Idaho State Veterans Home - Post Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Post Falls, Idaho.
- Location
- 590 S Pleasant View Rd, Post Falls, Idaho 83854
- CMS Provider Number
- 135148
- Inspections on file
- 10
- Latest survey
- November 11, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Idaho State Veterans Home - Post Falls during CMS and state inspections, most recent first.
A resident with multiple chronic conditions developed worsening pressure ulcers, including a right heel ulcer that progressed to Stage IV with infection, due to lapses in wound assessment, missing documentation, and delays in specialist wound care. Staff changes and administrative confusion further contributed to the lack of timely intervention and oversight.
A resident with diabetes and other chronic conditions was not seen by a podiatrist as ordered, resulting in a prolonged delay before a podiatry appointment was scheduled. The resident's toenails became thick, yellow, and misshapen during this period, and staff reported difficulty providing nail care. The delay was due to administrative confusion regarding VA care transfers, incomplete paperwork, and insurance or copay issues.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have a qualified Infection Preventionist (IP) working onsite at least part-time, as required. The current IP worked remotely and did not visit the facility, and the previous IP and DON, who had overseen infection control, had both resigned. The facility was left without a certified or qualified onsite IP, and recruitment for a replacement was ongoing.
Expired urinary pain relief tablets, fleet laxative enemas, and hydrogen peroxide were found available for use in a medication storage room. Staff interviews revealed confusion about responsibility for monitoring and removing expired medications, with the RN, pharmacist, and DON each providing different accounts of the process. Facility policy requires regular review and removal of expired medications, but this was not consistently followed.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency related to meal quality standards.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that mandate restraints only be used for medical treatment.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A resident did not receive the necessary care and services to maintain or improve ROM and mobility, resulting in a decline that was not attributed to a medical reason.
Surveyors found that an area was not free from accident hazards and lacked adequate supervision to prevent accidents, resulting in a deficiency for failing to maintain a safe environment.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility failed to implement an effective antibiotic stewardship program, lacking protocols for the duration and prophylactic use of antibiotics. A resident admitted with a UTI was prescribed Cephalexin without an end date, and the required Infection Report was not completed. The DNS, acting as the Infection Preventionist, confirmed the absence of evaluation for the resident's antibiotic use. Despite consistent prophylactic antibiotic use among residents, no issues were identified in trending reports, and the facility lacked criteria for comparing usage rates.
A facility failed to provide a resident with the necessary SNF ABN and NOMNC forms when skilled therapy services were discontinued. Due to miscommunication about the last covered day, the Health Information Specialist did not issue the notices, leaving the resident and their representative uninformed about potential costs and appeal rights.
Two residents experienced abuse from another resident with a history of aggression. The first incident involved a resident with vascular dementia who was accused of theft and physically harmed. A month later, another resident with cognitive and physical impairments was grabbed and caused pain. Both incidents were witnessed by staff, but the facility's abuse prevention policy was not effectively implemented, allowing the aggressive resident to harm others.
A facility failed to notify the Ombudsman about a resident's discharge to the hospital due to a lack of policy guidance and staff awareness. The resident, who had severe cognitive impairment, was transferred to the emergency department, but the Ombudsman was not informed as required. Interviews revealed that the Social Worker was unaware of the notification requirement, and the Administrator confirmed the policy did not address this need.
A resident with dementia and other medical conditions was found with dried feces on his body, indicating neglect in incontinence care. Despite facility policy requiring two staff members for care, discrepancies in staff reports revealed that the resident was not properly attended to during the night shift. The Abuse Response Team confirmed neglect, as the resident's condition suggested he had not been cleaned for several hours.
A resident with type two diabetes mellitus experienced hypoglycemia incidents, but the facility failed to follow its protocol. On two occasions, the resident's low blood glucose levels were not rechecked or documented, and the physician was not notified as required. Nursing staff did not adhere to the hypoglycemia treatment guidelines, leading to a deficiency in care.
A resident with cerebral infarction and hemiparesis was left without access to her call light, which was placed in a dresser drawer by a CNA. The resident, who required assistance for transfers and ambulation, was found by RN2 calling for help after the CNA informed RN2 of the oversight. The facility's policy requires call lights to be within reach, and staff confirmed this was a safety issue.
