Life Care Center Of Coeur D'alene
Inspection history, citations, penalties and survey trends for this long-term care facility in Coeur D'alene, Idaho.
- Location
- 500 West Aqua Avenue, Coeur D'alene, Idaho 83815
- CMS Provider Number
- 135122
- Inspections on file
- 22
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Life Care Center Of Coeur D'alene during CMS and state inspections, most recent first.
A resident with a right-hand contracture and aphasia had a care plan for weekly nail trimming and daytime use of a hand grip splint, but after an initial OT discharge with an orthotic, there were no further therapy referrals despite ongoing pain and frequent refusals to wear the splint. Over several months, TARs showed repeated refusals of the orthotic, yet there was no documented follow-up with the physician, therapy, or the resident’s representative, and no documented interventions for contracture-related pain. Staff later reported they could barely open the resident’s hand and had not seen the palm or nails, and ADL records lacked evidence that nails were trimmed or that refusals to nail care were documented. The resident ultimately developed a swollen, painful contracted hand with nails embedded into the palm, white/yellow drainage, and a documented palm wound and infection attributed by the NP to the fingernails digging into the palm.
Surveyors found that medication refrigerators used to store narcotics, vaccines, and insulins were not consistently monitored and documented per facility policy, with numerous missing temperature entries on both AM and PM shifts across multiple months in two medication rooms. An RN, an RCM, and an SDC acknowledged the incomplete logs, and the facility policy required at least daily monitoring for medications and twice-daily monitoring for vaccines, creating the potential for residents to receive medications and vaccines stored outside recommended temperature ranges.
Surveyors found that food service staff failed to follow basic sanitation and labeling practices, including a diet aide repeatedly entering and working in the kitchen without proper hand hygiene and with an improperly worn hair net. In the main freezer, icicles from the air condenser unit were melting and dripping into an open box of frozen egg patties. Resident refrigerators contained brown streaks and spots, and both staff and resident food items were stored without required labels or dates, with some frozen meals marked only by room number. Dust buildup was observed on a refrigerator air condenser unit, and the dietary manager acknowledged that both cleaning and monitoring of equipment and food labeling were not being performed as required.
During an Influenza A outbreak, staff failed to follow required infection prevention and control practices for PPE and droplet precautions. A CNA entered a droplet‑precaution room with inadequate PPE, handled urinals without proper hand hygiene, and returned shared goggles to a storage bin without sanitizing them. An SDC cleaned multi‑use goggles but did not allow the required disinfectant contact time before returning them to the bin. An Activities Assistant moved consecutively between influenza‑positive and negative rooms offering coffee and activities, performing hand hygiene but not changing her mask or wearing a gown, while droplet precautions were in place requiring full PPE including mask, gown, eye protection, and gloves.
Surveyors identified that a resident shower room was not maintained in a clean and sanitary condition when a black substance was observed on the lower portion of the shower wall. The Maintenance Director confirmed the shower was not clean after attempting to scrub the substance, and the Housekeeping Director acknowledged that, despite a schedule for daily shower cleaning, this shower room had not been properly cleaned.
A resident with multiple chronic conditions had four medication cups labeled with her name found at the bedside while the MAR indicated that her medications had been administered. A grievance was filed, but the facility’s investigation and response only briefly stated that residents had missed medications, that an LPN was educated, and that a provider was notified, without further detail. The Administrator later confirmed there was no medication error report or documentation of staff education related to medication storage, administration, or medications left at the bedside, demonstrating that the grievance was not thoroughly investigated.
A resident with severe cognitive impairment and multiple medical conditions was observed lying in bed with stool-soiled linens and stool leaking from an incontinence brief, unable to state how long they had been soiled. Later, a CNA provided incontinence care to the resident without closing the window blinds or using the privacy curtain, leaving the resident partially visible from the courtyard. The CNA subsequently acknowledged that the resident could be seen from outside and that the blinds or privacy curtain should have been used.
A resident with dementia, cognitive communication deficit, history of TIA, and adult failure to thrive, and a severely impaired BIMS score, was found soiled with stool leaking from her incontinence brief and was unable to state how long she had been in that condition. Although documentation indicated she used her call light appropriately, surveyors observed that she did not activate the push-button call light when prompted and only smiled in response, even when a CNA asked her to demonstrate its use without pointing to it. The facility failed to provide an appropriate adaptive call light despite the resident’s inability to effectively use the standard device, resulting in a lack of reasonable accommodation of her needs and preferences.
