Gateway Transitional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pocatello, Idaho.
- Location
- 527 Memorial Drive, Pocatello, Idaho 83201
- CMS Provider Number
- 135011
- Inspections on file
- 16
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Gateway Transitional Care Center during CMS and state inspections, most recent first.
A resident with neurological and mobility impairments was transported backwards in a Geri-Chair by a CNA who did not provide adequate supervision or attention, despite the resident showing signs of distress and a history of falls related to lack of supervision. The DON confirmed that staff were not attentive during the transport.
Surveyors found that the facility did not provide or document respiratory care and oxygen therapy as ordered by physicians for several residents. Orders lacked key details such as frequency and indications for use, and care plans did not specify when to start or stop oxygen. In some cases, low oxygen saturations were recorded without any documented nursing intervention. Additionally, oxygen equipment was not maintained or dated according to facility policy.
A resident with multiple medical conditions was found with artificial tears at their bedside without an order or a completed self-administration assessment. An LPN confirmed that the medication should not have been in the room and that the required evaluation had not been performed.
Two residents with significant mobility limitations were unable to access their call light devices because staff placed the devices out of reach—one on a trapeze bar and another wrapped around an overbed light. Both an LPN and the DON confirmed that the devices should have been attached to bed covers or blankets for easy access, but this was not done.
A resident with multiple diagnoses, including PTSD, was admitted and their MDS assessment failed to document PTSD as required. Record review and staff interview confirmed that the omission occurred, resulting in an inaccurate assessment of the resident's status.
A resident with spina bifida, anxiety, major depression, and PTSD was admitted, but their Baseline Care Plan did not include required information on mental and psychosocial needs. The care plan section on cognition was left unanswered, and staff confirmed these diagnoses should have been addressed.
The facility did not update care plans to reflect current needs and interventions for several residents, including changes in diet orders, discontinuation of Enhanced Barrier Precautions, specific caregiver preferences, new oxygen parameters, and the use of fall mats. Staff interviews and observations confirmed that these updates were not made in accordance with facility policy.
The facility did not administer bowel care medications as outlined in standing orders for a resident who experienced prolonged periods without a bowel movement, nor did staff contact a physician as required. Additionally, another resident received an IV without documented physician orders for the IV or dressing changes, as confirmed by the DON.
Nursing staff did not remove a resident's uneaten breakfast meal tray from her room within the expected two-hour timeframe, leaving it on the overbed table for over three hours until lunch was served. The resident, who has chronic kidney disease and mobility issues, noted that staff sometimes delay tray removal until the next meal is delivered, contrary to facility expectations.
The facility did not ensure that several nurse aides completed a State-approved training and competency evaluation program within four months of hire. Review of personnel files showed that four nurse aides had not finished the required training or passed the competency test in the required timeframe, and this was confirmed by the Executive Director.
A resident with multiple health conditions was given the wrong dose of Cranberry supplement and an incorrect multivitamin by an LPN, contrary to physician orders. The LPN recognized the errors after administration, contributing to a medication error rate above the acceptable threshold.
A medication cart was left unlocked and unattended in a resident-accessible area, and an expired vial of Novolog solution was found in a medication room. Staff confirmed both the lapse in securing the cart and the presence of expired medication, in violation of facility policy and professional standards.
Surveyors found that food items in the facility's kitchen and storage areas were not properly dated, covered, or discarded, and expired products were present. A resident's uneaten breakfast tray remained on the overbed table for over three hours, exceeding the facility's policy for timely tray removal. Staff confirmed these practices did not meet required standards.
A garbage can in the kitchen was found with a hole in its lid, contrary to FDA Food Code requirements for refuse receptacles to be kept covered. Staff and the executive director were unaware or acknowledged the need for a solid lid, creating the potential to attract pests and rodents and affect all residents and staff.
Staff failed to maintain sanitary storage of oxygen and CPAP equipment, with instances of a nasal cannula left uncovered on a bedside table, a CPAP mask found on the floor, oxygen tubing hanging uncovered on a wall, and CPAP equipment placed on linens and pillows without protection. These lapses were observed among several residents with chronic medical conditions, and the DON confirmed the equipment should have been stored appropriately.
The facility's kitchen was found to have sanitation deficiencies, including inadequate sanitizer solution strength, rust in the ice machine, and uncleanable surfaces due to peeling caulking. These issues were observed during inspections, with sanitizer levels below the required concentration and rust potentially contaminating ice. The caulking issue was linked to a long-standing pipe leak. Some corrective actions were noted in a follow-up inspection, but sanitizer concentration issues persisted.
