Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Karcher Post Acute during CMS and state inspections, most recent first.
Uncovered Dumpsters and Garbage Can: Based on observation, policy review, and staff interviews, the facility failed to ensure 3 of 3 dumpsters and 1 of 1 outside garbage can were properly closed. Three dumpsters and one garbage can were observed uncovered, and staff stated they should be closed or covered.
Respiratory care was not provided consistently with orders and facility policy. A resident with COPD, respiratory failure, heart failure, and dementia received oxygen without a documented order, and another resident with chronic respiratory failure, pulmonary edema, and COPD was receiving oxygen at 2 LPM when the order called for 3 LPM. In addition, several residents’ nebulizer masks and a nasal cannula were observed left out on tables, beds, or equipment without proper cleaning or storage, and one nebulizer had visible residue and liquid in the reservoir.
Food storage, tray handling, and labeling were deficient. A resident’s breakfast tray remained in the room hours after the meal, a dry food container was found with a cracked lid, and an opened ice cream container in the dining room freezer was unlabeled. Facility staff stated meal trays should be removed shortly after meals and resident foods should be labeled and dated.
A resident with neuromuscular dysfunction of the bladder and paraplegia was observed sitting in a wheelchair outside the Assisted Dining Room with a urinary bag containing urine uncovered on two occasions. The facility’s Dignity policy stated staff were expected to help residents keep urinary bags covered, and the DON stated the bag should be covered when informed of the observation.
A resident with CHF, pulmonary edema, and chronic respiratory failure had care plan and IDT documentation stating an Advance Directive was on file and up to date, but the document could not be found in the record. The ADON stated only a POST form was present, confirmed a POST is not an Advance Directive, and said there was no copy of the resident’s Advance Directive on file.
Failure to Investigate and Document Resident Grievance: A resident with Parkinson's disease and other diagnoses reported that his roommate's loud TV and use of the heater were preventing sleep and making the room too hot to breathe. The resident said he had told the SW multiple times, but the concern was not resolved, was not included in the grievance file, and the LSW acknowledged she did not complete a grievance form or make follow-up.
Seatbelt Used Without Required Restraint Assessment or Consent: A resident with Parkinson’s disease and post-surgical diagnoses was observed sitting in a power chair with a seatbelt on, but the record lacked documentation of a pre-restraint assessment or consent from the resident or representative before the seatbelt was used as a potential restraint. The ADON stated the resident should have been assessed and consent obtained, but could not find documentation that this occurred.
Inadequate Monitoring of Anti-Anxiety Medication Side Effects: A resident with dementia with behavioral disturbances, a history of falls, and anxiety was not appropriately monitored for anti-anxiety medication side effects. The care plan lacked documentation of side-effect monitoring, and the TAR only showed check marks without indicating whether drowsiness, slurred speech, dizziness, nausea, or aggressive/impulsive behavior were present or absent. The DON stated that side effects would be documented in a progress note if present and that the order would be changed to require Y/N documentation.
The facility failed to complete required discharge processes for two residents transferred to a higher level of care. One resident with supplemental O2 dependence, chronic pain, and major depressive disorder was found unresponsive with low O2 saturation and respiratory distress, and another resident with Parkinson’s disease was discharged to the hospital for flap surgery. In both cases, there was no documentation that the State LTC Ombudsman was notified, and one record also lacked documentation of what discharge information was sent to the receiving facility.
A resident admitted with aphasia, hemiplegia and hemiparesis, and stimulant abuse later received new diagnoses of bipolar II disorder and anxiety disorder, but the facility did not complete a new PASRR Level I. The ADON stated the resident should have had a new PASRR when the new MH diagnoses were identified.
PASRR screening was not completed accurately for two residents. One resident with bipolar disorder, depression, and chronic respiratory failure had a PASRR level 1 that incorrectly stated there were no major mental illnesses, and another resident with bipolar disorder and depression had no documented PASRR level 1 after readmission. The ADON and LSW confirmed the screening issues.
Incomplete Person-Centered Care Plans: The facility failed to ensure care plans reflected identified resident needs and behaviors. One resident’s care plan omitted anxiety despite an active dx and medication order, and another resident’s care plan did not include a colostomy, seatbelt use, or the correct target behaviors documented in the TAR. The DON, ADON, and LSW confirmed the missing and inaccurate care plan information.
A resident with cerebral palsy, dysphagia, and a PEG tube had NPO orders, but also had oral medication orders for a probiotic and Milk of Magnesia. An RN was observed giving the probiotic via PEG tube, and the DON later stated the resident should have nothing by mouth. The facility failed to clarify the physician orders to verify the correct route of medication administration.
PEG Tube Flush and Med Admin Orders Not Followed: A resident with a PEG tube, cerebral palsy, and dysphagia had physician orders for specific enteral flushes and bolus feeds. An RN was observed leaving the feeding bag connected after the feed was empty, then administering crushed meds one at a time through the PEG with water and flushing with more than the ordered amount between meds; the RN could not state how much water was used, and the DON said the RN did not follow the physician's flush orders.
