Idaho State Veterans Home - Pocatello
Inspection history, citations, penalties and survey trends for this long-term care facility in Pocatello, Idaho.
- Location
- 1957 Alvin Ricken Drive, Pocatello, Idaho 83201
- CMS Provider Number
- 135132
- Inspections on file
- 16
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Idaho State Veterans Home - Pocatello during CMS and state inspections, most recent first.
The facility did not document that residents and their representatives were informed of their right to formulate advance directives, affecting multiple residents with serious medical conditions. Although POST documents were present in the records, there was no evidence that information or assistance regarding advance directives was provided.
The facility did not consistently implement or document its bowel management protocol for several residents with conditions such as depression, Huntington’s disease, chronic kidney disease, and dementia, resulting in prolonged periods without bowel movements and lack of timely interventions as ordered by physicians. The DON confirmed that nursing staff failed to document all required steps of the protocol.
A resident with multiple medical conditions, including heart failure and obstructive uropathy, was observed with an uncovered urinary drainage bag that was visible from the open doorway. The DON confirmed that the bag should have been covered but was not.
A resident with dementia, known to be intrusive, struck another resident who was cleaning a fish tank, resulting in facial scratches and bleeding. The incident occurred in the presence of two nurses and two CNAs, despite care plan interventions and facility policy intended to prevent abuse.
A resident with multiple diagnoses, including PTSD, was not accurately assessed in the MDS, as section A1500 failed to indicate a serious mental illness despite a level II PASRR confirming the diagnosis. No correction was documented after the PASRR was received, and the DON acknowledged the oversight.
A resident with dementia and PTSD was admitted with a Level I PASRR that did not document PTSD, despite this diagnosis being present in the medical record. The facility did not request or complete a required Level II PASRR evaluation, and the DON acknowledged that an updated Level I and a Level II PASRR should have been completed.
Two residents did not receive care in accordance with their care plans: one was transferred by a CNA using a sit-to-stand device with only one staff member instead of the required two-person assist, and another had a PTSD diagnosis that was not addressed in their care plan. The DON confirmed both deficiencies.
A resident with multiple diagnoses was found with OTC medications at the bedside, including one without a physician's order, and staff did not obtain the necessary order. Additionally, a medication cart audit revealed that the narcotic accountability record was missing a required nurse signature, with both an LPN and the DON confirming that two nurses should have signed the record during cart exchanges.
Glucose test solutions were found without required open or expiration dates, and a resident's medications were left unattended at the bedside by an agency nurse unfamiliar with the resident's self-administration status. The DON confirmed the resident was not approved for self-administration, and medications should not have been left unsecured.
Staff failed to follow infection prevention protocols, including placing insulin syringes on a resident's bed instead of a protective barrier, not cleaning a blood pressure cuff between two residents, and not cleaning lift straps after use. These actions were acknowledged by the staff and confirmed by facility leadership.
A resident reported an incident of sexual abuse involving another resident, but the facility failed to notify the State Agency within the required two-hour timeframe. The Administrator, unaware of the reporting requirement, delayed the report, leaving residents at risk. The facility's policy mandates immediate reporting, but this was not followed, resulting in a deficiency.
A resident with Chronic Obstructive Sleep Apnea did not receive prescribed Norco pain medication and CPAP therapy due to a nurse's assumption that another staff member had addressed the resident's needs. Despite the resident's requests, the nurse did not administer the treatments, and the night nurse only provided the pain medication later, omitting the CPAP therapy.
The facility did not ensure alternatives to bed rails were attempted or assessed before use for two residents. Despite policies requiring a person-centered approach and documentation of alternatives, assessments lacked explanations for the continued use of bed rails. One resident with cervical fractures and a history of falls was observed with raised side rails, while another with heart disease and vertigo had side rails despite assessments indicating they were unnecessary.
Failure to Inform Residents of Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advance directive, as required by policy. For 10 out of 54 residents reviewed, there was no documentation in the medical records that the facility informed or provided written information regarding the right to formulate an advance directive. In each case, the residents' records contained a POST (Physician Orders for Scope of Treatment) document, but lacked an advance directive and any evidence that the facility had communicated the option or provided the necessary information to the resident or their representative. The affected residents had a range of significant medical conditions, including coronary artery disease, GERD, anemia, atrial fibrillation, hypertension, malnutrition, non-traumatic brain dysfunction, hyperlipidemia, thyroid disorder, diabetes, PTSD, chronic kidney disease, epilepsy, aphasia, hemiparesis, dementia, heart failure, and muscle weakness. In one instance, a resident had previously revoked a POA for healthcare, but there was still no documentation of an advance directive or that information about advance directives had been provided. The facility administrator confirmed the absence of both advance directives and documentation of having informed the residents or their representatives about their rights in these cases.