A resident with encephalopathy, DM, urinary retention, and a UTI was documented by Social Services as not having an advance directive, yet there was no record that the resident or representative received required information or assistance to formulate one, despite facility policy requiring such materials be provided upon admission. The SSD confirmed the resident had no advance directive and acknowledged the resident and/or representative should have been offered the opportunity to create one.
A resident with diabetes, severe protein-calorie malnutrition, and dependence on staff for personal care had a care plan and physician order requiring timely provider notification for changes in condition and for blood glucose levels above a specified threshold. Review of the MAR showed multiple blood glucose readings above that threshold, for which the order required both administration of Insulin Aspart and notification of the provider. Surveyors found no documentation that the provider had been notified for any of these elevated readings, and the DON confirmed that such documentation could not be located.
The facility did not provide required written bed-hold policy notifications to three hospitalized residents or their representatives. One resident with dementia, heart disease, and DM was hospitalized, and the Admissions Director acknowledged speaking with the POA but not providing a bed-hold document. Another resident with hemiplegia, hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety, and a third resident with UTI, DM, heart failure, and CKD were also hospitalized, yet their records contained no documentation of bed-hold notifications. The Administrator confirmed there was no record of such notifications for these two residents.
Two residents’ MDS assessments were inaccurately completed, leading to incorrect transmission of assessment data. For one resident with anxiety, depression, and personal care needs, a Quarterly MDS incorrectly indicated the use of physical restraints in bed or chair less than daily. For another resident with hemiplegia/hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder, the record showed a completed PASRR Level II, but the Annual MDS incorrectly documented that no PASRR Level II existed. These errors were identified through record review and confirmed by the DON.
Surveyors found that a resident with documented PTSD, anxiety, and depression did not have these mental health conditions recorded on the PASRR Level I, and no PASRR Level II was submitted to the state agency as required. The SSD later acknowledged that the PASRR Level I should have been corrected and a Level II completed, indicating that coordination of PASRR assessments and related care planning for this resident was not properly carried out.
Surveyors found that the facility did not consistently revise care plans or hold required care conferences. One resident with mobility and postural issues had outdated ambulation and neck brace interventions left on the care plan after treatment changes. Another resident with cellulitis and muscle weakness had a physician order for continuous offloading boots that was never added to the care plan and was repeatedly observed without the boots. A third resident who transitioned to hospice care did not have hospice/comfort care interventions incorporated into the care plan. In addition, quarterly care conferences were missed for a resident with PTSD, anxiety, and depression, and staff acknowledged these conferences had been overlooked.
Two residents did not receive medications in accordance with professional standards and physician orders. One resident with hypertension received metoprolol ER and lisinopril from an LPN without current BP and HR being checked, despite orders requiring parameters for holding the medications. Another resident with diabetes, kidney disease, and an ileostomy had active PRN orders for rectal Dulcolax suppositories and a Fleet enema, even though, as confirmed by the SDC, this resident should not have any rectal medication orders or those medications at all.
A resident with multiple comorbidities, including UTI, diabetes, heart failure, and CKD, experienced a significant change in condition characterized by somnolence, poor oral intake, and possible sepsis. Nursing staff sent an SBAR to the physician reporting the change and requesting further evaluation and treatment, and later sent a second SBAR noting ongoing lethargy, congestion, and refusal of medications and food, and asking for an exam, labs, or a portable CXR. The resident was later found catatonic and unresponsive and was sent to the ER after the physician was called. There was no documentation of any physician communication or response between the initial and subsequent SBARs, and facility leadership confirmed there was no record of a response to the first SBAR.
A resident with a right-hand contracture and history of stroke was discharged from OT with a right grip orthotic to be worn during the day as tolerated, and the care plan directed staff to apply the splint for extended periods. Over multiple months, documentation showed frequent refusals to wear the orthotic and increasing tightness of the hand, with CNAs reporting pain when attempting to open the hand. Although a physician note early on recommended re-evaluation for therapy, there was no further documentation that the physician, therapy department, or the resident’s representative were notified of the continued refusals, and no additional therapy referrals occurred. A restorative PROM program was started later, but the Restorative Coordinator was unaware of how long the hand had been unable to open, and the DON could not recall being informed of the ongoing refusals, demonstrating a failure to ensure appropriate ROM treatment and services and to communicate changes to the IDT.
A resident with diabetes, severe protein-calorie malnutrition, and personal care needs had physician orders for sliding-scale Insulin Aspart and scheduled and PRN Morphine Sulfate. Review of the MAR showed multiple evening shifts with no documented blood glucose checks or insulin administrations despite active sliding-scale orders, and the DON confirmed multiple blanks where insulin doses should have been recorded. In a separate incident, a nurse administered a full 15 mg PRN morphine tablet instead of the ordered half tablet, with the error identified when the resident questioned the dose and the order was re-checked.