The facility did not ensure accurate nurse staffing postings, failing to reflect actual staff hours and updated census information. Observations revealed postings only included anticipated hours for CNAs, RNs, and LPNs, and were not visible in certain areas, potentially leaving residents and visitors uninformed. The Administrator and RNC confirmed the lack of a policy and limited visibility of postings.
The facility failed to provide written bed hold notices to two residents or their representatives upon hospital transfer, as required by policy. One resident with multiple health issues was transferred twice without written notice, and another resident, who was cognitively intact, was also transferred without receiving a written notice. Staff interviews revealed confusion and non-compliance with the bed hold notice policy.
A resident's MDS assessments were inaccurately coded, failing to document their edentulous status and hospice care admission. Despite the resident's expressed need for dentures and a physician order for hospice care, these were not reflected in the assessments. The MDS Coordinator confirmed the errors, and the DNS expected accurate coding.
Two residents in an LTC facility experienced multiple falls due to inadequate supervision and inconsistent implementation of care plan interventions. One resident, with dementia and mobility issues, had 15 falls over a year, often without functioning pressure alarms. Another resident, with cognitive impairment, lacked required floor mats by her bed. Staff interviews and observations confirmed lapses in following care plans, contributing to the deficiency.
A resident with chronic respiratory failure was observed receiving oxygen at 4 LPM, contrary to the physician's order of 0-2 LPM. The facility's MAR/TAR showed improper documentation with 'x's instead of the flow rate. Staff interviews confirmed the need for documentation, and the DNS acknowledged and corrected the error.
A facility failed to attempt alternatives before using bed rails for a resident with multiple health issues, including dementia and fractures. The facility's policy required alternatives to be tried and a thorough assessment conducted before bed rail installation, but this was not done. The resident mentioned limited use of the rails, and the DNS confirmed the policy was not followed.
A facility failed to ensure the medical necessity of psychotropic medication for a resident with multiple diagnoses, including depression and anxiety. Despite minimal behavioral episodes, the resident was routinely administered several psychotropic medications. A recommendation for a psychiatric assessment to reduce duplicative therapy was not followed up, as confirmed by staff interviews, indicating a lapse in policy adherence.
The facility failed to ensure proper labeling and dating of insulin pens, as observed during a survey. Two insulin pens were found unlabeled, and none had an open date, contrary to the facility's policy. The DNS confirmed the expectation for each pen to have a pharmacy resident label, highlighting a lapse in policy adherence.
The facility failed to maintain infection control practices for three residents. A resident's nebulizer equipment was not cleaned or bagged, another's BiPAP machine was left unbagged, and a third resident's catheter drainage bag and tubing were in contact with the floor. The DNS confirmed these practices did not meet infection control expectations.
Two residents in the facility were found to have unsafe bed rail conditions, with significant gaps posing entrapment risks. One resident had a gap of 5 1/4 inches between the mattress and bed rail, while another had horizontal gaps of 12 to 13 inches and vertical gaps of 3 to 4 inches within the rails. The facility's maintenance program did not assess individual bed/mattress/rail combinations, leading to these deficiencies.
A resident with significant weight loss was prescribed Mighty Shake three times daily, but the facility provided a house-made shake with fewer calories without adjusting the resident's orders. The RD and dietary staff confirmed the discrepancy, and the ADNS and charge nurse emphasized the importance of matching orders with administered supplements.
Failure to Supervise Resident During Geri-Chair Transport
Penalty
Summary
The facility failed to assess the risks associated with transporting residents backwards in Geri-Chairs and did not provide adequate supervision during these transports. Specifically, a resident with cerebellar ataxia, cognitive communication deficit, and muscle spasms was observed being pulled backwards in a Geri-Chair by a CNA who was not attentive to the resident during the transport. The resident was visibly distressed, crying out, kicking, and attempting to move in the chair while being transported. The facility's records indicated that this resident had experienced three previous falls from her wheelchair, each related to lack of supervision when she was moving about and kicking, with one incident resulting in a head injury that required hospital care. The DON confirmed that staff were expected to be attentive during such transports but were not in this instance.
