Lakeside Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coeur D'alene, Idaho.
- Location
- 210 West Lacrosse Avenue, Coeur D'alene, Idaho 83814
- CMS Provider Number
- 135042
- Inspections on file
- 23
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lakeside Rehabilitation And Care Center during CMS and state inspections, most recent first.
Two residents did not have their comprehensive care plans updated to reflect essential care needs: one with an indwelling urinary catheter and another experiencing severe pain and spasms with movement. Staff interviews and record reviews confirmed that these critical aspects were omitted from the care plans, leaving gaps in guidance for proper care and pain management.
A resident with diabetes was repeatedly administered insulin when blood glucose levels were below the physician-ordered threshold, contrary to the written order to hold insulin if levels were under 150. Multiple instances of this error occurred over several months, with nursing staff unaware of the mistake and the DON not investigating beyond a single incident. No adverse effects were documented in the resident's records.
The facility failed to protect residents from abuse and neglect, with incidents of verbal, physical, and mental abuse reported. A resident's aggressive behavior was not adequately managed, leading to fear among other residents. Additionally, a resident did not receive necessary wound care, and physical abuse incidents involving staff and residents were inadequately addressed.
A LTC facility failed to prevent significant medication errors for four residents. A resident was hospitalized after receiving another's medication due to a nurse's failure to follow the six rights of medication administration. Another resident missed insulin due to a nurse being too busy, while a third received duplicate medication doses due to poor communication between shifts. A fourth resident did not receive insulin due to a shift change miscommunication.
The facility failed to maintain a clean kitchen environment, with inspections revealing condensation icicles falling onto food items and significant ice buildup in the walk-in freezer. Staff interviews highlighted unclear cleaning responsibilities, with the CDM unsure of maintenance schedules and the Maintenance Director emphasizing the need for spot cleaning by kitchen staff.
The facility failed to investigate abuse allegations involving two residents, leading to potential harm. A resident with multiple health issues reported feeling unsafe due to another resident's aggressive behavior, but no documentation was found in the facility's records. Another resident with serious health conditions also reported feeling unsafe, and although a grievance form was provided, the incident was not documented. The facility's leadership was unaware of the situation, indicating a lack of proper investigation.
The facility failed to update care plans for two residents, leading to deficiencies in monitoring and interventions. One resident's care plan lacked documentation for hypo/hypervolemia monitoring despite having renal failure, while another resident's care plan did not include weight management interventions or CPAP machine use, despite physician orders. The DON confirmed these omissions.
A resident with multiple sclerosis, who was cognitively intact, did not receive the scheduled two showers per week as per their care plan. The resident reported only receiving one shower weekly, leading to dissatisfaction with personal hygiene. An LPN confirmed a partial bed bath was given due to staffing shortages, while the DON acknowledged the care plan requirement for two showers weekly.
The facility failed to provide proper foot care for two residents, leading to potential harm. One resident with multiple diagnoses, including muscular dystrophy, had long, thick, and yellowish toenails with a blackened area, but was not referred to a podiatrist as directed. Another resident with diabetes had thick and long toenails, with no documentation of a podiatrist visit or physician notification. Both residents' care plans and physician orders were not followed.
A resident with autism, dementia, and potential schizotypal personality disorder did not receive timely psychiatric evaluation and behavioral services, despite escalating aggressive behavior. The facility's inability to provide necessary evaluations on-site and delay in alternative placement contributed to the deficiency.
An LPN improperly disposed of three pills, including prescription medications metoprolol and gabapentin, in a regular trash can instead of using the facility's Drug Buster Drug Disposal System. This action was against the facility's policy, as confirmed by the DON.
A facility failed to ensure staff wore appropriate PPE for a resident under Enhanced Barrier Precautions (EBP). A CNA was observed emptying a foley catheter drainage bag with only gloves, despite the requirement for both gloves and a gown. The resident had a STOP EBP sign and an isolation cart, and the facility's policy mandates gown and glove use for high-contact care activities. The CNA was re-educated after the incident.
Failure to Include Indwelling Catheter and Pain Management in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in deficiencies related to the omission of critical care needs. For one resident with a diagnosis of benign prostatic hyperplasia and an indwelling urinary catheter, the care plan did not document the presence or care requirements for the catheter. This omission was confirmed through record review and interviews with facility staff, including the Registered Nurse Supervisor, Director of Nursing, and Infection Preventionist, all of whom acknowledged that the catheter should have been included in the care plan to guide staff in providing appropriate care. For another resident with functional quadriplegia, multiple sclerosis, and chronic pain triggered by touch or movement, the care plan failed to address the resident's extreme pain and spasms during repositioning. Although the resident and multiple staff members reported significant pain and frequent refusal of repositioning due to discomfort, the care plan only referenced general skin impairment and pressure ulcer prevention without specific interventions for pain management during movement. The Assistant Director of Nurses attributed the lack of detail to issues with the care plan system following a facility acquisition, and the Director of Nursing confirmed the absence of pain-specific information in the care plan.
