Ironwood Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coeur D'alene, Idaho.
- Location
- 2200 Ironwood Place, Coeur D'alene, Idaho 83814
- CMS Provider Number
- 135053
- Inspections on file
- 16
- Latest survey
- March 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ironwood Rehabilitation And Care Center during CMS and state inspections, most recent first.
Two residents experienced abuse and neglect in the facility. One resident, who was deaf, reported a PT threw a soiled bed pan and urinal at her, while another resident was neglected by a NAIT who failed to provide incontinence care despite multiple requests. The facility's investigations confirmed these incidents, highlighting a failure to protect residents' rights.
The facility failed to employ sufficient staff with the necessary competencies and skills in food and nutrition services, impacting resident assessments and care plans. The DM had not completed certification, and the administrator held a food service certificate instead of a degree, potentially affecting all residents needing nutritional therapy.
A facility failed to provide a dignified dining experience for three residents, who received their meals at different times, causing potential psychosocial harm. The delay was due to the facility's meal order process, which did not account for residents' seating arrangements.
The facility did not adhere to its posted mealtime schedule, affecting 69 residents. Lunch service began 35 minutes after residents were seated, and breakfast service started 30 minutes late, with staggered service times for different halls. The DM and RD were unaware of the posted mealtimes, confirming a discrepancy between posted and actual mealtimes, potentially impacting residents' quality of life and medication schedules.
The facility failed to maintain a clean and sanitary kitchen environment, with issues such as undated and unlabeled food items, improper food storage, and significant cleanliness problems. Ice buildup was observed in the freezer, and dirt was found around the AC unit in the refrigerator. The Nutritional Services Director noted that deep cleaning was infrequent, and the maintenance director confirmed that cleaning responsibilities were assigned to kitchen staff. These deficiencies posed a risk to the 69 residents consuming food prepared by the facility.
The facility's Activity Room, used as a Bistro, had inadequate lighting due to missing bulbs and non-functional track lighting. A resident highlighted the issue, and both the Maintenance Director and Activity Director confirmed the problem, noting it affected residents' activities. The Interim DON stated the lighting issue was pending resolution during facility remodeling.
A resident with severe cognitive impairment alleged sexual abuse, but the facility delayed reporting the incident to administration and authorities for almost 14 hours. The facility's policy required immediate reporting, but the delay led to a failure to promptly inform the resident's physician, POA, and the State Agency. A medical examination found no physical evidence of abuse, and the resident later denied being harmed.
A resident with severe cognitive impairment reported an alleged sexual abuse incident, which the facility failed to investigate thoroughly and promptly. The investigation was delayed, and only one staff member was interviewed, while the resident was not assessed for harm until 14 hours later. The facility's Administrator admitted the investigation was incomplete and untimely.
The facility failed to update care plans for two residents, leading to discrepancies between current medical orders and documented care directives. One resident's care plan inaccurately reflected the use of a BiPAP machine, while another's did not include a recent physician's order for regular weight monitoring.
A resident with multiple diagnoses, including diabetes and atrial fibrillation, was observed scratching scabbed sores on her arm, but the facility failed to document a skin assessment or treatment plan. Despite CNAs applying lotion to alleviate itching, the type of lotion was unknown, and there was no record of a skin evaluation or updated care plan, as confirmed by the DON and RCM.
The facility failed to provide podiatry services as ordered for two residents, one with heart disease and cognitive impairment, and another with diabetes and heart disease. Despite physician orders and requests for podiatry care, the facility faced challenges in scheduling appointments due to clinic limitations and insurance issues. Both residents' medical records lacked documentation of podiatry visits, and the facility's policy on podiatry care was not provided during the survey.
A facility failed to document the rationale for continuing PRN alprazolam beyond 14 days for a resident with anxiety. The resident was prescribed Xanax 0.25 mg every 12 hours as needed, but there was no documentation supporting its use beyond the 14-day limit, as required by the State Operations Manual. The facility's Administrator confirmed the absence of a stop date or reason for continuation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving two residents. One resident, who was deaf and required a whiteboard for communication, reported that a physical therapist (PT) threw a soiled bed pan and urinal at her, causing urine to splash onto her arm. The incident occurred when the resident declined to attend a therapy session due to preparing to move rooms. The PT did not use the whiteboard to communicate and was reportedly yelling at the resident. A nursing assistant in training (NAIT) present during the incident confirmed the PT's actions and noted the resident was left with feces and urine on her. Another resident, who was cognitively intact and required extensive assistance with personal hygiene, experienced neglect when she used her call light multiple times to request help with incontinence care. A NAIT responded to her call light but failed to return with assistance, leaving the resident without the necessary care. Despite being informed by a registered nurse (RN) to assist the resident, the NAIT falsely claimed to have provided the care and informed another CNA that the resident had been helped. The resident reported the neglect, and the facility's investigation confirmed the NAIT's failure to provide care. These incidents highlight the facility's failure to ensure residents' rights to be free from abuse and neglect, placing all residents at risk of harm. The facility's investigations substantiated the allegations of abuse and neglect, confirming the inappropriate actions of the PT and the neglectful behavior of the NAIT.