Failure to Provide and Document Appropriate Respiratory Care and Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by physicians and did not ensure that physician orders and resident care plans included necessary interventions for oxygen therapy. For several residents, physician orders for oxygen therapy were incomplete, lacking essential details such as frequency of use, indications for use, baseline SpO2 levels, and clear instructions on when to initiate or discontinue oxygen. For example, two residents had orders for oxygen titration to maintain saturations above 90%, but the orders did not specify how often oxygen should be administered. Another resident's order and care plan did not document when to start or stop oxygen therapy, and the DON acknowledged that the order was too generic and should have included more specific instructions. Additionally, the facility did not document nursing interventions when a resident's oxygen saturation dropped below the prescribed threshold. In one case, a resident's oxygen saturation was recorded as low as 67% and 82% on different occasions, but there was no documentation of any nursing response or intervention to address these low levels, despite the care plan indicating oxygen should be administered per physician orders. The DON confirmed that staff should have addressed these low oxygen saturations but had not done so. The facility also failed to follow its own policy regarding the maintenance of oxygen equipment. For one resident, oxygen tubing and humidifier were not dated as required by facility policy, and the resident was unaware of when the equipment was last changed. The ADON confirmed that the tubing and humidifier should have been dated and were not, indicating a lapse in adherence to established protocols for respiratory care equipment.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to self-administer medications. A resident with multiple diagnoses, including atrial fibrillation and diabetes, was observed with a bottle of artificial tears on their bedside table. Review of the medical record showed that the self-administration of medication evaluation for eye drops was marked as 'Not Applicable.' Additionally, staff confirmed that the resident did not have an order for the artificial tears and that a self-administration assessment had not been completed. This sequence of events demonstrates that the facility did not follow required procedures to determine if the resident could safely self-administer medication.
Call Light Devices Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, as required by facility policy. In the first instance, a resident with paraplegia and hypertension reported that her call light device had been placed up high on the trapeze bar by staff after making her bed, making it inaccessible to her while she was in her wheelchair. Both an LPN and the DON confirmed that the call light device should have been attached to the bed covers for easy access, but it was not. In the second instance, another resident with polyosteoarthritis and obesity stated that her call light device was wrapped around the overbed light and was out of her reach while she was in her wheelchair. A nursing assistant and the DON both acknowledged that the call light device should have been attached to the blankets for easy access, but this was not done. These findings were based on observations, interviews, and policy review.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status. Specifically, for one resident admitted with multiple diagnoses including spina bifida, anxiety, major depression, and PTSD, the admission MDS assessment did not document the presence of PTSD in Section I, despite the resident having this diagnosis. Record review and staff interview confirmed that PTSD should have been included in the assessment, but it was omitted. This inaccuracy was identified during a review of the resident's records and through an interview with the Social Services Supervisor, who acknowledged the omission.
Failure to Address Mental and Psychosocial Needs in Baseline Care Plan
Penalty
Summary
The facility failed to include a resident's mental and psychosocial needs in the Baseline Care Plan within 48 hours of admission, as required by facility policy. Specifically, for one resident with multiple diagnoses including spina bifida, anxiety, major depression, and PTSD, the Baseline Care Plan did not address cognition, focus, goal, or intervention related to these mental health conditions. Clinical record review showed that these areas were left unanswered, and staff interviews confirmed that the resident's mental health diagnoses should have been included but were omitted.
Failure to Revise Care Plans to Reflect Current Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions for five residents. For one resident with a history of surgical aftercare and schizoaffective disorder, the care plan contained conflicting dietary instructions and was not updated to reflect a physician's order for a full liquid diet, despite staff acknowledgment of the need for this intervention. Another resident with chronic kidney disease and mobility issues had a care plan indicating Enhanced Barrier Precautions (EBP), but EBP had been discontinued and this change was not reflected in the care plan or in the room signage and supplies. A third resident with spina bifida, anxiety, depression, and PTSD had a care plan that did not document her request for no male caregivers, a preference confirmed by staff as necessary due to her history. Additionally, a resident with heart and respiratory failure had a care plan that was not updated to include new oxygen parameter orders, as confirmed by the ADON. Another resident with brain compression and aphasia had a fall mat intervention in place at the bedside, but this was not documented in the care plan. Staff interviews and observations confirmed that these care plans were not revised in accordance with the facility's policy, which requires updates after each assessment and as resident needs change.