Missing CNA Annual Training and Performance Review Documentation: Record review and staff interview showed the facility failed to ensure 1 of 3 CNAs had documentation of the required 12 hours of annual in-service training and a performance review. The Administrator confirmed the missing records after a request was made for CNA education and performance review files.
Inaccurate Medical Record Diagnosis Documentation: A resident admitted with multiple psychiatric diagnoses had a physician-documented active diagnosis of generalized anxiety disorder, but the diagnosis was not listed as active in the medical record. The ADON confirmed the record omission during interview.
A resident admitted with aphasia, hemiplegia, and hemiparesis after a stroke had documentation that he refused the pneumococcal vaccine, but the record did not show that he or his representative was offered the vaccine or educated on its risks and benefits. The MDS Nurse stated pneumococcal vaccines were offered on admission, but she could not find documentation that this resident received the required offer or education.
A resident with dementia, stroke history, and osteoporosis was injured during a transfer when staff, despite repeated refusals and care plan instructions to allow self-initiated, slow transfers, forcibly moved her from bed to wheelchair. The resident exhibited pain and agitation during the transfer, which was performed without proper footwear and against her will, resulting in a displaced femoral neck fracture. Staff interviews revealed the transfer was not in accordance with the care plan, and concerns were raised about the accuracy of the incident investigation.
Multiple residents experienced significant medication errors, including being given the wrong medication, incorrect dosages, missed doses, and omitted treatments. These errors led to actual harm in some cases, such as untreated pain and adverse reactions, and were confirmed through documentation and staff interviews.
A resident with multiple health conditions, including recent amputation and chronic pain, was found unresponsive and later diagnosed with a burn after a CNA failed to notify nursing staff about the use of a heating pad. The CNA observed the heating pad but did not report it, and the nurse was unaware of its presence until the resident was found unresponsive. The incident resulted in the resident requiring hospital care for the burn.
A resident with a history of eye cancer and dementia lost her prosthetic glass eye, which was documented in her care plan. Despite facility policy requiring investigation of missing items, there was no evidence that staff investigated or took action to locate or replace the missing property. The SSD and DON could not provide documentation of any follow-up or investigation.
A resident with dementia and chronic kidney disease, who required assistance with hygiene, had her hair cut by a CNA without consent, despite her religious beliefs prohibiting hair cutting. The resident's preference was not documented in her care plan, and the CNA was unaware of her religious restrictions, resulting in psychosocial harm.
A resident with diabetes and morbid obesity, who was cognitively intact, reported feeling publicly shamed by a dietitian regarding her dietary choices. The allegation of verbal abuse was not reported to the State Survey Agency within the required timeframe, with a delay of about six months before it was uploaded to the reporting portal.
A resident with diabetes and morbid obesity, who was cognitively intact, reported being publicly shamed by a dietitian regarding dietary choices and weight loss. The facility did not document protective measures, conduct interviews, or complete an investigation at the time, and delayed reporting the incident to the State Survey Agency for several months.
Two residents with documented PASARR level II determinations for serious mental illness had their MDS assessments incorrectly marked as 'no' in section A1500, despite RAI requirements to mark 'yes.' The MDS Coordinator was unaware of the correct procedure, resulting in inaccurate assessment documentation.
A resident with multiple medical conditions required assistance with daily hygiene, including hair care, and had a religious belief against cutting her hair. Although this preference was communicated to the facility at admission, it was not documented in her care plan. The administrator was aware of the belief but did not know why it was omitted from the care plan.
A resident with multiple chronic conditions and her representative were not given the opportunity to participate in care planning or attend care conferences, as required by facility policy. Documentation of care conferences was missing or incomplete, and the DON confirmed that records did not show who attended or what was discussed, resulting in a deficiency.
A resident with dementia and palliative care needs experienced a second fall after a soft touch call light intervention, implemented following a previous fall, was not maintained when the resident was moved to a new room. The call light was not transferred, leaving the resident without the necessary means to request assistance, which contributed to the unwitnessed fall.
A resident with chronic pain and dementia was prescribed multiple PRN pain medications, including acetaminophen, hydrocodone-acetaminophen, and tramadol, without clear parameters for administration. Despite a pharmacist's recommendation to clarify the orders using a pain scale, the physician made no changes, and the DON confirmed the lack of specificity in the medication orders.
Two residents experienced significant medication errors when one was given a higher dose of Oxycodone intended for another resident, and another received the wrong type of insulin after a nurse was distracted. In both cases, facility policies requiring verification of medication and resident identity were not followed.
A resident reported receiving meals that were not warm, and a test tray evaluation confirmed that both hot and cold food items were served at improper temperatures. The issue was traced to incorrect placement of food trays in the food cart and the dining cart not being turned on, as confirmed by the Registered Dietitian and Kitchen Manager.
Kitchen equipment and food storage areas were found to be inadequately maintained, with dust and dirt on the pan drying rack and walk-in freezer, thick black residue on aluminum skillets, and significant ice build-up affecting food boxes and pipes. The Dietary Manager and Administrator confirmed lapses in cleaning schedules and responsibilities, with uncertainty about when areas were last cleaned and confusion over staff versus third-party cleaning duties.