Failure to Follow Bowel Management Protocol and Physician Orders
Penalty
Summary
The facility failed to follow its established bowel management protocol for five residents whose records were reviewed for bowel and bladder care. According to the protocol, if a resident does not have a bowel movement within 48-72 hours, a series of progressive interventions, including administration of Bisacodyl tablets, suppositories, and enemas, should be implemented and documented. However, documentation revealed that for several residents, there were significant gaps between bowel movements—ranging from 120 to 144 hours—without evidence that the bowel management protocol was initiated or followed as ordered. Medication Administration Records (MARs) and CNA Task Bowel Activity logs showed that the required interventions were either not started in a timely manner or not documented as completed, despite the absence of bowel movements for extended periods. Specific examples include a resident with a history of femur fracture and depression who went five days without a bowel movement and did not have the protocol initiated, and another resident with Huntington’s disease and anxiety who experienced a prolonged period without a bowel movement despite multiple steps of the protocol being initiated without documented results. Additional residents with chronic kidney disease, PTSD, and dementia also experienced similar lapses, with the protocol either not started or not fully documented. The Director of Nursing confirmed that nursing staff did not document following all steps of the bowel protocol as required.
Failure to Maintain Resident Dignity by Not Covering Urinary Drainage Bag
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring the resident's urinary drainage bag was covered. The resident, who had multiple diagnoses including heart failure, diabetes, and obstructive uropathy, was observed with an uncovered urinary drainage bag that was visible from the open doorway of his room. This observation was confirmed by the Director of Nursing, who acknowledged that the urinary drainage bag should have been covered but was not at the time of the surveyor's visit.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. One resident, with a history of dementia and being intrusive into others' space, approached another resident who was cleaning a fish tank and began yelling. The situation escalated, resulting in the first resident striking the second resident across the face, causing three open scratches that drew blood. The care plan for the resident with dementia included interventions such as redirection and removal from the environment as needed, as well as observation and reporting of behaviors that could pose danger to self or others. At the time of the incident, two nurses and two CNAs were present and witnessed the altercation. The facility's policy stated that each resident has the right to be free from verbal, sexual, physical, and mental abuse. Despite the presence of staff and existing care plan interventions, the incident occurred, indicating a failure to implement measures to prevent resident-to-resident abuse as outlined in the facility's policy.
Failure to Accurately Complete MDS Assessment for Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident with multiple diagnoses, including hypertension, diabetes, and PTSD, a serious mental illness. The resident's MDS assessment did not indicate the presence of a serious mental illness in section A1500, despite a state level II PASRR documenting a diagnosis of PTSD. The medical record did not show that a correction was made to the MDS after the PASRR was received. The Director of Nursing confirmed that section A1500 should have been corrected following the receipt of the PASRR documentation.
Failure to Refer Resident for PASRR Level II Evaluation for Major Mental Illness
Penalty
Summary
The facility failed to refer a resident for further evaluation when the resident was diagnosed with a major mental illness. Specifically, one resident was admitted with multiple diagnoses, including dementia and PTSD. The Level I PASRR completed in Arizona did not document the PTSD diagnosis, even though it was present in the resident's medical record. As a result, a Level II PASRR was not requested or completed as required in Idaho. The Director of Nursing confirmed that an updated Level I PASRR should have been created to document PTSD and a Level II PASRR should have been requested, but this was not done.
Failure to Follow and Complete Resident Care Plans
Penalty
Summary
The facility failed to follow the comprehensive person-centered care plans for two residents. For one resident with diabetes, heart failure, and a history of CVA with left side hemiplegia and weakness, a CNA was observed transferring the resident from a wheelchair to bed using a sit-to-stand device with only one staff member, despite the care plan and physician orders requiring a two-person assist for transfers. For another resident with dementia and PTSD, the care plan did not include any interventions addressing the PTSD diagnosis. The Director of Nursing confirmed that the transfer was not performed according to the care plan and that the PTSD diagnosis should have been included in the care plan.