A resident with multiple diagnoses, including diabetes and severe protein-calorie malnutrition, was receiving hospice services with a documented DNR status, but the facility failed to maintain required hospice documentation in the medical record. Review of the chart showed there was no current hospice plan of care and no current terminal diagnosis certification. When requested by the surveyor, the DON produced only an expired terminal certification and a facility-generated care plan, and the Administrator confirmed that a current hospice plan of care and terminal certification were not present in the record.
The facility did not have a qualified director of food and nutrition services, affecting 82 residents. The Dietary Manager (DM) lacked the required Serv Safe Food Manager Certification, despite being employed for one and a half years. The DM cited working six months without a day off as the reason for not completing the necessary training. The Registered Dietitian (RD), present two days a week, was aware of the DM's lack of certification and highlighted its importance for managing the kitchen.
The facility failed to provide sufficient staffing and training in the dietary department, impacting the ability to safely and effectively serve meals to 81 residents. The dietary schedule showed inadequate staffing, with only two employees for most dinner services and one on Tuesdays. The Dietary Manager and staff reported severe understaffing, lack of training, and no in-service training since December 2022. The Registered Dietitian noted unaddressed suggestions and a failure to update a resident's diet tray ticket. Staff reported rushed work and mistakes due to understaffing.
The facility failed to maintain proper sanitation and food handling practices. Mold-like substance was found in the ice machine, and food items were improperly stored on the floor. A cook handled plates and food with bare hands and wiped his hands on his pants during tray line service. The Dietary Manager acknowledged the need for more training, and the Registered Dietitian noted that her recommendations were not followed.
The facility failed to serve meals consecutively at five of seven tables during meal service, affecting resident dignity and satisfaction. A resident expressed dissatisfaction with the daily meal service, attributing delays to having only one server. Interviews revealed staff were unaware of the policy to serve all residents at a table before moving to the next.
The facility exceeded the acceptable medication error rate, reaching 7.69% during observations. One resident received Lantus Solostar insulin later than the prescribed time, while another resident was administered multiple medications through a PEG tube in a manner inconsistent with facility policy. These actions were confirmed by the nurse involved.
A resident with diabetes experienced inadequate documentation of their blood sugar management in an LTC facility. An LPN failed to document a hypoglycemic event and the administration of glucose and glucagon. Similarly, an RN did not document the administration of insulin for hyperglycemia or recheck the blood sugar as required. These lapses in documentation raised concerns about the accuracy of the resident's medical records and their diabetes management.
A facility failed to implement proper infection control procedures for a resident requiring enhanced barrier precautions due to an invasive device. The resident, with diagnoses including stroke and diabetes, had orders for tube feeding and medication administration through a PEG tube. An RN was observed administering medications without wearing a protective gown, despite the requirement for such precautions. The RN confirmed the oversight in infection control measures.
A cognitively intact resident engaged in inappropriate sexual contact with two cognitively impaired residents in an LTC facility. Despite being educated about the inability of the residents to consent, the resident continued the behavior. The facility's response included supervision and eventual discharge of the offending resident, but the care plan interventions were insufficient to prevent further incidents.
Failure to Manage Hand Contracture and Nail Care Resulting in Palm Wound and Infection
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent and necessary care to prevent a pressure-type ulcer and infection in a resident with a right-hand contracture following a stroke. The resident had aphasia and a care plan that directed staff to trim and file his nails weekly and as needed, and to apply a right-hand grip splint during the day as tolerated. Occupational therapy initially evaluated the resident in July 2025 for feeding and right-hand contracture, discharged him on 7/15/25, and provided an orthotic splint to keep his fingers in a resting position. After this discharge, there were no further therapy referrals despite ongoing issues with the contracture. The resident frequently refused to wear the hand grip orthotic, with refusals documented on the TAR for most days over several consecutive months. A communication note to the physician on 10/6/25 documented that CNAs reported the resident refused to wear his brace and had high levels of pain when staff attempted to place their fingers into his contracted hand, and a re-evaluation for therapy options was recommended. However, there was no subsequent documentation that the physician, therapy department, or the resident’s representative were notified of the continued refusals after that date, and no documentation of further interventions or treatment for pain related to the right-hand contracture. Monthly summaries in early 2026 noted the contracture and refusal to wear the orthotic, but did not reflect additional action. By March 2026, the resident’s contracted hand had become swollen and painful, with nails digging into the palm and white/yellow drainage noted. A communication note on 3/12/26 recorded provider orders to trim nails, apply triple antibiotic ointment, and cover the wounds, along with a handwritten note that staff were unable to open the right hand to trim nails or apply ointment due to contraction and swelling. A provider note on 3/13/26 documented that the nails were embedded into the palm causing skin infection, and that after soaking the hand, the nails were trimmed and antibiotic cream placed in the palm. Staff interviews revealed that restorative staff could barely open the hand and had not seen the palm or fingernails, and that an LPN was aware of the resident’s refusal to wear the splint but did not document family education. The DON could not find documentation that the resident’s fingernails were trimmed or that refusals to nail care were recorded, and the nurse practitioner stated the wound was due to the fingernails digging into the palm. The National Library of Medicine reference cited in the report noted that spastic fingers pressing into the palm with overgrown nails can cause skin breakdown and atypical pressure ulceration.