A resident with diabetes and legal blindness was discharged from a facility without proper notice or the ability to appeal, following an incident where he sprayed another resident with a garden hose. The resident was sent to a motel without adequate means to manage his insulin-dependent diabetes, as he could not check his blood sugar. The discharge notice was in small print, which he could not read due to his visual impairment. Interviews revealed no history of aggressive behavior, and the resident expressed distress and a desire to return to the facility.
Uncovered Dumpsters and Garbage Can
Penalty
Summary
Dispose of garbage and refuse properly. Based on observation, review of the FDA Food Code, policy review, and staff interviews, the facility failed to ensure 3 of 3 dumpsters and 1 of 1 garbage can were properly closed. The U.S. Food and Drug Administration 2022 Food Code, 5-501.115, states that outside receptacles such as dumpsters must have tight-fitting lids, doors, or covers to keep pests out and contain odors. The facility policy titled, [NAME] Post Acute Trash and Dumpster Policy, stated that all trash must be placed inside designated dumpsters, trash should not be left on the ground, and lids should be closed after use and dumpsters not overfilled. On 5/29/26 at 10:30 AM, three dumpsters and one outside garbage can were observed uncovered. [NAME] #1 stated that the dumpsters should be closed and the garbage can should be covered. At 11:03 AM, the Dietary Director stated that the dumpsters and garbage can should be closed.
Respiratory equipment not cleaned, stored, or set according to orders
Penalty
Summary
The facility failed to ensure residents received respiratory services consistent with professional standards of practice. Surveyors found that respiratory devices for 5 of 16 residents were not cleaned and stored properly, and 2 of 16 residents reviewed for oxygen therapy did not have oxygen administered according to physician orders. The facility policy for oxygen administration required verification of a physician order before oxygen was provided, and the nebulizer policy directed staff to rinse, disinfect, air dry, and store equipment in a plastic bag with the resident’s name and date. Resident #22, who had diagnoses including COPD, respiratory failure, heart failure, and dementia, was observed asleep wearing a nasal cannula connected to a concentrator set at 3.5 LPM and later using a portable oxygen tank set at 2 LPM. However, the physician orders in the record did not document how much oxygen the resident should receive. The DON stated the resident did not have an oxygen order transcribed upon admission and should not have been receiving oxygen without a physician order. Resident #38, who had chronic respiratory failure, pulmonary edema, and COPD, had a physician order for continuous oxygen at 3 LPM via nasal cannula, but the TAR documented 2 LPM, and RN #1 confirmed the portable oxygen tank was set at 2 LPM when it should have been 3 LPM. Surveyors also observed multiple residents’ nebulizer face masks stored improperly. Resident #33’s mask was left on a bedside tabletop without a barrier or bag on multiple observations, Resident #37’s mask was observed upside down on top of the nebulizer machine, Resident #52’s mask was observed on top of the nebulizer machine on the dresser without a barrier or bag, and Resident #38’s mask was observed on the bedside table and later hanging over the back end of the table without a bag. Resident #16’s nebulizer was observed on the nightstand with white particles on the mask and liquid in the reservoir, with the mask touching the nightstand and tubing wrapped over the machine. Resident #8’s nasal cannula was observed resting directly on the blankets, and the DON confirmed it should be placed in a bag when not in use.
Food Storage, Tray Removal, and Labeling Deficiencies
Penalty
Summary
The facility failed to appropriately store, distribute, and label foods. During observation, a resident’s uncovered breakfast tray was still in the room at 11:50 AM even though the resident stated breakfast had been eaten at 7:30 AM, and a CNA stated breakfast trays for that hall are usually delivered around 7:30 AM. The ADON stated at 3:15 PM that meal trays should be picked up 30 minutes after they are finished. The report also cites FDA Food Code Section 3-501.19, which states that once a TCS food is removed from temperature control, it must be consumed or discarded within 4 hours. Kitchen and unit food storage practices were also found deficient. During kitchen observation, a Quaker Oats container was seen on a shelf with a cracked lid, and the Dietary Director later stated the box should not be used and was thrown out. In the assisted dining room freezer, an opened Tillamook ice cream container was observed unlabeled, and the RCM stated it should be labeled and dated. The facility policy required dry foods to be stored to maintain packaging integrity and resident foods on nursing units to be labeled with the resident’s name, item, and use-by date.
Uncovered urinary bag observed on resident in wheelchair
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 1 of 1 resident reviewed for respect and dignity, Resident #16. The facility's Dignity policy, revised February 2021, stated staff were expected to promote dignity by helping residents keep urinary bags covered. Resident #16 was admitted and later readmitted to the facility with diagnoses including neuromuscular dysfunction of the bladder and paraplegia. On 5/26/26 at 12:45 PM and again on 5/27/26 at 1:16 PM, Resident #16 was observed sitting in a wheelchair outside the Assisted Dining Room with a urinary bag containing urine uncovered. On 5/26/26 at 1:18 PM, the DON was informed of the uncovered urinary bag while walking by, and the DON stated that it should be covered.