Failure to Prevent Worsening and Infection of Pressure Ulcer Due to Lapses in Assessment and Documentation
Penalty
Summary
The facility failed to prevent the worsening of a pressure ulcer for a resident with multiple comorbidities, including dementia, heart failure, diabetes, and chronic kidney disease. The resident developed pressure ulcers on multiple sites, most notably the right heel, which deteriorated from an unstageable deep tissue injury to a Stage IV ulcer with infection. Documentation shows that the wound increased in size, developed slough and eschar, and became infected, as evidenced by foul odor, drainage, and a positive wound culture for Streptococcus agalactiae. The resident experienced pain during wound care, and antibiotics were started after infection was confirmed. There were significant lapses in wound assessment and documentation. Weekly Pressure Ulcer Records were missing for extended periods, specifically from early August to late September, and there was no documentation of wound status or refusal of care during this time. The Treatment Administration Record indicated that wound care was being provided, but there was no corresponding assessment or progress documentation. Staff interviews revealed that there was no dedicated Wound Nurse during a critical period, and nurse managers were responsible for wound care without clear oversight or knowledge of the resident's wound status. The current CNO and Nurse Manager were not present during the period in question and could not provide information about the care provided. Delays in obtaining specialist wound care further contributed to the deficiency. A referral to a wound clinic was made in late September, but due to administrative confusion regarding the resident's veteran status and required transfer of care, the appointment was not scheduled until early November. During this time, the resident's wounds continued to deteriorate, and the wound clinic physician was unable to perform debridement due to the resident's pain. The lack of timely assessment, documentation, and specialist intervention resulted in the resident suffering harm from a worsening, infected pressure ulcer.
Failure to Ensure Timely Podiatry Care for Diabetic Resident
Penalty
Summary
A resident with multiple diagnoses, including dementia, heart failure, and diabetes, was not seen by a podiatrist as ordered by the physician. Nursing progress notes indicated that a referral for diabetic foot care was initiated, and the physician assistant agreed to the podiatry consult. However, there was a significant delay of approximately 10 weeks before the resident was scheduled to be seen by a podiatrist. During this period, observations showed the resident's toenails were thick, yellowish, and misshapen, and the wound nurse reported difficulty in providing nail care due to the condition of the toenails. The delay in scheduling the podiatry appointment was attributed to administrative and procedural issues, including confusion regarding the transfer of care for a veteran patient, incomplete paperwork, and insurance or copay barriers. Staff interviews revealed a lack of awareness about the need to transfer care between VA facilities and challenges in securing an appointment due to staffing shortages at the VA hospital. Attempts to refer the resident to private providers were unsuccessful due to insurance limitations and refusal to pay copays.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Designate Qualified Onsite Infection Preventionist
Penalty
Summary
The facility failed to designate one or more qualified individuals as Infection Preventionists (IPs) who are responsible for the Infection Prevention and Control Program (IPCP) and who physically work onsite at least part-time. Review of the facility's employee listing showed there was no designated IP working onsite. An interview with the current IP revealed that she worked remotely and did not spend any time onsite, although she had been assisting the facility since April. She also stated that the facility had hired an IP, but that individual had quit a few weeks prior, and no one currently at the facility was certified or qualified as an IP. Further interviews with the Administrator confirmed that the previous IP, a registered nurse, had started in August but was still in the process of completing the required training before resigning in July. The previous Director of Nursing (PDON), who had overseen the IPCP, also resigned in May. The Administrator provided a training certificate for the PDON and indicated that the previous IP had completed infection prevention modules through the CDC, but no completion certificate was available. The facility had been actively recruiting for a new IP since the last resignation.