Failure to Prevent Significant Medication Errors in Insulin Administration
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic neuropathy was administered insulin despite blood sugar levels being below the physician-ordered threshold for administration. The physician's order specified that insulin should be held if the capillary blood glucose (CBG) was under 150, and the physician should be notified if CBG was less than 70 or more than 360. However, medication administration records over a three-month period showed multiple instances where insulin was given when the resident's blood sugar was below 150, with values ranging from 86 to 149. The only incident report completed documented one such occurrence, but there was no evidence of adverse effects in the resident's progress notes. Interviews with nursing staff revealed a lack of awareness regarding the medication errors, with one LPN stating she did not realize the errors and an RN attributing the mistake to the way the order was written. The DON was not aware of the repeated errors and had not investigated further incidents beyond the one documented. The facility's medication administration policy required medications to be given according to physician orders as indicated on the electronic medication administration record, which was not followed in these instances.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving verbal, physical, and mental abuse. Several residents experienced verbal abuse from another resident, who exhibited aggressive behavior due to his medical conditions. Despite recommendations for specialist evaluations, the facility did not document any referrals, and the resident continued to pose a threat to others. Interviews with residents revealed a pervasive fear of this resident, indicating a failure to ensure a safe environment. Additionally, the facility did not provide necessary wound care for a resident with a pressure ulcer. The resident was on hospice care, but there was no documentation of wound treatment orders or a care plan. The facility's lack of coordination with the hospice agency resulted in neglect of the resident's medical needs, highlighting a breakdown in communication and responsibility for the resident's care. Physical abuse incidents were also reported, involving staff and resident interactions. A CNA was terminated after physically abusing a resident, and another resident reported being slapped by a fellow resident. These incidents were not adequately addressed, as evidenced by incomplete background checks and insufficient supervision, further demonstrating the facility's failure to protect residents from harm.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting four residents. Resident #129 was mistakenly given a cup of pills intended for another resident, leading to dizziness and hypotension, requiring hospitalization. The error occurred because the float nurse did not adhere to the six rights of medication administration, which include verifying the right medication, dose, dosage form, route, resident, and time. Resident #3 did not receive a scheduled blood sugar check or her prescribed insulin dose due to the day shift nurse being too busy. The nurse failed to ask for assistance and did not complete an incident report, subsequently not returning to work. This oversight resulted in a lapse in the resident's diabetes management, although no immediate harm was reported. Resident #125 received duplicate doses of Norco and Clonazepam due to a lack of communication between the day and evening shift nurses. The travel agency contract nurse administered the second dose without checking the medication administration record (MAR) for the last dose given. Additionally, Resident #127 did not receive his sliding scale insulin due to miscommunication between two nurses during shift change, although no adverse effects were noted.
Deficiency in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during inspections. During the initial inspection, condensation icicles from the cooling fans in the walk-in freezer were found falling onto food items such as cardboard boxes of frozen vegetables. Additionally, there was a significant ice buildup around a pipe behind the condenser. A subsequent inspection revealed similar issues, with icicles falling onto both cardboard boxes of vegetables and opened packages of frozen hamburgers. These conditions were in violation of FDA Food Code regulations, which require that food not be stored in direct contact with ice or water if the packaging is susceptible to water entry. Interviews with facility staff revealed a lack of clarity regarding cleaning responsibilities. The Certified Dietary Manager (CDM) indicated that facility maintenance was responsible for cleaning the refrigerators and walk-in freezers, but was unsure when the last inspection of the condenser pipe occurred. The Maintenance Director confirmed that a deep cleaning had been completed over the summer, but emphasized that kitchen staff were responsible for spot cleaning to prevent ice buildup. Despite having a documented cleaning schedule, the CDM could not explain the large ice accumulation, indicating a failure in adhering to the cleaning protocols.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, which created a potential risk for harm. Resident #4, who has multiple diagnoses including diabetes and chronic hypertensive kidney disease, reported feeling unsafe due to another resident, Resident #61, entering their room and yelling. Despite this incident, there were no reports or documentation found in the facility's grievances, SBARs, or I&A reports for 2024 that addressed this situation. Similarly, Resident #46, with diagnoses including acute and chronic respiratory failure, pulmonary embolism, diabetes, and congestive heart failure, expressed feeling unsafe due to Resident #61's behavior. The resident reported that Resident #61 would wander into their room and yell, causing fear and concern for personal safety. Although a grievance form was provided by an LPN, there was no documentation of the incident in the facility's records. The facility's Administrator and DON were unaware of Resident #61's actions, indicating a lack of proper investigation and documentation of the abuse allegations.