Advance Directive Not Located in Resident Record
Penalty
Summary
The facility failed to ensure residents exercised their right to formulate an Advance Directive for Resident #33. The State Operations Manual defines an Advance Directive as a written instruction such as a living will or durable power of attorney for health care, and distinguishes a POLST form from an Advance Directive. Resident #33 was readmitted with multiple diagnoses including congestive heart failure, pulmonary edema, and chronic respiratory failure. Resident #33’s care plan, initiated on 5/4/26 and revised on 5/18/26, documented that the resident had an Advance Directive on file and that it was up to date. An IDT Conference Note dated 5/12/26 also documented that the resident’s Advance Directives were reviewed, accurate, and up to date. However, the resident’s Advance Directive could not be located in the record. On 5/28/26, the ADON stated she only saw the resident’s POST form, acknowledged that a POST form is different from an Advance Directive, and stated she did not believe Resident #33 ever gave the facility an Advance Directive; she confirmed there was no copy on file.
Failure to Investigate and Document Resident Grievance
Penalty
Summary
The facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them for Resident #6. The resident was admitted and later readmitted with multiple diagnoses, including aftercare following surgery on the skin and subcutaneous tissue and Parkinson's disease with dyskinesia. On 5/26/26 at 10:27 AM, the resident stated he was unable to sleep because his roommate's TV was too loud and that the roommate was turning the heater on, making the room too hot and difficult to breathe. The resident said he had reported these concerns to the Social Worker three times, including that morning, but nothing had changed. Review of the facility's grievance file did not include the resident's concerns about his roommate. On 5/26/26 at 2:19 PM, the LSW stated the resident had expressed concerns about his roommate and that she spoke to the roommate, who denied turning on the heater. The LSW stated headphones were offered, but the roommate refused, and the resident said he would wear headphones only if the roommate did too. The LSW stated the resident raised the concern again that morning and it was not resolved. She also stated she failed to complete a grievance form for the resident and did not make a follow-up, acknowledging that she should have.
Seatbelt Used Without Required Restraint Assessment or Consent
Penalty
Summary
The facility failed to ensure a seatbelt was assessed as a potential restraint and that consent was obtained from the resident and/or the resident’s representative before use. Resident #6 was admitted and later readmitted with diagnoses including aftercare following surgery on the skin and subcutaneous tissue and Parkinson’s Disease with dyskinesia. The resident was observed sitting in a power chair with a seatbelt on on two separate occasions, but the record did not include documentation that the resident was assessed before the seatbelt was used as a potential restraint. The facility’s Use of Restraints policy stated that a pre-restraining assessment and review must be completed before placing a resident in restraints and that restraints shall only be used upon a physician’s written order and after obtaining consent from the resident and/or representative. The ADON stated the resident should have been assessed and consent obtained before initiating the seatbelt use and was unable to find documentation that this had occurred.
Inadequate Monitoring of Anti-Anxiety Medication Side Effects
Penalty
Summary
The facility failed to ensure residents were appropriately monitored for side effects of anti-anxiety medication for Resident #9, who was admitted with dementia with behavioral disturbances, a history of falls, and anxiety. The care plan contained no documentation of monitoring for anti-anxiety medication side effects, even though a physician order dated 3/16/26 directed staff to monitor for drowsiness, slurred speech, dizziness, nausea, and aggressive or impulsive behavior. The TAR for anti-anxiety side-effect monitoring from 3/16/26 through 5/26/26 showed only a check mark for each entry and did not indicate whether side effects were present or absent or include descriptive information needed to evaluate the resident's response to treatment. During interview on 5/29/26 at 10:30 AM, the DON stated the record reflected monitoring for side effects and that if side effects were present, the nurse would enter a progress note; when asked how the facility evaluated the resident's ongoing need for the medication based on the monitoring entries, the DON stated she would change the order to require Y for yes and N for no to indicate whether side effects were present.
Failure to Document Required Transfer Notifications and Discharge Information
Penalty
Summary
The facility failed to follow the required discharge process when two residents were transferred to a higher level of care. Resident #16, who had diagnoses including dependence on supplemental oxygen, chronic pain, and major depressive disorder, was found unresponsive with an oxygen saturation of 70% and respiratory distress with snoring and gasping respirations. The nurse called 911, and the resident was transported to a higher level of care, but the record contained no documentation that the State Long-Term Care Ombudsman was notified of the transfer. The record for Resident #16 also did not show what discharge information, such as medical records, medication lists, or clinical summaries, was provided to the receiving healthcare institution. Resident #6, who had diagnoses including aftercare following surgery on the skin and subcutaneous tissue and Parkinson's Disease with dyskinesia, was discharged to the hospital for flap surgery, and there was no documentation that the Ombudsman was notified of that discharge. Staff stated the facility did not notify the Ombudsman of hospital discharges and that they were notifying the Ombudsman only when residents were discharged to the community or home.
Failure to Complete PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a PASRR was completed when new mental health diagnoses were identified for Resident #4. The resident was admitted with diagnoses including aphasia, hemiplegia and hemiparesis, and stimulant abuse, and the medical record later documented new diagnoses of bipolar II disorder and anxiety disorder. Appendix PP of the State Operations Manual states that any resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition must be referred to the appropriate state-designated authority for review. During interview, the ADON stated that Resident #4 should have had a new PASRR Level I completed when the bipolar II disorder and anxiety disorder diagnoses were made.