Failure to Consistently Monitor and Document Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that medication refrigerator temperatures were routinely monitored and documented as required by its Medication Storage in Refrigerator/Freezer policy. That policy stated that medications and biologicals must be stored at appropriate temperatures per manufacturers' specifications, that medication storage areas should be monitored at least once daily, and that vaccine storage temperatures should be monitored twice daily. During inspection of the A-Wing medication storage room with an RN, surveyors observed two refrigerators: a black refrigerator storing narcotic medications and a silver refrigerator storing vaccines and insulins. Review of the temperature logs showed multiple days with no recorded temperatures. For the silver refrigerator, morning shift temperatures were missing on 5 of 28 days in February and 8 of 20 days in March, and PM shift temperatures were missing on 2 of 28 days in February and 5 of 20 days in March. For the black refrigerator, morning shift temperatures were missing on 5 of 28 days in February and 10 of 20 days in March, and PM shift temperatures were missing on 3 of 28 days in February and 5 of 20 days in March. When the RCM reviewed the A-Wing refrigerator temperature logs, she stated she did not think temperature monitoring was being done as required. In the D-Wing medication storage room, inspected with the SDC, the refrigerator containing narcotic medications also had inconsistently documented temperatures. Review of those logs showed that on the AM shift, temperatures were not recorded on 15 of 30 days in January and 16 of 28 days in February, and on the PM shift, temperatures were not recorded on 2 of 28 days in February and 2 of 20 days in March. The SDC stated there should not be blanks on the medication room refrigerator temperature logs. The deficient practice created the potential for harm if residents received vaccines or medications with reduced potency and safety from improper storage.
Food Service Sanitation and Labeling Deficiencies in Dietary and Resident Refrigeration Areas
Penalty
Summary
Surveyors identified multiple food service and sanitation deficiencies affecting 75 of 76 residents who received food prepared in the facility’s kitchen. A diet aide was observed working with an improperly worn hair net that did not cover the front portion of her head, leaving tendrils of hair framing her face. The same diet aide was seen taking food carts out of the kitchen and returning without performing hand hygiene, and later entering the kitchen again without washing her hands or wearing her hair net appropriately, despite the dietary manager’s acknowledgement that all food service employees are required to wear hair nets correctly and perform hand hygiene when entering the kitchen. In the main kitchen freezer, surveyors twice observed 2‑inch icicles forming on the air condenser unit and melting, with water dripping directly into an opened box of frozen egg patties. The dietary manager stated that trays under the condenser should catch the ice but sometimes do not, and that food should not be left unwrapped. In the A‑Wing resident refrigerator, brown streaks were present on the interior upper door, staff food and resident food items were stored without labels or dates, and frozen resident meals were marked only with room numbers and lacked names and dates, contrary to the dietary manager’s statement that all resident food should be labeled with name and date. Dust particles were observed hanging from the bolts of the refrigerator air condenser unit on two occasions, and the dietary manager stated the unit should have been cleaned more frequently. In the D‑Wing resident refrigerator, brown spots were observed on the interior door and back wall, and the dietary manager stated housekeeping was responsible for cleaning the refrigerators daily.
