2 minutes, she did not realize the meter had to remain wet for that duration. Additionally, a resident with COPD, depression, and cardiomegaly had a physician order for continuous oxygen at 3 LPM via nasal cannula. This resident was observed not wearing oxygen, and a CNA picked the nasal cannula up from the floor and assisted the resident in placing it without replacing the tubing. The CNA stated the cannula and tubing should have been discarded and replaced when found on the floor, and the CNO confirmed oxygen supplies should be discarded and replaced weekly or when found on the floor and not used.
Failure to Maintain Resident Dignity During Personal Care and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect in accordance with its Dignity policy dated 9/12/25, which states that each resident has the right to be treated with dignity and respect and specifies avoiding demeaning practices such as leaving urinary catheter bags uncovered. For one resident with diabetes and a need for assistance with personal care, a CNA removed the resident’s shirt without pulling the privacy curtain, even though the resident’s roommate was present in the room and able to observe the undressing. The resident later stated she usually pulls the curtain so her roommate cannot see her being changed but had forgotten on this occasion, and the CNA acknowledged she should have provided privacy before removing the shirt. For another resident with multiple diagnoses including enterocolitis due to Clostridium difficile and COPD, surveyors observed from the hallway that the resident’s urinary catheter bag was hanging on the side of the bed without a privacy bag or cover, with the room door open and the bag visible from the hallway. Nursing staff later stated the catheter bag had not been covered because the resident had just returned to the room and that the CNA must have forgotten to cover it. The CNO confirmed that the catheter bag should have been covered or placed in a privacy bag and that it had not been, contrary to the facility’s policy on promoting resident dignity.
Failure to Obtain Informed Consent Before Initiating Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to initiating a psychotropic medication for one resident reviewed for unnecessary medications. The resident, who had diagnoses including COPD, depression, and cardiomegaly, was ordered Aripiprazole 5 mg by mouth once daily on 11/27/25. Record review showed that the resident’s Psychoactive Medication Informed Consent form, which listed Aripiprazole 5 mg along with Bupropion 150 mg and Fluoxetine 40 mg, was not signed until 1/16/26, after the medication had already been started. In an interview, the CEO acknowledged that the resident should have signed a Psychotropic Medication Acknowledgement Consent prior to administration of Aripiprazole but had not done so.
Failure to Assess and Authorize Resident Self-Administration of Eye Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy for assessing and authorizing resident self-administration of medications. The facility’s Self-Administration of Medication policy, revised 9/16/25, states that residents may self-administer medications when it is determined to be safe and appropriate, that the assessment will include whether bedside storage is appropriate, and that if self-administration is approved, a physician’s order will be obtained and the care plan updated. Resident #59, who had diagnoses including paraplegia and depression, was observed on 3/30/26 at 10:07 AM with one bottle of Artificial Tears eye drops and one bottle of Prednisolone Acetate eye drops sitting on the bedside table. At 10:22 AM the same day, an LPN stated that this resident should not have had the Artificial Tears and Prednisolone Acetate eye drops at the bedside. Review of the resident’s medical record at 1:27 PM showed an IDT self-administration assessment dated 3/17/26, in which the criterion "Can correctly administer eye drops or eye ointments according to proper procedure" was marked as "Not applicable." The medical record also contained physician orders for Prednisolone Acetate ophthalmic suspension 1% with a start date of 3/19/26 and Artificial Tears ophthalmic solution 0.2-0.2-1% with a start date of 3/20/26. On 3/31/26 at 5:17 PM, the CNO confirmed that the resident should not have had eye drops at the bedside and had not been approved by the IDT for self-administration of eye medications. The report states this failure created the potential for adverse effects if medications were self-administered inappropriately by the resident.
Failure to Assist Resident in Formulating an Advance Directive
Penalty
Summary
The facility failed to ensure a resident and their representative received assistance to exercise the right to formulate an advance directive. Record review showed that one resident, admitted with multiple diagnoses including quadriplegia and depression, had a Physician Orders for Scope of Treatment (POST) form in the medical record but no documented advance directive. The record also lacked documentation that the facility had informed the resident or provided written information about the right to formulate an advance directive. During interview, the Administrator stated that the facility only had POST documents for this resident, confirming the absence of advance directive documentation or evidence of required information being provided. This deficient practice created the potential for harm or adverse outcomes if the resident’s wishes were not followed or documented regarding their advance care planning.