PASRR Screening Not Completed Accurately
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed accurately for 2 of 4 residents reviewed. Resident #22 was admitted with multiple diagnoses including bipolar disorder, depression, and chronic respiratory failure, but the PASRR level 1 dated 5/14/26 documented that the resident did not have any major mental illnesses, including bipolar disorder. On 5/28/26 at 2:22 PM, the ADON stated that Resident #22's PASRR level 1 was not accurate and should have been corrected upon admission. Resident #44 was readmitted with multiple diagnoses including bipolar disorder and depression, but there was no documentation in the record showing that a PASRR level 1 had been completed when the resident returned to the facility. On 5/28/26 at 2:40 PM, the ADON and LSW confirmed that Resident #44's PASRR should have been completed when the resident readmitted.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were developed for residents with identified needs. The facility policy stated that comprehensive, person-centered care plans are to be developed within seven days of completion of the required MDS assessment and no more than 21 days after admission. Review of records and staff interviews showed that Resident #5, admitted with diagnoses including unspecified psychosis, depression, and insomnia, had an MDS documenting depression and a psychotic disorder, and a physician progress note documented generalized anxiety disorder with an order for Duloxetine 20 mg at bedtime for anxiety. However, the resident’s care plan did not include anxiety, related needs, or interventions. The DON confirmed that the anxiety diagnosis and associated interventions should have been included in the care plan. Resident #6 was admitted and later readmitted with diagnoses including aftercare following surgery on the skin and subcutaneous tissue and Parkinson’s Disease with dyskinesia. During interview, the resident stated he had a colostomy, but the care plan did not document the colostomy. The resident was also observed sitting in a power chair with a seatbelt on, and the care plan did not document seatbelt use. In addition, the TAR documented monitored behaviors of verbal aggression, vulgar/sexual remarks, tearfulness, and isolation, while the care plan listed different behaviors such as sadness related to loss of an ex-wife, frustration with medical circumstances, rejection of care/medicines, and yelling/lashing out. The DON, ADON, and LSW each confirmed that the colostomy, seatbelt use, and target behaviors were not accurately reflected in the care plan.
Unclarified medication route orders
Penalty
Summary
The facility failed to ensure physician orders were clarified to verify the correct route of medication administration. Based on observation, record review, the NCSBN website, and staff interview, it was determined that staff did not clarify an order before administering medication, despite the professional obligation to verify any incomplete, inaccurate, unclear, or contraindicated order before implementation. The facility policy for administering medications stated medications are to be given safely and as prescribed, and that the right method (route) of administration must be checked before giving the medication. Resident #2 was admitted with multiple diagnoses including cerebral palsy and dysphagia and had a PEG tube for medication, nutrition, and hydration. The resident had an order for NPO to texture, diet, and consistency, yet also had orders for a probiotic oral capsule to be given by mouth and Milk of Magnesia oral suspension to be given by mouth as needed. During observation, an RN administered a probiotic via PEG tube. The DON later stated the resident was NPO and should have nothing by mouth.
PEG Tube Flush and Medication Orders Not Followed
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for a resident with a PEG tube and physician-ordered enteral flushes and medication administration. Resident #2 was admitted with diagnoses including cerebral palsy and dysphagia, and had orders for enteral water flushes of 15-30 cc before and after medication administration when multiple medications were given together, 5-10 cc before individual medications, and 15-30 cc before and after tube feeding administration and discontinuation. The resident also had an order for Vital AF 1.2 bolus feeds four times daily with 75 ml flushes before and after bolus feeding. On observation, the resident's feeding bag was empty for an extended period, and RN #1 prepared 13 crushed medications in individual cups before entering the room to administer them. The resident's empty feeding bag remained connected to the PEG tube, with enteral feeding still in the tubing, while RN #2 put 240 ml of water into the feeding bag as a bolus. RN #1 then mixed each medication with water and administered them one at a time through the PEG tube using a large syringe, flushing with more than 30 ml of water between each medication and returning to the sink three times to obtain approximately 250 ml of water each time. When questioned, RN #1 stated he did not know how much water he used and said the feeding should have finished earlier, but he did not flush the PEG tube until before medication administration. The DON stated the tube should be checked for residual and flushed within minutes of completion, and later stated RN #1 did not follow the physician's orders regarding flushing the PEG tube.
Missing CNA Annual Training and Performance Review Documentation
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training and performance reviews. Record review and staff interview showed this was true for 1 of 3 CNAs reviewed for skills and qualifications. On 5/29/26 at 12:57 PM, a request was made for CNA education records and performance reviews, and on 5/29/26 at 1:50 PM, the Administrator stated that 1 of 3 CNAs did not have documentation of the required 12 hours of annual training or a performance review.
Inaccurate Medical Record Diagnosis Documentation
Penalty
Summary
The facility failed to ensure resident records accurately reflected active medical diagnoses for Resident #5, who was admitted with multiple diagnoses including unspecified psychosis, depression, and insomnia. A physician progress note documented that Resident #5 had an active diagnosis of generalized anxiety disorder, but review of the medical record showed that generalized anxiety disorder was not listed as an active diagnosis. During interview, the ADON confirmed that the record did not include generalized anxiety disorder as an active diagnosis and stated the record would be updated to reflect the physician's documented diagnosis.
Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was identified as deficient because the facility did not ensure immunizations were offered and/or provided as indicated. Record review showed that Resident #4, who was admitted with multiple diagnoses including aphasia, hemiplegia, and hemiparesis affecting the right dominant side following a stroke, had documentation that he refused the pneumococcal vaccine on 10/21/24. However, there was no documentation in the resident's record that he and/or his representatives were offered the vaccine or educated about the risks and benefits of pneumococcal vaccination. During interview, the MDS Nurse, who was the previous IP, stated pneumococcal vaccine was being offered to residents upon admission, but she was unable to find documentation that Resident #4 was offered or educated regarding the risks and benefits of the pneumococcal vaccination.
Failure to Prevent Abuse During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to protect a resident from abuse during a transfer, resulting in actual harm. The resident, who had a history of dementia, stroke, fractures, and osteoporosis, was care planned to be handled gently, allowed to initiate transfers at her own pace, and required two staff for stand pivot transfers or a mechanical lift if fatigued. The care plan also emphasized monitoring for pain and respecting the resident's resistance to care. Despite these directives, staff attempted to transfer the resident from bed to wheelchair against her will after she repeatedly refused to get up, expressing pain and agitation. Multiple staff statements and documentation revealed that the resident was approached several times throughout the morning and consistently refused to get out of bed. LPNs instructed CNAs to let the resident rest if she refused, but a restorative nurse aide insisted on getting her up for restorative activities. During the transfer, the resident was picked up under her arms without footwear, while she was yelling and striking out. The transfer was performed despite her resistance, and she was placed firmly into her wheelchair, at which point staff heard snapping or cracking sounds. Immediately after, the resident exhibited abnormal movements and vocalizations, prompting staff to seek medical attention. Hospital records confirmed the resident sustained a displaced left femoral neck fracture. Staff interviews and documentation indicated that the transfer was not performed according to the resident's care plan or her expressed wishes. Additionally, there were concerns about the integrity of the incident investigation, as one CNA reported that his original statement was altered by the DON to minimize the severity of the incident. The failure to follow the care plan and respect the resident's refusals directly led to the injury and constituted abuse as defined by regulatory guidelines.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving eight residents. Errors included administering the wrong medication, incorrect dosages, omission of prescribed medications, and failure to follow physician orders. For example, one resident with dementia and other chronic conditions was given her roommate's opioid pain medication, resulting in increased lethargy and drowsiness that required medical intervention. Another resident with a history of vertebral fractures and cancer did not receive her prescribed narcotic pain medication as requested, leading to untreated and increased pain for several hours. Additional incidents involved residents receiving incorrect doses of medications for chronic conditions such as fibromyalgia, with one resident repeatedly given the wrong dose or missing doses of Lyrica. Another resident with osteomyelitis and kidney failure was administered the wrong intravenous antibiotic. There were also cases where enteral feedings were omitted, a resident received a higher dose of a sleep medication than ordered, and a resident was given a transdermal patch with the wrong dosage of fentanyl, which was not discovered until the following day. Further, a resident receiving end-of-life care was administered another resident's tramadol instead of the prescribed alprazolam for anxiety. These errors were confirmed through record reviews, incident and accident reports, and staff interviews, with the DON verifying the occurrences. The medication errors resulted in actual harm to some residents and had the potential for adverse outcomes for others due to the failure to adhere to the eight rights of medication administration.
Failure to Prevent Accident Hazard from Unauthorized Heating Pad Use
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to notify the nurse that a resident was using a heating pad. The resident, who had multiple diagnoses including diabetes, kidney disease, chronic pain, and a recent surgical amputation, was found unresponsive by a registered nurse (RN) during a medication pass. The RN discovered hot compresses under the resident's gown and was unaware that the resident had access to a heating pad. The CNA had observed the heating pad earlier but did not check if it was on or report its presence to the nurse. There was no documentation indicating that the nurse was informed about the heating pad or that it was placed behind the resident. The resident was subsequently found to have a burn and required hospital care for the injury. The incident report and staff interviews confirmed that the CNA did not follow protocol by failing to communicate the use of the heating pad to nursing staff. The resident's medical record also lacked documentation of the heating pad's use or any related skin issues prior to the incident. The director of nursing (DON) confirmed that the CNA should have reported the heating pad but did not do so.
Failure to Investigate and Address Missing Resident Property
Penalty
Summary
The facility failed to investigate and take prompt corrective action regarding a resident's missing property, specifically a prosthetic glass eye. According to the facility's policy, all grievances and complaints, including missing items, are to be investigated and resolved. The resident in question had a history of cancer in the right eye, resulting in removal of the eye and use of a prosthetic, which she frequently removed. The care plan documented that the resident lost her glass eye and that the physician recommended leaving it out due to complications. Despite documentation in the care plan about the missing glass eye, there was no evidence that the facility investigated the loss or took action to locate or replace the item. The Social Services Director (SSD) and the Director of Nursing (DON) were unable to provide any documentation of an investigation or follow-up regarding the missing property. The SSD reported hearing that the resident may have left the prosthetic on a meal tray, which was subsequently removed, but no formal investigation or documentation was found.