Expired Medications Found in Medication Storage Room
Penalty
Summary
Expired medications, including urinary pain relief tablets, fleet laxative enemas, and bottles of hydrogen peroxide, were found available for use in the medication storage room during an observation. The facility's policies require the pharmacist to review all medications for expiration dates and remove expired or discontinued drugs at least every thirty days. However, the expired medications observed had not been removed, and staff interviews revealed uncertainty regarding who was responsible for monitoring and removing expired medications from the medication room. The RN present during the observation acknowledged the presence of expired medications and stated that the pharmacy consultant regularly checked for expired items, but could not confirm how often central supply staff performed checks. The pharmacist confirmed that she manually tracked medications with pharmacy labels, while central supply staff were responsible for other medications. The DON, in the presence of the administrator, was initially unsure who was responsible for monitoring expired medications and later stated that all nurses were responsible for checking the medication rooms.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the meals did not consistently meet standards for taste, appearance, or temperature at the time of service.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in ROM or mobility, except in cases where such decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve the resident's physical abilities were not implemented as required.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the presence of accident hazards and insufficient supervision in the area, as directly observed by surveyors. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of protocols addressing the duration and prophylactic use of antibiotics. The policy required the Infection Preventionist to be notified when a resident was admitted with an antibiotic, and for the staff nurse to complete an Infection Report and Criteria Checklist. However, for one resident admitted with a urinary tract infection and prescribed Cephalexin for prophylaxis, there was no end date for the medication, and the required Infection Report and Criteria Checklist was not completed. The Director of Nursing Service, who was acting as the Infection Preventionist, confirmed the absence of evaluation for the resident's antibiotic use and acknowledged that the policy did not include monitoring the duration of antibiotic use. The facility's quarterly Antibiotic Stewardship meetings and monthly infection control tracking showed a consistent number of residents receiving prophylactic antibiotics without stop dates, yet no issues were identified in the trending reports. The Director of Nursing Service, who had been absent for three weeks, stated that the facility did not have goals or criteria for comparing the rate of prophylactic antibiotic use and did not view the current use as problematic. The Administrator expressed concern over the high prophylactic use of antibiotics and intended to discuss the matter with the Director of Nursing Service and the Medical Director.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a resident with the necessary Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage form and the Notice of Medicare Non-coverage (NOMNC) form when skilled therapy services were being discontinued. This oversight involved a resident who had skilled days remaining and planned to stay in the facility. The facility's policy required that these notices be delivered at least two days before the last covered day, but due to miscommunication and confusion regarding the last covered day, the forms were not issued. As a result, the resident and their representative were not informed about the potential costs of continuing care or their right to appeal the decision. The Health Information Specialist, responsible for preparing and delivering these notices, did not issue them due to conflicting information about the resident's last covered day. Initially informed that services would not end, the specialist did not prepare the forms. Later, it was confirmed that the services would indeed end on the originally planned date, but by then, it was too late to provide the required two-day notice. The specialist did not understand that the notices should have been issued even if late, resulting in the resident and their representative not receiving any notification or verbal communication about the discontinuation of services.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident abuse, as evidenced by two separate incidents involving a resident with a history of wandering and aggression. The first incident involved a resident with vascular dementia and intact cognition, who reported that another resident with severely impaired cognition entered his room, accused him of theft, and caused skin abrasions. The incident was witnessed by a CNA who intervened and reported it to the Administrator. Despite the initiation of 15-minute checks on the aggressive resident, another incident occurred a month later. The second incident involved a resident with moderate cognitive impairment and physical disabilities, who was grabbed and pulled by the same aggressive resident in the hallway, causing pain. This incident was witnessed by a CNA, and emergency services were called. The aggressive resident was discharged to the hospital following this incident. The facility's policy on abuse prevention was not effectively implemented, as the aggressive resident had a prior incident of aggression that was not adequately addressed, leading to further harm.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman regarding the discharge of a resident, identified as R24, who was transferred to the hospital. The facility's policy on involuntary transfers and discharges, dated February 2023, did not include any information about notifying the Ombudsman when a resident is discharged to the hospital. This oversight was evident in the case of R24, who had severe cognitive impairment and was sent to the emergency department via ambulance. The review of R24's records, including the Face Sheet, Minimum Data Set, and Progress Notes, confirmed that there was no documentation of the Ombudsman being informed about the discharge. Interviews with facility staff revealed a lack of awareness and clarity regarding the notification process. The Social Worker, during her orientation, was not informed about the requirement to notify the Ombudsman, and as a result, did not do so for R24's discharge. The Administrator confirmed that the responsibility for notifying the Ombudsman lay with the Social Workers, but acknowledged that the current facility policy did not address this requirement. This lack of communication and policy oversight led to the deficiency in notifying the Ombudsman about the resident's transfer to the hospital.