Environmental Hazards and Poor Sanitation in Resident Rooms and Shower Areas
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident care areas, including two resident rooms and several shower rooms. In one resident room, the door frame protective molding was torn with sharp, jagged edges, and in another room, an electrical wall outlet was broken with jagged edges. These conditions were directly observed by surveyors on multiple dates. The Maintenance Director later stated he had been unaware of the needed repairs to the room door frame molding and the broken electrical outlet. Additional environmental deficiencies were observed in several shower rooms. In the Grand Teton Hall shower room, the tile floor at the entry door had broken tile and missing grout. In the Palisades Hall shower room, the wall heater had broken and rusted areas on the front and sides, with the heater base broken, jagged, and partially disconnected from the floor; the tile floor had dark black residue in the grout and around the floor drain, and several broken floor tiles with open divots and dark black residue in the exposed areas. In the Mesa Hall shower room, the wall heater cover was removed and lying on the floor, leaving exposed wiring on the bottom side of the heater. A CNA stated the shower rooms did not look like they had been cleaned and should have been. Later observation of the Palisades Hall shower stall revealed a large amount of dark strands of hair in the drain and on the shower stall floor. The Maintenance Director also stated he was unaware that the heaters needed repair and that the shower rooms did not appear to have been cleaned.
Failure to Implement Respiratory Device Orders on Admission
Penalty
Summary
The facility failed to ensure hospital discharge instructions were reviewed upon admission so that physician orders were in place to meet residents’ medical needs. One resident with chronic respiratory failure with hypoxia and obstructive sleep apnea was admitted with a CPAP machine present in his room and reported using it at night. Surveyors observed the CPAP machine on the resident’s dresser, and the resident confirmed nighttime use. However, the Chief Nursing Officer (CNO) later stated that there was no physician order for the CPAP, and it was not included on the resident’s care plan or Minimum Data Set (MDS), despite the resident’s diagnoses and reported use of the device. Another resident admitted with COPD and chronic kidney disease had an AVAP machine at bedside and stated she used it at night to help her breathe while sleeping. Review of this resident’s hospital transfer orders documented detailed AVAP settings, including IPAP and EPAP ranges, respiratory rate, tidal volume, and oxygen bleed-in parameters with humidification and SpO2 targets, as well as instructions for use each night. Despite these specific hospital discharge instructions, review of the resident’s medical record on a later date showed no physician orders for AVAP use. The CNO confirmed that the AVAP was not on the resident’s orders and acknowledged it should have been, and the survey findings stated that this failure placed the residents at risk of delayed respiratory care and assessments.
Failure to Complete Significant Change MDS After Initiation of Hospice Care
Penalty
Summary
The facility failed to complete a significant change in condition or status assessment MDS within 14 days after a resident began hospice care, resulting in an inaccurate reflection of the resident’s status. The resident was admitted with multiple diagnoses, including chronic respiratory failure with hypoxia and dementia. A physician order dated 2/19/26 documented end-of-life care with hospice services, and the resident’s care plan also documented that hospice care started on that date. Despite this documented change in condition and care approach, the facility did not complete the required significant change MDS assessment within the mandated timeframe. On 3/31/26, the MDS coordinator acknowledged that the significant change assessment had not been completed and stated it should have been. On 4/1/26, the CNO similarly stated that the significant change in condition or status assessment MDS should have been completed within 14 days of the start of hospice care and had not been. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments.