Improper PPE Use and Droplet Precautions During Influenza A Outbreak
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of PPE and droplet precautions during an Influenza A outbreak. A CNA entered a room with residents on droplet precautions wearing only goggles and one glove, handled a resident’s urinal, then returned it to the nightstand without gloves. She then went to the roommate’s bedside, applied gloves without performing hand hygiene, handled and emptied a second urinal, and returned it to the bedside. After exiting, she removed her gown and gloves and performed hand hygiene, but removed her goggles and placed them back into a shared storage bin without sanitizing them. The CNA acknowledged she should have performed hand hygiene before donning gloves and should not have returned the goggles to the bin without cleaning them, and she reported that sanitation wipes for the multi‑use goggles were not sufficiently available. Surveyors also observed the Staff Development Coordinator (SDC) cleaning multi‑use goggles with an alcohol wipe and immediately returning them to the storage bin without allowing the required contact time for disinfection, despite stating that goggles should remain out on a clean barrier until dry or for 2 minutes. During the same Influenza A outbreak, multiple rooms were identified as positive for Influenza A and placed on droplet precautions requiring staff to wear face masks and perform hand hygiene before entry. An Activities Assistant was observed repeatedly entering both Influenza A–positive and negative rooms in succession to offer coffee and coloring sheets, performing hand hygiene between rooms but not changing her mask, and stating she did not need a gown and did not need to change her mask because she was not performing cares. The Infection Preventionist later confirmed that precautions for these residents should have included hand hygiene, face mask, gown, eye protection, and gloves, and the DON confirmed new positive Influenza A cases among additional residents and roommates during this period.
Unclean Resident Shower Room with Black Microbial Substance on Shower Wall
Penalty
Summary
The facility failed to ensure that a resident shower area was maintained in a clean and sanitary condition, affecting 1 of 1 shower rooms observed. During an inspection of a resident shower room, surveyors observed a black substance on the lower portion of the shower wall. When the Maintenance Director used the tip of a thermometer to scrub the black substance, he stated that the shower was not clean. The Housekeeping Director reported that showers were scheduled to be cleaned daily and confirmed that the shower room was not clean. The report notes that this failure created the potential for harm if residents were exposed to black microbial substances on the grout of the shower walls.
Incomplete Investigation of Medication-Related Grievance
Penalty
Summary
The facility failed to thoroughly investigate a grievance related to medication administration and handling for a resident who had been readmitted with multiple diagnoses including Parkinson's disease, diabetes, hypothyroidism, pulmonary hypertension, and chronic kidney disease. A grievance filed on 8/2/25 documented that four medication cups labeled with this resident’s name were found at her bedside, while a review of her MAR for the same date showed that she had been documented as having received her medications. The grievance investigation and response completed on 8/4/25 stated that the residents involved had missed their medications, that the LPN involved had been educated, and that the provider was notified, but did not include additional information about the investigation. During an interview on 3/20/26, the Administrator stated there was no record of a medication error report or staff education related to medication storage, administration, or medications left at the resident’s bedside, and acknowledged that such documentation should have existed. This failure to conduct and document a complete investigation of the grievance, including the apparent discrepancy between the MAR and the medications found at the bedside, resulted in the facility not honoring the requirement to fully investigate and resolve resident grievances.
Failure to Maintain Resident Dignity and Privacy During Incontinence Care
Penalty
Summary
The deficiency involves failure to ensure a resident was treated with dignity and respect during incontinence care and toileting needs. The resident had multiple diagnoses including cognitive communication deficit, history of TIA, adult failure to thrive, and dementia, with an Annual MDS BIMS score of 5 indicating severe cognitive impairment. During observation, the resident was found in bed with blankets folded back and linens soiled with stool, with a distinct stool odor and stool leaking from the left side of the incontinence brief. The resident pointed to the brief and said "mess" but was unable to state how long she had been soiled and did not indicate whether she had used the call light for assistance. Later the same day, a CNA entered the resident’s room to perform bowel and bladder rounds and incontinence care. During this care, the window blinds remained open with the courtyard visible, and the privacy curtain was not in use, remaining pulled back to the corner of the room above the bed. When questioned, the CNA acknowledged she did not use the privacy curtain and initially stated that resident rooms could not be seen from outside. After accompanying the surveyor to the courtyard, the CNA was able to see part of the resident through the open blinds and acknowledged she should have closed the blinds or used the privacy curtain during care.
Failure to Provide Adaptive Call Light for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s need for an appropriate adaptive call light despite the resident’s inability to use the standard push-button call light. The resident was admitted with multiple diagnoses including cognitive communication deficit, history of TIA, adult failure to thrive, and dementia, and had an Annual MDS assessment showing a BIMS score of 5, indicating severe cognitive impairment. A Social Services progress note documented that the resident used her call light appropriately to make needs and preferences known. However, during surveyor observation, the resident was found in her room with a distinct odor of stool and brown stool leaking from the left side of her incontinence brief. When asked how long she had been soiled, the resident stated she did not know, and when asked if she had used her call light to ask for help, she did not respond and shrugged her shoulders. Later that afternoon, a CNA entered the resident’s room and provided incontinence care. When interviewed, the CNA stated the resident was able to use the call light. Surveyors then asked the CNA to have the resident demonstrate how to use the call light. The resident smiled at the CNA and the surveyors but did not use the call light. When surveyors instructed the CNA not to point to the call light and the CNA again asked the resident to use it, the resident continued to smile without activating the device. These observations and interviews showed that the resident was not effectively able to use the standard push-button call light and had not been provided with an appropriate adaptive call light to accommodate her needs and preferences.