Failure to Follow Bowel Care Protocols and Obtain Physician Orders for IV Therapy
Penalty
Summary
The facility failed to follow its own standing orders for bowel care and did not obtain required physician orders for IV insertion and dressing changes. For one resident with chronic kidney disease and mobility issues, documentation showed significant gaps between bowel movements, with intervals of 120 and 180 hours, despite the resident's normal pattern of daily bowel movements. Although the resident was receiving a daily bowel maintenance medication as ordered by the physician, there was no documentation that the facility's standing order medications for constipation were administered during these periods. The Director of Nursing confirmed that staff should have followed the standing order and contacted the physician when the resident had not had a bowel movement within 72 hours, but this was not done. Additionally, another resident with a hip fracture and COPD was observed with an IV inserted, but there were no physician orders documented for the IV or for dressing changes in the medical record. The Director of Nursing confirmed that the IV was started and that orders should have been present in the record, but they were not. These findings indicate that the facility did not provide treatment and care according to physician orders and established protocols.
Failure to Timely Remove Meal Trays from Resident Room
Penalty
Summary
Nursing staff failed to remove a resident's uneaten breakfast meal tray from her room in a timely manner, as observed during survey. The tray remained on the overbed table for over three hours after delivery, still present when lunch was being served. The resident, who had a history of chronic kidney disease and mobility issues, reported that staff sometimes waited to pick up the breakfast tray until delivering the lunch meal. According to the Director of Nursing, meal trays were expected to be picked up within two hours of delivery, but this standard was not met in this instance.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that full-time nurse aides who had been employed for more than four months completed a State-approved training and competency evaluation program within the required timeframe. During a review of personnel files for ten nurse aides, it was found that four had not completed the necessary training or passed the required competency evaluation within four months of their hire dates. Specifically, one nurse aide had not completed a course after being hired, another had not completed a course, a third had not passed the test and needed to retake the course, and a fourth had also not completed a course. The Executive Director confirmed that these nurse aides were not certified nursing assistants and acknowledged the need for improvement in ensuring timely certification.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including a fractured left humerus and diabetes, did not receive medications as ordered by the physician. The physician's orders specified that the resident should receive a 500 mg Cranberry oral tablet and a Multivitamin oral tablet once daily. During medication administration, an LPN provided a 450 mg Cranberry tablet, which was the incorrect dose, and a Multivitamin with minerals, which was not the medication ordered. The LPN later acknowledged that both the dose and the medication administered were incorrect and indicated the need to clarify the orders with the physician. This incident contributed to a facility medication error rate of 6.9%.
Failure to Secure Medication Carts and Remove Expired Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly stored and labeled according to professional standards. Specifically, one medication cart was observed left unlocked and unattended in an area accessible to residents, contrary to facility policy requiring carts to be locked when not attended by authorized staff. Additionally, an expired vial of Novolog solution was found stored in a medication room, and staff confirmed it should have been discarded. These deficiencies were identified through direct observation, policy review, and staff interviews, and affected both medication storage areas and medication carts.
Deficiencies in Food Storage, Labeling, and Meal Tray Handling
Penalty
Summary
Surveyors identified multiple deficiencies related to food storage, labeling, and handling within the facility. Observations revealed that food items, such as bags of English muffins and a box of pizza, were not dated, and a box of frozen sliced carrots was not covered in the kitchen. Additionally, expired food items, including cans of evaporated milk, cans of Glucerna, and a container of applesauce, were found in storage and resident unit refrigerators. The Dietary Supervisor and Registered Dietitian confirmed that these items should have been dated, covered, or discarded according to facility policy and the Idaho Food Code. In one instance, a resident with chronic kidney disease and mobility issues was observed with an uneaten breakfast tray left on her overbed table for over three hours after delivery. The resident reported that nursing staff sometimes waited to pick up the breakfast tray until delivering the lunch tray. The Director of Nursing confirmed that meal trays should be picked up within two hours of delivery, which had not occurred in this case.
Improperly Covered Garbage Can in Kitchen
Penalty
Summary
Surveyors observed that a garbage can located in the kitchen next to the freezers had a hole in its lid, which did not comply with the U.S. Food and Drug Administration 2022 Food Code requirement for refuse receptacles to be kept covered. During interviews, a dietary staff member stated she was unaware that the garbage can should have had a solid lid, and the executive director confirmed that the garbage can should have had a solid lid but did not. This failure to properly cover garbage cans had the potential to attract pests and rodents into the kitchen, potentially affecting all residents and staff in the facility. No specific residents or staff were directly affected at the time of the observation, and no additional medical history or conditions were noted in relation to this deficiency.