Failure to Ensure Proper Management and Documentation of Medications
Penalty
Summary
The facility failed to ensure proper management of over-the-counter (OTC) and controlled medications for its residents. One resident, admitted with multiple diagnoses including epilepsy and aphasia, was observed with a bottle of Tylenol and Nyquil at the bedside; while there was a physician's order for Tylenol, there was no order for Nyquil. The Director of Nursing (DON) confirmed that residents often bring in OTC medications without notifying nursing staff, and in this case, staff did not obtain a physician's order for the Nyquil as required. Additionally, during a medication cart audit, it was found that the narcotic accountability record was missing a required licensed nurse signature, and both an LPN and the DON confirmed that two nurses should have signed the record when accepting or releasing the medication cart.
Failure to Properly Label Biologicals and Secure Medications
Penalty
Summary
Surveyors observed that glucose test solutions in the facility were not labeled with the date they were opened or their expiration date, as required. Both an LPN and an RN confirmed that the glucose test solutions should have been dated when opened, but were not. Additionally, a resident with multiple diagnoses, including hypertension, diabetes, and PTSD, was found to have their morning medications left unattended in a medication cup on their bedside table without a licensed nurse present. The nurse responsible, who was an agency nurse on her first day with the resident, was unaware if the resident had a self-medication administration assessment. The DON later confirmed that the resident was not approved to self-administer medications and that the nurse should not have left the medications at the bedside.
Infection Control Lapses in Medication Administration and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observed incidents involving staff and residents. In one instance, a registered nurse placed insulin syringes directly on a resident's bed while preparing to administer medication, rather than using a protective barrier on the bedside table as required. Both the nurse and the infection preventionist acknowledged that this was not in accordance with facility protocol. The resident involved had a history of coronary artery disease and diabetes and was receiving insulin therapy at the time of the incident. Additional deficiencies were observed in the cleaning and disinfection of shared medical equipment. A nurse was seen using a blood pressure cuff on two different residents without cleaning it between uses, contrary to the facility's policy. Furthermore, a certified nursing assistant cleaned a sit-to-stand device after a resident transfer but failed to clean the straps, instead draping the uncleaned straps over the sanitized device. The director of nursing confirmed that the straps should have been cleaned. These lapses in infection control practices were confirmed through staff interviews and record review.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving Resident #149 to the State Agency within the required two-hour timeframe. Resident #149, who was admitted with diagnoses including post-hospitalization care for a fracture, Type 2 Diabetes, major depressive disorder, and anxiety disorder, reported that Resident #22 entered the shower room while she was bathing and later made inappropriate comments and physical contact. The incident was reported to the facility's Administrator on 1/15/24, but the Administrator advised staff they had 24 hours to report the incident and did not report it to the State Agency until 1/16/24. The facility's policy requires immediate reporting of suspected abuse, but the Administrator was unaware of the two-hour reporting requirement. This delay in reporting resulted in the allegation not being acted upon in a timely manner, leaving Resident #149 and other residents at risk. The facility's failure to adhere to the reporting guidelines outlined in their policy and federal regulations led to a deficiency in ensuring resident safety and timely investigation of abuse allegations.
Failure to Administer Pain Medication and CPAP Treatment
Penalty
Summary
The facility failed to follow physician orders for a resident's pain medication and respiratory treatment, which were crucial for managing the resident's chronic conditions. The resident, who was diagnosed with Chronic Obstructive Sleep Apnea, was supposed to receive Norco for pain management and CPAP therapy with oxygen at bedtime. However, on a specific evening, the resident did not receive the prescribed Norco medication or the CPAP treatment as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The deficiency occurred when RN #2, the evening nurse, did not administer the required treatments, assuming another staff member had addressed the resident's needs. Despite the resident's repeated requests for his routine treatments, RN #2 failed to respond, citing being busy with another resident. The Director of Nursing (DON) confirmed that RN #2 did not provide the necessary care and that the night nurse only administered the pain medication later, neglecting the CPAP treatment entirely.
Failure to Assess and Document Alternatives to Bed Rails
Penalty
Summary
The facility failed to ensure that alternatives to bed rails were attempted or assessed before placing bed rails on residents' beds, specifically for two residents. The facility's policy, dated October 2023, mandates a person-centered approach and the use of appropriate alternatives before installing bed rails. However, the assessments for the residents did not document why alternatives failed or why bed rails continued to be used when assessments indicated they were no longer needed. Resident #34, with multiple diagnoses including cervical fractures and a history of falling, was observed with raised side rails despite an assessment recommending only 1/4 bed rails. The assessment did not explain how attempted alternatives failed. Similarly, Resident #33, with diagnoses including heart disease and vertigo, was observed with raised side rails even though assessments from July 2023 and January 2024 indicated no need for bed rails. The facility's administrator acknowledged the expectation to try all alternatives before using side rails.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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