Resident's Religious Rights Not Honored During Hair Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) cut a resident's hair without obtaining her consent. The resident, who had been admitted following a stroke and had diagnoses including chronic kidney disease and dementia, required assistance with daily hygiene tasks such as bathing and hair care. The incident report documented that the CNA cut approximately an inch to an inch and a half from the resident's hair after encountering resistance while brushing out knots. There was no documentation indicating that the resident was asked for her consent prior to the haircut. The resident and her representative both stated that she does not cut her hair for religious reasons, a preference that was communicated to the facility upon admission. The resident became visibly upset during the interview, expressing that cutting her hair was against her religious beliefs. The care plan did not reflect her preference to keep her hair long or her religious beliefs regarding hair cutting. The administrator confirmed awareness of the resident's religious beliefs but stated the CNA was unaware of them at the time of the incident.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident with diabetes and morbid obesity, who was cognitively intact at the time of the incident. According to the grievance log, the resident felt publicly shamed by the dietitian in front of other residents when questioned about her food choices and told she would have lost more weight if she had adhered to the diet plan. This grievance, dated in October, was not reported to the State Survey Agency's Long-Term Care Reporting Portal until approximately six months later, despite regulatory requirements for timely reporting of suspected abuse. The delay in reporting was discovered during a review of grievances by facility leadership, who noted the incident had not been previously reported as required.
Failure to Investigate and Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was thoroughly investigated. The incident involved a resident with multiple diagnoses, including diabetes and morbid obesity, who was cognitively intact at the time. According to the grievance log, the resident reported being publicly shamed by the dietitian in the presence of others, with comments made about her dietary choices and weight loss. The documentation of the grievance did not include information on protective measures for the resident, interviews with staff or the resident, or the facility's investigative conclusions at the time of the incident. Additionally, the incident was not reported to the State Survey Agency's Long-Term Care Reporting Portal until approximately six months after it occurred. The delay in reporting and lack of thorough documentation and investigation at the time of the grievance constituted a failure to respond appropriately to an alleged violation of abuse. The deficiency was identified through record review, grievance log review, and staff interviews.
Inaccurate MDS Documentation of PASARR Level II Determinations
Penalty
Summary
The facility failed to ensure that residents' Minimum Data Set (MDS) assessments accurately reflected the presence of a PASARR (Preadmission Screening and Resident Review) level II determination for serious mental illness, as required by the Resident Assessment Instrument (RAI). Specifically, two residents with documented PASARR level II determinations in their medical records had their MDS assessments incorrectly marked as 'no' in section A1500, which should have been marked 'yes' according to the RAI guidelines. One resident had a diagnosis of bipolar disorder and a completed PASARR level II, while another had multiple diagnoses including dementia, anxiety, and depression, and also had a PASARR level II on file. The MDS Coordinator stated that she was unaware that the presence of a PASARR level II required marking 'yes' at A1500, leading to the inaccurate documentation for both residents.
Religious Preference Not Reflected in Care Plan
Penalty
Summary
The facility failed to include a resident's religious preference regarding hair care in her care plan, despite being informed of this preference upon admission. The resident, who was admitted following a stroke and had chronic kidney disease and dementia, required assistance with daily hygiene, including hair care. During interviews, the resident and her representative both stated that she does not cut her hair for religious reasons, and this information was communicated to the facility on the day of admission. However, a review of the care plan showed no documentation of her preference to wear her hair long or her religious belief that her hair should not be cut. The facility administrator acknowledged awareness of the resident's religious beliefs but was unaware of why these were not reflected in the care plan.
Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that residents and their representatives were given the opportunity to participate in care planning and attend care conferences, as required by facility policy. Specifically, for one resident with multiple diagnoses including renal disease, hypertension, dementia, depression, and respiratory failure, there was no documentation of care conferences with the resident or her representative from August 2024 through January 2025. The facility's policy mandates that care conferences be scheduled upon admission, quarterly, and with any significant change, and that these meetings be documented in the electronic health record (EHR). Despite the care plan instructing quarterly care conferences, the resident's representative reported not being contacted about any care conferences since the previous summer. The Director of Nursing (DON) confirmed that while care conferences were being completed and placed in the nursing progress notes, they were documented incorrectly, resulting in no record of who attended or what was discussed. This lack of proper documentation and communication led to the deficiency identified during the review.
Failure to Maintain Fall Prevention Interventions After Room Change
Penalty
Summary
The facility failed to implement and maintain interventions to reduce the risk of accidents for a resident with dementia, Alzheimer's disease, and palliative care needs. After an initial fall, the facility identified the need for a soft touch call light to be kept within the resident's reach and for the resident to be kept under supervision as much as possible. However, when the resident was moved to a new room, the soft touch call light was not transferred with her, resulting in the resident not having access to the intervention that had been put in place to prevent further falls. This oversight led to a second unwitnessed fall, during which the resident attempted to transfer herself and was found on the floor next to her bed. The resident was unable to explain the circumstances of the fall, and it was determined that she did not activate the call light prior to the incident. The deficiency was identified through reviews of incident reports, medical records, and staff interviews, which confirmed that the intervention to prevent falls was not consistently implemented.
