Karcher Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Nampa, Idaho.
- Location
- 1127 Caldwell Blvd, Nampa, Idaho 83651
- CMS Provider Number
- 135110
- Inspections on file
- 21
- Latest survey
- November 7, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Karcher Post Acute during CMS and state inspections, most recent first.
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.
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.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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