Neglect in Incontinence Care for Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, identified as R23, who was dependent on staff for activities of daily living. R23, who had diagnoses including dementia, kidney disease, neurogenic bladder, and uropathy, was found with dried feces on various parts of his body, including his hands, face, neck, and catheter tubing. The incident was reported by CNAs who discovered the condition at 6:20 AM, indicating that the resident had been left in this state for several hours. The facility's policy required two staff members to be present when providing care to R23, but this was not adhered to during the night shift. Interviews with staff revealed discrepancies in the care provided to R23. CNA4 and CNA5 were responsible for the last rounds, which began at 4:00 AM. CNA4 reported that CNA5 claimed to have provided care to R23 at 5:15 AM, including emptying the catheter bag and changing the brief. However, CNA2 and CNA3 found R23 in a state that suggested he had not been cleaned for several hours, with dried feces on his body and a full catheter bag. CNA5, when interviewed, could not recall providing care to R23 and was assigned to a different unit that night. The Director of Nursing Services (DNS) confirmed that the documentation of care was not done in real-time and that the information was recorded before the last rounds. The Abuse Response Team, consisting of the Administrator, DNS, RN Manager, and Social Workers, validated neglect related to R23's care. The team concluded that the bowel movement had occurred before 5:15 AM, as the stool was dried, indicating a failure to provide timely and appropriate care to the resident.
Failure to Follow Hypoglycemia Protocol for Insulin-Dependent Resident
Penalty
Summary
The facility failed to provide appropriate nursing care and services for a resident, identified as R16, who was using insulin and experienced hypoglycemia incidents. The facility's policy required that blood glucose (BG) levels below 70 mg/dl should be treated with 15 grams of carbohydrates, rechecked in 15 minutes, and the physician notified. However, there were instances where R16's low blood sugar levels were not rechecked or documented, and the physician was not contacted as per the protocol. This oversight was noted on two occasions, with BG levels recorded at 64 and 58, where the necessary follow-up actions were not documented or performed. R16, who had a diagnosis of type two diabetes mellitus, was receiving insulin treatment and had intact cognition. The resident reported experiencing low blood sugar incidents and recalled being given orange juice for low blood sugar. On one occasion, the resident's morning BG level was 64, and although the insulin dose was held, there was no documentation of a recheck or physician notification. Similarly, another incident recorded a BG level of 58, where the insulin was held, and snacks and juice were given, but again, there was no documentation of a physician being contacted or the BG level being rechecked. Interviews with nursing staff revealed a lack of adherence to the hypoglycemia protocol. RN6 and RN5, who were responsible for R16's care during these incidents, failed to document the rechecking of BG levels and did not notify the physician as required. The Director of Nursing Services (DNS) later identified these deficiencies and noted that the physician should have been notified for BG levels below 70. The RN Manager confirmed the protocol and emphasized the need for documentation of BG rechecks and physician contact in the medical record.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as R16, by not ensuring her call light was within reach. R16, who was admitted with diagnoses including cerebral infarction, hemiplegia, and hemiparesis, had intact cognition and was at risk for falls due to poor mobility and left-sided hemiparesis from a stroke. The care plan for R16 included the use of a call light to seek staff assistance for transfers and ambulation. However, on the night of the incident, a CNA forgot to return R16's call light, leaving it in a dresser drawer out of her reach. This oversight was discovered when RN2 received a text message from the CNA after her shift ended, prompting RN2 to check on R16, who was found maladjusted in bed and calling for help. The facility's policy, as stated in the Resident Safety Policy, mandates that call lights should be placed within easy reach of residents at all times. Interviews with staff, including the Administrator, DNS, RN2, and the Social Worker, confirmed that the call light was not within R16's reach, which was a violation of the facility's policy and a potential safety issue. The incident was investigated by the previous DON, who arrived at the facility in the early hours following the incident. The staff acknowledged the importance of keeping call lights accessible to residents to ensure their safety and uphold their rights.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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