Failure to Provide Information and Assistance for Advance Directive Formulation
Penalty
Summary
The facility failed to ensure a resident received information and assistance to formulate an advance directive as required by its Advance Directives and Advance Care Planning policy. The policy, reviewed on 9/26/25, stated that residents or their responsible parties are to receive materials upon admission regarding their rights to make decisions about medical care, including accepting or refusing treatment and forming advance directives. Resident #74 was admitted with multiple diagnoses including encephalopathy, diabetes, urinary retention, and a UTI, and a Social Services assessment documented that the resident did not have an advance directive. However, there was no documentation in the resident’s record that information was provided to help formulate an advance directive, and the Social Services Director confirmed that the resident did not have an advance directive and that the resident and/or representative should have been offered the opportunity to formulate one. This deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored if they were incapacitated.
Failure to Notify Provider of Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician of elevated blood glucose levels as required by a physician’s order and the resident’s diabetic care plan. A resident with multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care, had a diabetic care plan revised on 1/22/26 that directed staff to provide timely notification to the physician for any change in condition. A physician’s order dated 2/2/26 specified administration of Insulin Aspart per sliding scale and required staff to give 6 units and notify the provider when blood glucose was greater than 351. Review of the MAR from 2/2/26 to 3/18/26 showed multiple blood glucose readings above 351 (384, 378, 366, 365, 362, 506, and 409), all meeting the threshold for provider notification. When surveyors requested documentation of provider notification for these elevated readings, the DON confirmed she was unable to locate any documentation that the provider had been notified. This failure to follow the physician’s order and the care plan regarding provider notification for elevated blood glucose levels constituted the cited deficiency.
Failure to Provide Required Bed-Hold Policy Notifications Upon Hospitalization
Penalty
Summary
The facility failed to provide residents and/or their representatives with written notice of the facility's bed-hold policy for residents whose records were reviewed for discharges. Record review and staff interviews showed that 3 of 6 residents in the discharge sample did not receive required bed-hold notifications. For one resident with dementia, heart disease, and diabetes who was hospitalized between specified dates, the medical record contained no documentation that a bed-hold notification was provided to her or her representative. The Admissions Director confirmed in an interview that, although she spoke with the resident's POA, she did not provide a bed-hold document. Another resident with hemiplegia, hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder was admitted and later readmitted to the facility, and was subsequently admitted to the hospital; however, there was no documentation that a bed-hold notification was provided to her or her representative at the time of hospitalization. A third resident with a urinary tract infection, diabetes, heart failure, and chronic kidney disease was also admitted to the hospital, and her record similarly lacked any documentation of a bed-hold notification. The Administrator stated that the facility did not have any record of a bed-hold notification being provided for the second and third residents.
Inaccurate MDS Coding for Restraints and PASRR Level II Status
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two of three residents reviewed, resulting in inaccurate transmission of assessment data. For one resident admitted with anxiety, depression, and a need for assistance with personal care, a Quarterly MDS dated [DATE] documented in Section P0100 that physical restraints were used in a chair or in bed less than daily, although the DON later confirmed this coding was inaccurate. For another resident admitted with hemiplegia/hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder, the record showed a PASRR Level II completed on 7/13/21, but the Annual MDS dated [DATE] documented at A1500 that the resident did not have a PASRR Level II. On 3/18/25, the DON stated that this Annual MDS assessment was not accurately completed and that A1500 should have been marked "Yes" to reflect the existing PASRR Level II. These inaccuracies in MDS coding for physical restraints and PASRR Level II status were identified through record review and confirmed by staff interview with the DON.
Failure to Complete Correct PASRR Level I and Required Level II for Resident With Mental Health Diagnoses
Penalty
Summary
Surveyors determined that the facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program by not providing a required PASRR Level II to the designated state agency for one resident. The resident was admitted with multiple diagnoses, including PTSD, anxiety, and depression. A PASRR Level I completed on 3/27/25 did not document that the resident had PTSD or an anxiety disorder, despite these diagnoses being present. During an interview on 3/18/26 at 9:34 AM, the Social Services Director (SSD) acknowledged that the resident should have had a corrected PASRR Level I completed, along with a PASRR Level II, due to the PTSD and anxiety diagnoses. This failure resulted in incomplete coordination of care and lack of appropriate documentation of interventions in the resident’s care plan, as identified through observation, policy review, and staff interviews. The deficient practice was identified for 1 of 2 residents whose records were reviewed for PASRR documentation and was based on the discrepancy between the resident’s documented mental health diagnoses and the information recorded on the PASRR Level I, as well as the absence of a PASRR Level II referral to the state agency.