Removal Plan
- PT #1 was suspended during the investigation, then terminated from employment at the facility.
- The State Licensure Board was notified of the abuse allegations and investigative findings related to PT #1's involvement in the incident.
- All staff were educated on abuse/neglect and identifying burnout.
- Staff were offered counseling services for burnout.
- NAIT #1 was suspended immediately during the investigation.
- The facility provided retraining to all nursing staff regarding abuse, neglect, and how to manage burnout.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility was found to have deficiencies in employing sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services. This includes the failure to adequately perform resident assessments, develop individual plans of care, and consider the number, acuity, and diagnoses of the resident population. The deficiency was identified through documentation and staff interviews, revealing that the facility's part-time dietitian and the director of food and nutrition services (DM) did not meet the required qualifications as outlined in the State Operations Manual, Appendix PP. The DM, who had been in the position for five years, had completed food services manager training but had not yet taken the certification exam. Additionally, the facility's administrator, an LPN, held a food service certificate rather than a degree. These staffing inadequacies had the potential to affect all residents requiring medical nutrition therapy, nutritional assessments, and appropriate dietary interventions, as the facility did not have a full-time qualified dietitian or a properly certified director of food and nutrition services.
Failure to Provide Timely and Dignified Dining Experience
Penalty
Summary
The facility failed to treat each resident with respect and dignity, which affected their quality of life and dining experience. This deficiency was observed in the dining room, where three residents did not receive their meals in a timely manner or at the same time as others at their table. Specifically, Resident #1 was observed eating her meal at 12:40 PM, while Resident #17 received his meal at 12:45 PM and required assistance from a feeding aide. Resident #28 initially received the wrong meal type at 12:49 PM, which was then corrected to a mechanical chopped meal at 12:53 PM, and she began eating with assistance at 12:55 PM. The delay in meal service was attributed to the facility's process of filling meal orders based on meal tickets received, without prior knowledge of residents' seating arrangements. The Dietary Manager (DM) explained that staff attempt to serve residents together, but this does not always occur as planned. This inconsistency in meal service timing created the potential for psychosocial harm, as residents may feel excluded from the dining experience.
Failure to Adhere to Posted Mealtime Schedule
Penalty
Summary
The facility failed to provide meal service according to the posted mealtime schedule, potentially affecting 69 residents. Observations revealed that during lunch, residents were seated at 12:00 PM, but the first tray was not delivered until 12:35 PM, with the last meal served at 12:53 PM. Similarly, during breakfast, residents were seated at 7:30 AM, but meal service did not begin until 8:00 AM, with staggered service times for different halls. The Dining Manager (DM) and Registered Dietitian (RD) were unaware of the posted mealtimes and confirmed that the actual mealtimes differed from those posted. This discrepancy could lead to poor quality of life, nutritional issues, and complications with medications that need to be taken with meals.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during inspections. During the initial inspection, several issues were noted, including undated and unlabeled food items such as noodle soup, shredded carrots, and a container of noodle/macaroni spiral salad in the refrigerator. Additionally, a fully cooked ham was improperly stored on top of liquid eggs. The kitchen also had significant cleanliness issues, with a brown layer of dirt around the AC unit and across the ceiling, directly above open and undated bags of shredded lettuce and an open container of dry, grated parmesan cheese. Ice buildup was observed in the freezer, with ice growing from a cardboard food box and from the ceiling, and two large ice cream containers were left unsealed under the freezer ceiling. A follow-up inspection revealed persistent issues, including ice buildup in the freezer and dirt around the AC unit in the refrigerator. The facility's cleaning schedule indicated that the freezer floor was not cleaned on several dates, and the maintenance director confirmed that while equipment was checked, the cleaning of refrigerators and freezers was the responsibility of the kitchen staff. The Nutritional Services Director acknowledged that deep cleaning was done monthly or quarterly, and the ice buildup was attributed to a freezer door that did not close properly. These deficiencies had the potential to affect the 69 residents who consumed food prepared by the facility, placing them at risk for potential contamination and adverse health outcomes.
Inadequate Lighting in Activity Room
Penalty
Summary
The facility failed to ensure that the Activity Room, which was being used as the facility's Bistro, had adequate and comfortable lighting for residents to enjoy their activities. This deficiency was observed when a resident requested the surveyor to visit the Activity Room, where it was noted that the lighting was dim due to missing light bulbs and multiple lights being out on the track lighting. The Maintenance Director acknowledged the issue, stating that the light tracks could not be replaced because they were no longer available in the area and that the previous administrator had planned to address it during the facility's remodeling. The Activity Director confirmed that residents had expressed concerns about the inadequate lighting, which affected their ability to perform activities such as working on jigsaw puzzles and applying nail polish. The Interim DON also stated that the track lighting had not been replaced due to the pending remodeling of the facility.