Improper Storage of Oxygen and CPAP Equipment
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices regarding the storage of oxygen supplies and respiratory equipment for multiple residents. Observations revealed that a resident's nasal cannula was left uncovered on a bedside table, another resident's CPAP mask was found on the floor next to the bed, and a third resident's oxygen tubing and nasal cannula were hanging uncovered on the wall. Additionally, a resident's CPAP mask and tubing were observed placed on a pile of linens and pillows in a chair, without being bagged or otherwise protected. These deficiencies were confirmed through direct observation, policy review, and staff interviews. The Director of Nursing acknowledged that the oxygen supplies and CPAP equipment should not have been stored on the floor, on furniture, or left uncovered, and should have been stored appropriately when not in use. The improper storage practices were identified for four residents with various medical conditions, including COPD, spina bifida, diabetes, emphysema, polyosteoarthritis, and obesity.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during a survey. The initial inspection revealed several issues, including inadequate sanitizer solution strength, rust inside the ice machine, and uncleanable surfaces due to peeling caulking in the dishwashing area. Specifically, the sanitizer solution used for wiping cloths was found to be below the required concentration, with one bucket containing no sanitizer and another at only 100 ppm, while the desired level was 200 ppm. Additionally, rust was observed on a screw inside the ice machine, which could potentially contaminate the ice. The inspection also noted that the caulking around pipes in the dishwashing area was partially adhered and had food particles trapped underneath, creating an uncleanable surface. This issue was attributed to a leak in the pipes that had been ongoing since at least October 2023, with maintenance staff applying caulking to seal the leak. The Dietary Supervisor and Dietary Assistant confirmed the presence of these issues during the inspection. A follow-up inspection found that some corrective actions had been taken, such as replacing the rusted screw in the ice machine and removing the excess caulking after the leak was repaired. However, during this inspection, one of the sanitizer buckets still tested below the required concentration, indicating that the sanitizer solution's effectiveness decreased over time and needed regular changing. The Dietary Supervisor acknowledged that the test strips might not have been held in the solution long enough during the initial tests, which could have contributed to the inadequate readings.
Inaccurate Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the required nursing staff posting accurately reflected the actual staff hours available to care for the 76 current residents. Additionally, the postings did not include an updated census for each shift, which is necessary to account for any admissions, discharges, or transfers to acute care. On specific dates, the nurse staffing postings were observed to include only the anticipated hours for CNAs, RNs, and LPNs, rather than the actual hours worked. Furthermore, the postings were not visible in certain areas of the facility, such as the R and D/C hall Nurse's Stations, potentially leaving residents, family members, or visitors uninformed about the available nursing staff. During an interview, the Administrator and RNC confirmed the absence of a policy regarding the nurse staff posting and acknowledged the limited visibility of the postings for certain halls.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide a written bed hold notice to residents or their representatives upon transfer to a hospital, as required by their policy. This deficiency was identified for two residents who were transferred to the hospital. The facility's Bed Hold policy mandates that residents or their representatives be informed in writing of their right to a bed hold for 7 days upon admission and again before a transfer to a hospital or therapeutic leave. In cases of emergency transfers, the notice should be provided within 24 hours. However, the facility did not adhere to this policy, as evidenced by the lack of written notices for the residents reviewed. Resident #24, who had multiple serious health conditions, was transferred to the hospital on two occasions due to critical health issues. In both instances, there was no documentation of a written bed hold notice being provided to the resident or her representative. Similarly, Resident #10, who was cognitively intact and had chronic health issues, was transferred to the hospital without a written bed hold notice being provided to him or his sister. Interviews with staff revealed a lack of understanding and execution of the bed hold notice policy, with some staff members incorrectly assuming that verbal notifications sufficed or that social services would handle the notices.
Inaccurate MDS Assessments for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to potential unmet care needs. The resident, who was admitted with multiple diagnoses including diabetes and hemiplegia following a stroke, was found to have inaccuracies in their MDS assessments. During an interview, the resident expressed a need for dentures, as they were edentulous. However, the MDS assessments did not document this condition, despite a Nutrition - Admission Evaluation confirming the resident's edentulous status. The MDS Coordinator later confirmed that the assessments were incorrectly coded and should have included this information. Additionally, the resident had a physician order for hospice care, indicating a terminal prognosis. However, the significant change of status MDS assessment did not reflect the resident's hospice care status or terminal prognosis. The MDS Coordinator acknowledged that the resident should have been coded for hospice care and a terminal prognosis, as intended by the significant change assessment. The Director of Nursing Services (DNS) stated that it was expected for MDS assessments to be coded accurately.