Failure to Revise Care Plans and Conduct Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans and to conduct required care conferences in accordance with its policy. The facility’s policy stated that care plans should be reviewed and revised when changes occur to update the plan of care. For one resident with heart disease, difficulty walking, abnormal posture, and kyphosis, the care plan still contained an outdated direction to ambulate with therapy only after a new restorative walking program was initiated, and it continued to list use of a neck brace even though the brace had been discontinued months earlier. The resident was observed holding her head at an angle with her hand, and no neck brace was present in the room. The Staff Development Coordinator acknowledged that the ambulation direction should have been discontinued when the new restorative program started and that the care plan was not updated when the neck brace was discontinued. Another resident with cellulitis of the right limb, muscle weakness, and a need for assistance with personal care had a physician order for offloading boots to be applied to both feet at all times, but this intervention was not included in the care plan, and the resident was repeatedly observed without the boots. The DON confirmed the care plan should have been revised to include this intervention. A third resident with hemiplegia and hemiparesis following a stroke transitioned to hospice services, as documented in a progress note, but the care plan did not include hospice or comfort care interventions; the ADON confirmed the care plan should have been revised upon admission to hospice. A fourth resident with PTSD, anxiety, and depression did not have documentation of quarterly care conferences for two required quarters, and the Social Services Director stated those conferences were overlooked and not completed.
Failure to Follow Medication Administration Standards and Verify Appropriate Routes
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans for two residents. For one resident with hypertension and acute pancreatitis, physician orders directed that lisinopril 10 mg by mouth daily be held for systolic blood pressure less than 100, and metoprolol succinate extended-release 25 mg by mouth daily be held for heart rate less than 55 or systolic blood pressure less than 100. On the morning of 3/19/26, an LPN administered both metoprolol and lisinopril without checking the resident’s blood pressure and heart rate at that time. The LPN later stated that vital signs had been taken earlier by a CNA and were 132/78, and acknowledged she probably should have checked the vital signs prior to administering the anti-hypertensive medications. The facility also failed to ensure correct medication orders and routes of administration for another resident with diabetes, kidney disease, and an ileostomy. This resident’s record contained active orders for Dulcolax (bisacodyl) 10 mg suppository to be inserted rectally as needed for constipation and a Fleet enema to be inserted rectally as needed for constipation, both ordered on 5/8/23. Given the resident’s ileostomy, the Staff Development Coordinator confirmed that the resident should not have any orders for medications to be given rectally and that the routes on the bisacodyl and enema orders were wrong, and further stated the resident should not even have those orders. These issues were identified through observation, record review, policy review, and staff interviews.
Failure to Obtain Timely Physician Response After Resident Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely physician response and quality treatment and care in accordance with professional standards of practice when the resident experienced a change in condition. The resident was admitted with multiple diagnoses, including urinary tract infection, diabetes, heart failure, and chronic kidney disease. In the early morning, a nursing progress note documented that an SBAR was sent to the resident’s physician at 12:42 AM, reporting the resident was hard to arouse, appeared somnolent, had slept most of the shift, had eaten no dinner, and might be showing signs and symptoms of sepsis or a urinary tract infection, and requested further evaluation and treatment. Later that day, at 3:45 PM, another nursing progress note documented a second SBAR to the physician, reporting congestion, refusal of medications and food throughout the day, and that the resident had been sleeping most of the day, and asked if the physician could see the resident, order labs, or a portable chest X-ray. At 4:10 PM, the nurse documented that the resident was found in bed catatonic and unresponsive when brought to the nurse at 3:20 PM, and the physician was called and approved sending the resident to the ER via emergency transport. There was no documentation that the physician communicated with the facility between the first SBAR at 12:42 AM and the second SBAR at 3:45 PM, and the Administrator later acknowledged the facility had no record of a physician response to the initial SBAR before the resident was sent to the ER.