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions, as evidenced by deficiencies found in the care plans of two residents. Resident #4, who was admitted with multiple diagnoses including diabetes and chronic hypertensive kidney disease, had a care plan that directed staff to monitor for signs of hypo/hypervolemia and acute renal failure. However, a review of the MAR/TAR for September through October 2024 showed no documentation of such monitoring. The Director of Nursing (DON) confirmed the absence of blood work tracking and acknowledged that Resident #4's care plan was not updated to reflect these needs. Resident #17, admitted with diagnoses including rib fractures, COPD, and diabetes, expressed a desire to lose weight and had a physician's order for Semiglutide, an anti-diabetic and anti-obesity medication, with weekly weights to be taken. Despite this, the resident's care plan did not include any weight management interventions. Additionally, Resident #17 reported not receiving assistance with a CPAP machine, which was ordered by a physician. The care plan did not reflect the use of the CPAP machine, and the DON confirmed the care plan was not updated to include this intervention.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a resident who required extensive assistance with personal hygiene and showers. The resident, who was cognitively intact and had multiple sclerosis, was care planned to receive two showers a week. However, the resident reported only receiving one shower per week, specifically on Sundays, and not on Wednesdays as scheduled. The resident expressed dissatisfaction with the lack of showers, noting greasy hair and the need for a shave by the end of the week. The facility's records indicated that the resident received two showers a week, except for one instance of refusal and another when the resident was unavailable. Interviews with the resident and staff revealed discrepancies in the care provided. The resident stated that he did not refuse showers and was not informed of the reasons for missed showers. An LPN confirmed that the resident received a partial bed bath on a Wednesday due to staffing shortages, with only one aide available on the floor that day. The Director of Nursing acknowledged that the resident was supposed to receive two showers a week, as per the care plan. The facility's policy emphasized the importance of meeting personal care needs to promote a healthy environment and prevent infection, yet the care delivery did not align with the resident's care plan.
Failure to Provide Proper Foot Care for Residents
Penalty
Summary
The facility failed to provide appropriate foot care for two residents, leading to potential harm due to lack of proper treatment. Resident #22, who has multiple diagnoses including chronic respiratory failure and muscular dystrophy, was not referred to a podiatrist despite a care plan directive. Observations revealed that Resident #22's toenails were long, thick, and yellowish, with a blackened area on the right big toe. There was no documentation indicating that Resident #22 had been seen by a podiatrist or that the physician was notified about the condition of her toenails. Similarly, Resident #48, who has diagnoses including diabetes and chronic obstructive pulmonary disease, was not referred to a podiatrist as directed by the care plan. Observations showed that Resident #48's toenails were thick and long, and there was no documentation of a podiatrist visit or physician notification regarding the toenail condition. Both residents had care plans and physician orders that were not followed, resulting in a lack of proper foot care and monitoring.
Failure to Provide Timely Psychiatric Care for Resident with Mental Disorders
Penalty
Summary
The facility failed to provide appropriate treatment and behavioral services to a resident with mental disorders, including autism, dementia with agitation, and a potential schizotypal personality disorder. The resident was admitted with a history of aggressive and verbally abusive behaviors, and the care plan included strategies for managing these behaviors. However, despite recommendations for a psychiatric evaluation, the resident did not receive one until several months later, after exhibiting escalating aggressive behavior and being sent to the hospital for lethargy and confusion related to lithium management. The facility's social services noted the resident's behavior was inappropriate and posed a risk to the safety of other residents and staff. Despite recognizing the need for a psychiatric evaluation and alternative placement, the facility was not equipped to provide the necessary evaluations on-site. The resident's behavior continued to escalate, leading to a psychiatric consultation only after the situation had deteriorated significantly. The lack of timely psychiatric intervention and appropriate placement contributed to the deficiency in care for the resident.
Improper Medication Disposal by LPN
Penalty
Summary
The facility failed to ensure proper disposal of medications, as observed during a survey. An LPN was seen disposing of three pills in a regular trash can, which was against the facility's policy for medication disposal. The facility's procedure required medications to be disposed of using the Drug Buster Drug Disposal System. The LPN initially claimed the pills were over-the-counter medications, but later identified them as ASA, metoprolol, and gabapentin, the latter two being prescription medications. The Director of Nursing confirmed that the medications should have been disposed of in the drug buster, not the regular trash can.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for a resident under Enhanced Barrier Precautions (EBP). During an observation, a Certified Nurse Aide (CNA) was seen emptying the urine from a foley catheter drainage bag while only wearing gloves, despite the requirement to wear both gloves and a gown. The resident, who had a STOP EBP sign on their door and an isolation cart outside, confirmed that staff usually wore gowns and gloves when providing care. The resident had a diagnosis of malignant neoplasm of the endometrium and was moderately cognitively impaired. The facility's policy on Enhanced Barrier Precautions, dated April 2024, mandates the use of gowns and gloves for high-contact resident care activities for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. The Infection Preventionist stated that all staff are trained on EBP requirements and that the CNA was re-educated following the incident. However, the CNA's failure to adhere to the EBP protocol during the observed care activity led to the deficiency.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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