Failure to Accurately Complete PASARR Level I and Initiate Required Level II Evaluation
Penalty
Summary
The facility failed to ensure that a Level I Pre-admission Screening and Resident Review (PASARR I) was completed correctly for one resident, resulting in an omission of documented mental health diagnoses that should have triggered a Level II PASARR. Facility policy dated 8/29/25 required that a Level I PASRR be completed on potential admissions prior to admission, with a positive Level I screen leading to an in-depth Level II evaluation by the state-designated authority and a determination letter obtained prior to admission. The resident, who was initially admitted and later readmitted with multiple diagnoses including chronic post-traumatic stress disorder (PTSD) and joint replacement surgery aftercare, had Level I PASRR screenings dated 3/3/26 and 3/13/26 that did not document his PTSD and anxiety disorders. The resident’s medical record on 3/3/26 showed a medical diagnosis of chronic PTSD, yet as of 3/30/26 at 12:00 PM there was no documentation that a Level II PASARR had been completed, despite these qualifying mental health conditions. Staff later acknowledged that a Level II PASARR had only just been completed and sent for review, confirming that the required Level II process had not been initiated in a timely manner based on the resident’s documented diagnoses. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility.
Failure to Care Plan for Resident’s PTSD Diagnosis
Penalty
Summary
Surveyors found that the facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s diagnosed Post-Traumatic Stress Disorder (PTSD). The facility’s policy on Comprehensive Care Plan and Conferences, dated 9/3/25, required that care plans reflect residents’ individual conditions, risks, needs, behaviors, cultural values, and preferences, and include measurable goals, appropriate interventions, and realistic timeframes. Resident #13 was initially admitted and later readmitted with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, and the medical record dated 3/3/26 documented a diagnosis of chronic PTSD. However, on 3/31/26 at 2:09 PM, review of the resident’s care plan showed no focus, interventions, or tasks addressing the PTSD diagnosis. On 4/1/26 at 12:47 PM, the CNO confirmed that the resident’s PTSD diagnosis should have been care planned and had not been, demonstrating noncompliance with the facility’s care planning policy.
Failure to Update Care Plans for New Edema and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise resident care plans to reflect current physician orders and resident needs, as required by its Resident Care Plan Revisions policy. The policy, revised on 9/3/25, states that updates to the care plan will occur as needed based on the resident’s response to interventions or changes in condition. For one resident with a history including a right tibia fracture and anxiety, a physician order dated 3/6/26 directed edema management of the right lower leg with application of a Tubi grip in the morning and removal in the evening. On multiple observations on 3/30/26 and 4/2/26, the resident was seen sitting in her room without the ordered Tubi grip in place, and during an interview the resident reported that her right lower leg had been swollen for a while. Review of the resident’s care plan and Treatment Administration Record (TAR) on 4/2/26 showed no documentation of the Tubi grip order. A second resident, with diagnoses including COPD, depression, and cardiomegaly, had a physician order dated 3/9/26 for oxygen at 3 LPM continuously via nasal cannula using an oxygen concentrator and/or tank. Review of this resident’s care plan on 4/1/26 showed only prior oxygen interventions: oxygen via nasal prongs at 0–4 L PRN to maintain saturation at 90% or greater, initiated 2/10/25, and oxygen at 2 L/min continuously via nasal cannula, initiated 6/24/25. The more recent continuous 3 LPM oxygen order was not reflected in the care plan. In both cases, the CNO acknowledged that the residents’ care plans (and, for the first resident, the TAR) should have been updated to include the current physician orders but had not been revised.
Failure to Follow Bowel Protocol and PICC Line Orders
Penalty
Summary
The deficiency involves failure to follow physician orders and facility policies for bowel management and infusion therapy. For one resident with Parkinson's disease and chronic kidney disease, the facility had a standing bowel protocol with stepwise orders for Senna, Bisacodyl tablets, Bisacodyl suppository, and Fleet enema, including instructions to call the physician if no bowel movement occurred within specified time frames. The medication administration record showed this resident had a bowel movement on 3/17/26 and not again until 3/22/26, a gap of over 96 hours, without any bowel management medications documented as given between 3/20/26 and 3/22/26. There was no documentation in the nursing progress notes that the physician was contacted during this period despite the protocol requirements, and the Regional Clinical Specialist later stated that refusals had been recorded only on a separate bowel care worksheet and not on the MAR or in progress notes, where they should have been documented. The deficiency also includes improper management and documentation of a PICC line for another resident with interstitial lung disease and heart failure. Observation revealed a PICC line in the resident’s right upper extremity with an undated dressing, loose edges, and unsecured tubing, contrary to the facility’s infusion therapy policy requiring adherence to aseptic technique and proper maintenance of infusion equipment and catheters. An LPN acknowledged the absence of a date on the dressing and was unsure if the line was still in use. Review of the medical record showed an order for IV Ertapenem for sepsis related to pneumonia that ended on 3/1/26, and an RN reported she could not locate current orders for the PICC line and stated that the line may have been discontinued, but in either case it should have been removed or had active orders.