Delayed Reporting of Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment in a timely manner. The resident, who had a history of dementia with agitation and anxiety, made a statement about being raped, which was initially reported by a CNA. However, the nursing staff did not report this allegation to the facility's administration until the following morning, resulting in a delay of almost 14 hours before notifying the police and other relevant authorities. The facility's policy required such allegations to be reported immediately, but not later than two hours after the allegation was made. The delay in reporting led to a failure to promptly inform the resident's physician, POA, and the State Agency. The resident's initial complaint was followed by a medical examination that found no physical evidence of abuse, and the resident later denied being harmed. Despite this, the facility's failure to adhere to its abuse reporting policy created a potential for psychosocial harm to the resident. The incident report section for notifying agencies was left blank, indicating a lack of proper documentation and communication regarding the incident.
Inadequate Investigation of Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged sexual abuse incident involving a resident with severe cognitive impairment. The resident, who had multiple diagnoses including dementia and anxiety, reported an incident of sexual abuse, which was not promptly or comprehensively investigated. The initial allegation was made on the evening of May 13, 2024, but the investigation was not initiated until the following day, May 14, 2024. The investigation report documented that only one staff member was interviewed, and the nursing staff who received the initial allegation was unavailable for interview as she was a travel nurse no longer working at the facility. Furthermore, the investigation did not include interviews with additional staff or residents who might have had relevant information. The resident was not assessed for physical or psychosocial harm until nearly 14 hours after the initial allegation. The facility's Administrator, who also served as the Abuse Coordinator, acknowledged that the investigation lacked thoroughness and timeliness, as it did not include necessary assessments and statements from other potential witnesses or involved parties.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions, as evidenced by the cases of two residents. Resident #42, who was admitted with multiple diagnoses including diabetes and obstructive sleep apnea, reported that she was supposed to be tested for a BiPAP machine but had not been able to use it due to the facility's requirement for a hospital evaluation. Her care plan, initiated in May 2024, still documented the use of the BiPAP machine despite the order being discontinued in July 2024. The facility's staff confirmed that the care plan was not updated to reflect the discontinuation and the new order for a sleep study. Resident #32, admitted with a diagnosis of anxiety, had a physician's order to be weighed every Monday morning. However, the care plan did not reflect this current order, instead directing staff to notify the physician of significant weight gain. The Interim DON acknowledged that the care plan should have been updated with the current physician's order. These oversights in updating care plans placed residents at risk of adverse outcomes due to the lack of accurate and current care directives.
Failure to Conduct Skin Assessment for Resident
Penalty
Summary
The facility failed to follow professional standards of practice for a resident who was not evaluated for a skin condition. The resident, who had multiple diagnoses including diabetes, atrial fibrillation, anemia, and obstructive sleep apnea, was observed scratching at scabbed sores on her upper right arm. Despite the resident's report of being a picker/scratcher and suspecting medication as a cause, there was no documentation of a skin assessment or treatment plan for the arm sores or itching in the resident's medical record. Staff interviews revealed that while CNAs applied lotion to the resident's arms to alleviate itching, the type of lotion used was unknown, and there was no record of a skin assessment being completed. The Director of Nursing (DON) and Resident Care Manager (RCM) confirmed the absence of necessary documentation and acknowledged that a skin evaluation or dermatology review should have been conducted. Additionally, there were no progress notes indicating the application of lotion to the resident's arms, and the care plan had not been updated to address the skin condition.
Failure to Provide Podiatry Services as Ordered
Penalty
Summary
The facility failed to provide podiatry services as ordered for two residents, leading to a deficiency in care. Resident #13, who was severely cognitively impaired and diagnosed with heart disease, had a physician's order for a podiatry referral due to an ingrown toenail. Despite the POA's request for podiatry care, the facility faced challenges in scheduling an appointment because the podiatry clinic was not accepting new patients for nail or callus care. The facility attempted to find alternative podiatry services, but Resident #13's electronic medical record did not document any podiatry visit as per the physician's orders. Resident #61, with diagnoses including diabetes and heart disease, also required podiatry care. The resident expressed a need to see a podiatrist, but was informed that the service was not covered by insurance. A physician's order indicated the resident may see a podiatrist as needed, and a progress note suggested a referral for podiatry related to diabetes. However, there was no documentation of a referral or podiatry visit in the resident's medical record. The facility's administration confirmed the lack of follow-up and scheduling for both residents' podiatry appointments, and the facility's policy on podiatry care was not provided to the survey team during the survey.
Failure to Document PRN Alprazolam Use Beyond 14 Days
Penalty
Summary
The facility failed to ensure that a resident receiving PRN alprazolam, an anti-anxiety medication, had a clear indication for its use and a clinical rationale for its continued use beyond 14 days. This deficiency was identified during a record review and staff interview, which revealed that the resident was prescribed Xanax (alprazolam) 0.25 mg every 12 hours as needed for anxiety, without documentation supporting its continuation beyond the 14-day limit. The State Operations Manual requires that PRN orders for anti-psychotropic drugs be limited to 14 days unless the attending physician documents a rationale for extending the order. The absence of such documentation for the resident's medication order was confirmed by the facility's Administrator, who acknowledged that the order lacked a stop date or reason for continuation beyond the specified period.
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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