Inadequate Fall Prevention Measures in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent falls for two residents, leading to a potential risk of significant injuries. Resident #67, who has multiple diagnoses including dementia and unsteadiness, experienced 15 falls over a year. The facility's fall prevention policy required incident reports and action plans for each fall, but the reports often lacked documentation on the effectiveness of pressure alarms and whether they were functioning properly. Observations and interviews revealed that interventions such as keeping the wheelchair away from the bed and ensuring alarms were transferred with the resident were inconsistently applied. Resident #67's care plan included various interventions like using a wireless pressure alarm, keeping the bed in a low position, and ensuring the call light was within reach. However, the fall reports frequently noted that alarms did not sound or were not in place, and there was a lack of follow-up on why these alarms failed. Additionally, staff interviews indicated that Resident #67 was sometimes left unattended, contrary to her care plan requirements, which contributed to the falls. Resident #22, with a history of stroke and cognitive impairment, was also at high risk for falls. Her care plan required the use of floor mats next to her bed, but observations showed these mats were not consistently in place. The DNS confirmed the absence of the mats during an observation, acknowledging that care-planned interventions were not consistently implemented. This lack of adherence to care plans and failure to ensure proper supervision and interventions contributed to the deficiency in preventing falls for these residents.
Failure to Administer Oxygen Therapy Per Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy according to the physician's orders. The resident, who had multiple diagnoses including chronic respiratory failure with hypoxia, was observed to be receiving oxygen at a flow rate of 4 liters per minute (LPM) via nasal cannula, despite the physician's order specifying a flow rate of 0-2 LPM. This discrepancy was noted during multiple observations over several days. The resident himself stated that he was supposed to be on 3 or 4 LPM, which was inconsistent with the physician's order. The facility's Medication Administration Record/Treatment Administration Record (MAR/TAR) for the resident showed an 'x' in each box for the flow rate instead of the actual flow rate, indicating a lack of proper documentation. This issue persisted even after a new physician order was issued to adjust the oxygen flow rate to 0-4 LPM. Interviews with staff, including an LPN and the Director of Nursing Services (DNS), confirmed that the oxygen flow rate should have been documented, and the DNS acknowledged the documentation errors. The DNS subsequently made changes to the resident's record to allow for proper documentation of the oxygen flow rate.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to ensure that alternatives to bed rails were attempted and that a thorough assessment of the resident for the risk of entrapment was conducted before the placement of bed rails. This deficiency was identified for one resident who was reviewed for bed rail use. The facility's policy, revised in January 2022, required that appropriate alternatives be attempted prior to the installation of bed rails and that a comprehensive assessment be conducted to evaluate the risks and benefits of bed rail use. However, the facility did not adhere to this policy, as no alternatives were attempted for the resident in question. The resident involved was admitted with multiple diagnoses, including multiple fractures, protein calorie malnutrition, dementia, insomnia, and a history of transient ischemic attacks. During an interview, the resident mentioned that she did not really use the side rails, although they were put up, and she sometimes used them to turn in bed. The evaluation conducted by a licensed nurse indicated that the resident used side rails for mobility and security, but it was noted that no previous measures were attempted as alternatives. The Director of Nursing Services confirmed that the policy was not followed, and alternatives should have been attempted prior to the use of side rails.