Failure to Verify Enteral Tube Placement Before Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility’s care and treatment of a resident with an enteral feeding tube when staff failed to verify tube placement prior to administering medication. The facility’s “Medication Administration Enteral Access Device” policy, released 9/16/25, directed staff to follow general professional standards for safe administration of medications and to verify tube placement per facility protocol. The resident, admitted with diagnoses including paraplegia and dysphagia, had a physician’s order dated 1/21/26 specifying that medications may be crushed or given in liquid form via the enteral tube and that tube placement must be checked via auscultation before medication administration. On 4/1/26 at 9:00 AM, an RN administered 30 mL of water through the resident’s enteral tube, followed by 20 mL of liquid hydroxyzine HCl, and then flushed the tube with 30 mL of water, without verifying tube placement beforehand. When interviewed shortly afterward, the RN stated she was unsure of the facility’s policy on checking tube placement and residual prior to administering medications, and the CNO reported that the facility’s G-tube policy did not require checking residual or placement before feedings or medication administration, indicating placement was only checked by x-ray at the time of insertion. This failure to verify tube placement before medication administration was determined to be a lack of adequate care and treatment for the resident reviewed for enteral tube use, creating the potential for harm if complications developed from improper medication administration via the enteral access device.
Failure to Provide Ordered Oxygen and Safe PAP Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services as ordered for three residents requiring continuous or prescribed oxygen and PAP therapy. Facility policy required BiPAP/CPAP therapy to be provided in accordance with physician orders and professional standards, and the PAP user manual specified that when oxygen is used with the device, a specific pressure valve must be installed between the device and oxygen source, and that the device must be turned on before oxygen and off after oxygen is turned off to prevent oxygen accumulation and fire risk. For one resident with COPD, depression, and cardiomegaly, a physician order dated 3/9/26 required oxygen at 3 LPM continuously via nasal cannula, yet surveyors observed on three separate dates and times that the resident was in her room without the nasal cannula in place. The CNO confirmed that this resident should have had her oxygen on continuously as ordered and had not. Another resident with PTSD and joint replacement aftercare had CPAP orders specifying CPAP with 2 L/min oxygen at bedtime and a separate physician order for oxygen at 3 L via nasal cannula every shift for obstructive sleep apnea. On observation with an RN present, the resident’s oxygen concentrator was on and bleeding 3.5 LPM of oxygen into the CPAP device while the CPAP device itself was turned off, and no required Respironics pressure valve was installed in the PAP circuit. Additional observations on two mornings showed the resident was not using ordered oxygen, and an RN stated the resident does not use oxygen during the day and questioned whether there was an order for daytime use. A third resident with acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture had a physician order and care plan for 2 LPM oxygen continuously via nasal cannula to maintain SpO2 at or above 90%, yet was observed not using oxygen, and medical record entries documented SpO2 readings of 88% on two dates while on room air only. The CNO stated staff should have ensured ordered oxygen use for the two residents, acknowledged oxygen should not bleed into a PAP device when not in use, and reported being unaware of the requirement for the Respironics pressure valve or whether any PAP devices in the facility had it.