Failure to Clarify Duplicate PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs by allowing duplicate pain medication therapy without clear parameters for administration. A resident with multiple diagnoses, including dementia, fibromyalgia, and chronic pain syndrome, was readmitted with physician orders for acetaminophen, hydrocodone-acetaminophen, and tramadol, all prescribed as needed for pain but without specific instructions or parameters to guide their use. The consulting pharmacist recommended updating the hydrocodone and tramadol orders to include clear instructions based on the pain scale, but the physician declined to make changes. The Director of Nursing acknowledged that the orders for these medications were not clear and required more specific instructions.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with multiple diagnoses, including a left leg fracture and chronic pain, was ordered to receive 5 mg of Oxycodone every three hours. However, the resident was administered 10 mg of Oxycodone, which was intended for her roommate, due to the nurse pulling and administering medications for both residents at the same time. The facility's policy required verification of medication and resident identity prior to administration, but these procedures were not followed, resulting in the medication error. In the second case, a resident with diabetes was ordered to receive specific doses of Insulin Lispro according to a sliding scale and a separate order for Lantus SoloStar insulin. The resident was given the incorrect type of insulin after the nurse became distracted by questions from family members during medication administration. The facility's policy required staff to confirm medication orders and verify medications before administration, but this was not adhered to, leading to the administration of the wrong insulin. Documentation of staff training following this incident was requested but not provided.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors found that the facility failed to ensure food was served at appropriate temperatures, as evidenced by both resident interview and direct observation. One resident who ate meals in their room reported that their food was not warm upon delivery. During a test tray evaluation, the main dish and side items were found to be below recommended hot holding temperatures, while cold items were above recommended cold holding temperatures. The Registered Dietitian confirmed that the food trays had been placed incorrectly in the food cart, with the hot side on the cold section and the cold side on the hot section. Additionally, the Kitchen Manager acknowledged that the dining cart was usually not turned on, which meant food remained at the temperature it was plated, and improper tray placement further affected food temperatures before reaching residents.
Failure to Maintain and Sanitize Kitchen Equipment and Food Storage Areas
Penalty
Summary
Surveyors observed that kitchen equipment and food storage areas were not properly maintained, cleaned, or sanitized. Specifically, a layer of dark brown dust was found coating the pan drying rack, and a darker brown coating of dirt was present in the corner of the walk-in freezer. The Dietary Manager confirmed that the pan drying rack was dusty and should have been cleaned, and was unable to state when the freezer was last cleaned, noting that a third-party source was responsible for its cleaning. Additionally, three aluminum skillets were found with a thick layer of black coating on both the interior and exterior, which could be scraped off with a fingernail. The Dietary Manager acknowledged that the skillets should not have had this residue. Further observations revealed a thick layer of ice build-up on the pipe going from the walk-in refrigerator into the freezer, as well as a large sheet of ice coating a stack of three opened cardboard boxes of pizza dough. The Dietary Manager stated that ice should not be coating the food boxes, pipes, or dripping from the air condenser unit, and again indicated that a third-party company was responsible for cleaning the walk-in units, but did not know when this last occurred. The Administrator stated that the walk-in refrigerator and freezer should be cleaned whenever dirty and that either maintenance or kitchen staff should be responsible for cleaning, clarifying that the outside vendor only handled equipment maintenance, not cleaning.
Resident Discharged Without Proper Notice or Appeal Rights
Penalty
Summary
The facility failed to ensure a resident's right to remain in the facility and the right to appeal a facility-initiated discharge. This deficiency was identified for a resident with multiple diagnoses, including Type 2 Diabetes Mellitus, long-term use of insulin, depression, and legal blindness. The resident was cognitively intact and had no history of physical or verbal behavioral symptoms directed towards others. An incident occurred where the resident sprayed another resident with a garden hose after a verbal altercation, leading to the facility's decision to discharge him. The facility's policy required a 30-day notice for discharge unless the resident's or others' health and safety were endangered. However, the resident was discharged to a motel without proper documentation or discussion of his right to remain for 30 days or appeal the discharge. The resident was not provided with adequate means to manage his diabetes, as he was unable to check his blood sugar and safely administer insulin due to his visual impairment. The discharge notice was in small print, which the resident could not read, and he was emotionally distressed by the situation. Interviews with staff and other residents indicated that the resident did not have a history of aggressive behavior, and the incident with the garden hose was isolated. The facility's immediate action plan involved notifying local police and separating the involved residents, but there was no evidence of a serious crime that would justify an immediate discharge. The resident expressed a desire to return to the facility, stating he had nowhere else to go, and was not informed of his rights regarding the discharge process.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 215 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchards Of Cascadia, The | 1 mi | ★★★★★ | 7 | 1 |
| Meadow View Nursing And Rehabilitation | 1.5 mi | ★★★★★ | 13 | 0 |
| Sunny Ridge | 4.1 mi | ★★★★★ | 16 | 0 |
| Cascadia Of Nampa | 4.5 mi | ★★★★★ | 16 | 1 |
| Canyon West Of Cascadia | 4.7 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.