Failure to Ensure Medical Necessity of Psychotropic Medication
Penalty
Summary
The facility failed to ensure the medical necessity of psychotropic medication administration for a resident, leading to the potential for negative side effects from unnecessary medication. The facility's policy required gradual dose reductions (GDR) and behavioral interventions unless clinically contraindicated. However, the resident, who was cognitively intact and diagnosed with paraplegia, anxiety disorder, insomnia, and depression, was routinely administered multiple psychotropic medications, including duloxetine, risperidone, trazodone, and buspirone, without documented evidence of behaviors warranting such medication levels. The resident's comprehensive care plan indicated the use of these medications for various symptoms, but behavior monitoring showed minimal episodes of anxiety and irritability. A Psychotropic Interdisciplinary Team (IDT) meeting recommended a psychiatric provider assessment for GDR of risperidone due to duplicative therapy for depression. However, there was no documentation of follow-up or referral to a psychiatric provider, as confirmed by staff interviews, indicating a lapse in the facility's adherence to its policy and the IDT's recommendation.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications available for residents were properly labeled and had not expired, as observed during a survey. Specifically, two out of five insulin pens in a medication cart were not labeled correctly. One Lantus insulin pen was labeled for a specific resident, while an Admelog insulin pen had no label. Additionally, another set of insulin pens included two labeled for a different resident and a third pen without a label. None of the pens had an open date, which is a requirement according to the facility's policy. The facility's policy on labeling medications and biologicals, revised in May 2020, mandates that each prescription medication label must include the resident's name, medication name, prescribed dose and strength, expiration date, route of administration, and specific directions for use. The policy also requires that multi-dose vials be dated and discarded within 28 days unless specified otherwise by the manufacturer. During an interview, the Director of Nursing Services (DNS) confirmed the expectation that each insulin pen should have a pharmacy resident label, indicating a lapse in adherence to the facility's labeling policy.
Infection Control Deficiencies in Equipment Handling
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by observations of three residents' equipment. Resident #10, who was moderately cognitively impaired and receiving continuous oxygen therapy, had nebulizer equipment that was not appropriately cleaned or bagged after use. Residual nebulizer solution was observed in the nebulizer basket, and the mask and basket were left unbagged on the resident's television stand during multiple observations. The Director of Nursing Services (DNS) confirmed that the equipment was not properly maintained to prevent potential pathogen collection. Resident #63, also moderately cognitively impaired and receiving continuous oxygen therapy, had a BiPAP machine that was not bagged when not in use. The BiPAP mask and tubing were observed on an overbed table next to the resident's bed without being bagged. The DNS and Assistant Director of Nursing Services (ADNS) confirmed the equipment was not appropriately bagged, contrary to the DNS's expectations. Additionally, Resident #182, who had an indwelling catheter due to obstructive uropathy, was observed with the catheter drainage bag and tubing in contact with the floor. The DNS stated that the expectation was for urinary catheter drainage bags and tubing to be kept off the floor to avoid contamination.
Failure to Maintain Safe Bed Rails
Penalty
Summary
The facility failed to ensure the safety and maintenance of bed rails for two residents, leading to potential risks of entrapment. Resident #10, who was moderately cognitively impaired and required substantial assistance for bed mobility, had a bed rail installed without proper documentation of routine physical checks. Observations revealed a significant gap of approximately 5 to 6 inches between the mattress and the bed rail, which was confirmed by the Maintenance Director to be 5 1/4 inches wide. This gap posed a risk of entrapment, as the facility's policy required no gaps wide enough to entrap a resident's body parts. Similarly, Resident #22, who was severely cognitively impaired and required assistance for bed mobility, had bed rails with horizontal gaps of 12 to 13 inches and vertical gaps of 3 to 4 inches. These measurements were confirmed by the Maintenance Director, who acknowledged that the facility's program directed that gaps should not exceed 4 1/4 inches. However, the facility did not assess the specific bed/mattress/rail combinations for each resident, leading to the oversight of these unsafe conditions. The Maintenance Director admitted that while general bed types were assessed for safety, individual assessments of each resident's bed were not conducted due to the large number of beds in the facility. The DNS expressed that all beds with rails were expected to be maintained safely to prevent entrapment risks, highlighting a discrepancy between the facility's expectations and actual practices.
Failure to Administer Prescribed Dietary Supplement
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with multiple diagnoses, including dementia, adult failure to thrive, and dysphagia, who experienced significant unplanned weight loss. The resident was prescribed a dietary supplement, Mighty Shake, to be administered three times a day to address weight loss. However, the facility switched to providing a house-made shake instead of the prescribed Mighty Shake without adjusting the resident's orders or consulting the physician. This resulted in the resident receiving fewer calories than prescribed, as the house shake contained 166 calories per serving compared to the 220 calories in the Mighty Shake. Interviews with dietary staff and the registered dietitian (RD) confirmed that the facility had been serving the house shake instead of the Mighty Shake for several months. The RD acknowledged that the nutritional content of the house shake was not equivalent to the Mighty Shake and that the residents' orders had not been updated to reflect the change in the product being administered. The assistant director of nursing services (ADNS) and a charge nurse verified the importance of ensuring that orders match the supplements being administered and confirmed that the resident received the house shake instead of the prescribed Mighty Shake.
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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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