Failure to Implement Non-Pharmacological Interventions Prior to PRN Pain Medication
Penalty
Summary
Surveyors identified a deficiency in pain management when the facility failed to follow its Pain Assessment and Management policy, which required development and implementation of both non-pharmacological and pharmacological interventions to address pain. The care plan for Resident #53, who had diagnoses including acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture, documented that the facility would attempt non-pharmacological pain interventions as part of the treatment plan. Physician orders dated 2/11/26 and 3/20/26 authorized Hydrocodone-Acetaminophen 5-325 mg every four hours as needed. However, review of the MAR on 3/30/26 showed no documentation that non-pharmacological pain management was attempted prior to administering the PRN hydrocodone on multiple dates (3/17/26, 3/18/26, 3/20/26, 3/23/26, and 3/24/26). In an interview on 4/1/26, the CNO confirmed that non-pharmacological pain management should have been offered before administering the hydrocodone and that it had not been, resulting in the facility’s failure to provide adequate pain management for this resident. This failure created the potential for residents to experience continual pain and distress.
Failure to Follow Vital Sign Parameters Before Administering Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse was competent in medication administration according to physician orders and facility policy. The facility’s Medication Administration policy, revised 9/10/25, required that when medications had vital sign parameters, vital signs must be taken prior to preparing the medication. Resident #21, admitted with interstitial lung disease and heart failure, had a physician’s order for Metoprolol Succinate ER 12.5 mg by mouth in the morning for hypertension, with instructions to hold the dose for systolic blood pressure (SBP) less than 100 or heart rate less than 50. On 3/30/26 at 9:35 AM, LPN #2 administered the resident’s medications, including Metoprolol, and only checked the resident’s blood pressure after the medication was given, contrary to the order and policy requiring vital signs beforehand. The CNO confirmed that the nurse should have checked the resident’s vital signs before administering the medication. Review of LPN #2’s oral medication administration competency form showed she had completed training, including the requirement that vital sign parameters be taken per facility practice before pouring medication, yet this was not followed in practice. This failure was identified for 1 of 5 nurses observed during medication administration and was determined to have the potential to affect all residents in the facility and increase the risk of harm to residents.
Failure to Accurately 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 posted daily staffing sheets on 3/30/26 at 4:17 PM, surveyors identified multiple dates with missing sheets or incomplete staffing data: on 5/6/25 there was no RN or LPN data listed for the day and evening shifts; on 9/8/25 there was no RN or LPN data listed for the evening shift; on 9/19/25 there was no CNA data listed for the day, evening, or night shifts; and on 12/7/25, 12/20/25, and 12/21/25 the daily staffing sheets were missing entirely. In addition, on 12/22/25 the posted information showed only one RN for 8 hours on the evening shift with no licensed nurses scheduled for the day or night shifts. On 3/31/26 at 4:00 PM, the Staffing Coordinator acknowledged that the missing staffing data and sheets for the identified dates should not have been missing but were. This deficient practice had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who might seek to review the facility’s staffing levels, by preventing accurate review of nurse staffing information for the affected dates and shifts.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide a resident with prior written notice regarding a room change, as required. A resident with chronic obstructive pulmonary disease and diabetes was admitted to the facility and was documented as being in a specific room. However, the resident was moved to a different room over a weekend without any written documentation or notification provided to the resident about the nature or date of the move. This was confirmed through observation, record review, and staff interviews, with the Director of Clinical Services acknowledging the absence of required written notice in the resident's medical record.
Failure to Notify State LTC Ombudsman of Resident Discharges and Transfers
Penalty
Summary
The facility failed to ensure that copies of residents' discharge or transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman, as required by facility policy. This deficiency was identified through interviews, policy review, and record review, and was found to affect three residents who experienced transfers or discharges. Specifically, one resident with a sacrum fracture and diabetes was transferred to the emergency department, another resident with hemiplegia and heart disease was transferred to the emergency department and did not return, and a third resident with heart disease and diabetes was discharged to an assisted living facility. In each case, there was no documentation that the required notice was provided to the State Ombudsman. Further investigation revealed that the facility's policy, last revised in April 2025, required that copies of discharge or transfer notices be sent to the Ombudsman, with notices to be sent monthly. However, the Region 6 State Ombudsman confirmed that no such notices were received for several months in 2025. The Director of Clinical Services stated that the facility's Social Worker had left in March 2025, and as a result, the required notices were not sent during March, April, May, and part of June 2025.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure that meals were prepared in accordance with residents' documented allergies, intolerances, and preferences, as required by its own nutrition policy. One resident with a documented allergy to tomatoes and melon was served chicken with a red, tomato-based sauce, which the resident could not eat due to his allergy. The resident's medical record and printed meal ticket both indicated these allergies, yet the meal was still provided. The food service manager confirmed, after investigation, that the resident had indeed been served a meal containing a tomato-based sauce, contrary to his dietary restrictions. This deficiency was identified through observation, policy review, and interviews with the resident and staff, and it had the potential to affect all residents with special dietary needs who dined in the facility.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food storage standards, as observed during a survey. Food items in the kitchen pantry were stored only 4.5 inches above the floor, contrary to the FDA Food Code requirement of at least 6 inches. This was confirmed by the Culinary Director. Additionally, the inside of the kitchen ice machine was found to have a pink slimy substance along the white panel, indicating inadequate cleaning of equipment that comes into contact with food. The Culinary Director and Registered Dietitian acknowledged the presence of the substance. Further observations revealed that kitchen cookware, including sheet pans, pots, and skillets, had black residue encrusted along various parts, despite being cleaned and sanitized according to manufacturer recommendations. The Culinary Director and Registered Dietitian were unable to explain the presence of the residue. Moreover, a layer of dust particles was observed hanging from the ceiling in front of the condenser fans in the kitchen walk-in refrigerator, which was verified by the Culinary Director. These deficiencies had the potential to affect the 53 residents who consumed food prepared by the facility.
Deficient Care Plans for Residents
Penalty
Summary
The facility failed to ensure that resident-centered care plans were comprehensively written for four residents, leading to deficiencies in their care. Resident #6, who was admitted with multiple diagnoses including metabolic encephalopathy, Parkinson's disease, and dementia, had a care plan that did not include directions for managing her dementia. The CEO acknowledged that the care plan should have included this information. Similarly, Resident #34, with diagnoses including heart failure and chronic kidney disease, had a physician order for a foley catheter, but his care plan lacked directions for its care, which was confirmed by the CEO. Resident #36, diagnosed with chronic obstructive pulmonary disease, had preferences for activities such as reading and listening to music, which were documented in an Admission MDS assessment. However, his care plan did not address these preferences, and he was observed without any reading materials in his room. The CEO confirmed the absence of an activity care plan. Additionally, Resident #8, with chronic kidney disease and neuropathic bladder, had a physician's order for a foley catheter, but his care plan did not reflect this order. The CEO confirmed that a care plan should have been developed to include these new orders.
Failure to Update Resident Care Plan After Medication Changes
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current needs and interventions, as required by the CMS SOM, Appendix PP. This deficiency was identified for one resident who had multiple diagnoses, including bipolar and psychotic disorders. The resident's physician orders indicated that several medications, including Depakote, Mirtazapine, and Lorazepam, were discontinued on specific dates. However, the resident's care plan, which was initiated earlier, still documented the use of antidepressant medications related to bipolar disorder and depression. The CEO confirmed that the care plan should have been updated to reflect the changes in the physician's orders when the medications were discontinued, but it was not. This oversight created a risk of adverse outcomes if care and services were not provided according to the resident's changing needs.
Failure to Administer Oxygen Therapy Per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy according to physician orders, which was identified during a survey. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), had a care plan that required supplemental oxygen to be administered via nasal cannula as ordered. A physician assistant's progress notes indicated that the resident's oxygen levels were consistently above 92 percent while on two liters of oxygen, leading to an order to reduce the oxygen to one liter per minute to prevent carbon dioxide retention and abdominal pain. During an observation, the resident was found receiving oxygen therapy at a rate of two liters per minute, contrary to the physician's order of one liter per minute. This discrepancy was confirmed by RN #1, who reviewed the physician's order and verified that the oxygen flow rate was incorrectly set. The failure to adhere to the prescribed oxygen therapy created the potential for harm by not meeting the resident's respiratory needs as directed by the physician.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by the cases of two residents. Resident #42, who was admitted with multiple diagnoses including amputation and gangrene, experienced a medication error involving oxycodone. The prescription indicated a dosage of 10 mg every four hours as needed for pain, but the Medication Administration Record (MAR) incorrectly documented the administration of 10 mg, while the controlled drug record showed that only 5 mg was administered on multiple occasions. This discrepancy was identified by an LPN, but not before the error occurred eight times over several days. Resident #48, admitted with conditions such as diabetes and chronic pain, also experienced a medication error. An order change increased the Lyrica dosage to 150 mg at bedtime, but the MAR showed that the resident received only 100 mg on three consecutive nights. This error was confirmed by the CEO, who acknowledged that the wrong dose was administered. These incidents highlight the facility's failure to ensure accurate transcription and administration of medication orders, leading to significant medication errors for both residents.
Medication Errors Lead to Hospitalization and Potential Harm
Penalty
Summary
The facility failed to protect residents from significant medication errors, affecting two out of four residents reviewed. Resident #1, who had multiple diagnoses including encephalopathy and high blood pressure, was mistakenly given another resident's medications by LPN #1. This error occurred because LPN #1 was unfamiliar with the hall she was assigned to and confused Resident #1 with Resident #2, who had the same first name. The medications intended for Resident #2 included several drugs that were contraindicated for Resident #1, leading to a significant change in Resident #1's condition, including altered mental status and decreased blood pressure, necessitating hospitalization. Resident #3, with diagnoses including end-stage renal disease and diabetes, was potentially given the wrong type of insulin by LPN #3. The LPN was unsure whether she administered Lantus instead of the prescribed NovoLog after checking the resident's blood sugar. The error was immediately reported to the physician, and the resident was monitored for adverse symptoms. Fortunately, Resident #3 did not require further medical intervention following the incident.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for a resident, leading to medication administration discrepancies. The resident, who was admitted with multiple diagnoses including an elbow fracture, Parkinson's Disease, and acute respiratory failure, had her medications crushed and mixed with food without a physician's order. This practice was based on a recommendation from a Speech Therapist, but it was not documented in the resident's medical record. The resident's medications, including Levothyroxine, Benztropine, Bupropion, Clonazepam, Donepezil, Doxycycline, and Memantine, were administered in this manner over a period of time. Additionally, the resident's Levothyroxine, which was ordered to be given at 5:30 AM, was administered in the evening by an LPN. The LPN stated that she was aware of the morning schedule but chose to administer it at night to avoid waking the resident early, as she was informed the resident disliked early wake-ups. The Director of Nursing Services and the Regional Clinical RN were unaware of these practices until alerted by the surveyors, and there was no physician approval for the time change of the Levothyroxine administration.
Failure to Remove Discontinued Medication from Cart
Penalty
Summary
The facility failed to ensure that medications were properly reconciled and removed from a medication cart when discontinued, as observed during a survey. This deficiency was identified in one of three medication carts inspected, specifically affecting a resident who had been prescribed hydrocodone 5/325 mg. The medication order for hydrocodone was discontinued on 10/12/24, yet the blister pack containing 31 tablets remained in the cart until it was discovered on 10/29/24. During the inspection, an LPN was observed preparing to dispose of the medication, acknowledging that it should have been removed the day it was discontinued. The CRN confirmed that opioid medications should be removed from the cart by the next working day after discontinuation. This oversight created a potential risk for medication administration errors and diversion, affecting 19 residents who received medications from the same cart. Resident #105, who was involved in this incident, was admitted with multiple diagnoses, including metabolic acidosis, diabetes, and hypertension. The failure to remove the discontinued hydrocodone from the medication cart was a significant oversight in the facility's pharmaceutical services, as it posed an increased risk for medication errors and potential harm to the residents.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were labeled correctly, as observed during an inspection of a medication cart. Specifically, the blister pack label for a resident's prescribed oxycodone 5 mg did not reflect the updated order of four times a day (every 6 hours) and instead stated every 4 hours as needed. This discrepancy was noted during an inspection of the 300 Hall medication cart with an LPN present. The resident involved had multiple diagnoses, including a left arm fracture, heart failure, hypertension, and pain, and had their medication order changed on 10/24/24. However, the label on the blister pack was not updated to reflect this change, which was acknowledged by the LPN, who stated that a sticker should have been placed on the blister pack to indicate the new order.
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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