Failure to Address Ongoing Refusal of Hand Orthotic and ROM Needs
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a right-hand contracture received appropriate treatment and services to maintain or improve range of motion (ROM) and prevent further decline. The resident, who had a history of stroke with aphasia and a right-hand contracture, was discharged from OT with a right grip orthotic/resting hand splint to be worn during daylight hours as tolerated, with an excellent prognosis to maintain function with consistent staff support. The care plan directed staff to apply the right-hand grip splint for eight hours as tolerated. Subsequent documentation showed the resident frequently refused to wear the orthotic, with TAR entries indicating refusals on numerous days over several consecutive months. A physician communication in early October documented that CNAs reported the resident refused to wear the brace daily and exhibited high pain when staff attempted to place fingers into his contracted hand, and a re-evaluation for therapy options was recommended. Despite ongoing refusals documented in the TAR and monthly summaries noting the resident’s contractures and refusal to wear the orthotic, there was no further documentation after early October that the physician, therapy department, or the resident’s representative were notified of these continued refusals. The resident was not referred back to therapy after his initial OT discharge in July, even though the OT and DOR confirmed no subsequent therapy referrals. A restorative program for PROM to the right hand was initiated in January, with care plan directions to perform PROM and approach the resident by asking to hold his hand, and restorative evaluations in February and March documented participation in the PROM program. However, the Restorative Coordinator stated she was unaware of how long the resident had been unable to open his right hand and that he was referred to the restorative program only in January due to tightness. The DON stated that the expectation when a resident continued to refuse a splint would be to refer to therapy, notify the representative, provide education, and notify the physician, but she did not recall being informed of the ongoing refusals. The lack of timely and consistent communication and follow-through with the interdisciplinary team regarding the resident’s persistent refusals to wear the orthotic and his increasing hand tightness led to the deficiency.
Failure to Administer Insulin as Ordered and Incorrect PRN Morphine Dose
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors related to insulin administration and morphine dosing. The resident had multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care. The resident’s diabetic care plan, revised 1/22/26, directed staff to provide timely notification to the physician for any change in condition, and a physician’s order dated 2/2/26 specified a sliding scale regimen for Insulin Aspart Injection Solution 100 units/mL based on blood glucose ranges, including instructions to give 6 units and notify the provider if the blood sugar was greater than 351. Review of the MAR from 2/2/26 to 3/18/26 showed no documented insulin administrations or blood sugar checks on multiple evening shifts (2/2, 2/8, 2/9, 2/12, 2/15, 2/23, 2/27, 3/5, 3/6, 3/12, 3/15, and 3/16). The DON confirmed that the insulin administration record contained multiple blanks and that there was documentation of blood sugar readings but no documentation of insulin doses administered. The facility also failed to follow physician orders for PRN morphine for the same resident. The resident’s record contained two morphine orders: Morphine Sulfate 15 mg, 0.5 tablet by mouth every 1 hour PRN for pain/dyspnea, and Morphine Sulfate 15 mg, 15 mg by mouth three times a day for pain. A nursing progress note dated 3/4/26 documented that the resident was given the wrong dose of PRN morphine. A medication error report from 3/4/26 at 3:15 AM recorded that a licensed nurse administered a full 15 mg tablet instead of the ordered half tablet for the PRN dose. The error was identified when the resident asked whether a whole or half tablet had been given and stated that only half should have been administered. The licensed nurse verified the order and acknowledged that a medication error had occurred, and the DON later confirmed the occurrence of this error.
Missing Current Hospice Plan of Care and Terminal Certification
Penalty
Summary
Facility staff failed to ensure that required hospice documentation was complete and available in the medical record for a resident receiving hospice services. The resident had multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care, and the hospice care plan revised on a specified date documented that the resident was on hospice and had a DNR code status. Record review showed there was no current hospice plan of care and no current terminal diagnosis certification in the resident’s chart, both of which are required to initiate and maintain hospice services. When the surveyor requested these documents, the DON later provided a terminal certification with a benefit period that had expired 23 days earlier and only a facility-generated care plan, and the Administrator acknowledged that there was no current terminal certification or hospice plan of care in the resident’s record. The absence of required hospice documents created the potential for delayed or incomplete care due to lack of access to the hospice plan of care and current terminal certification.
Lack of Qualified Food Service Director
Penalty
Summary
The facility failed to ensure a qualified director of food and nutrition services was in place to oversee the dietary department, potentially affecting 82 residents. The job description for the Food Service Director, dated 09/28/22, required a minimum course of study in food safety, such as the Serv Safe Food Manager Certification, to be completed before 10/01/23. However, during an interview on 10/01/24, the Dietary Manager (DM) revealed that he had been employed for one and a half years without obtaining the necessary certification or completing any Serv-Safe courses. The DM attributed this to working six months straight without a day off, leaving no time for training. Additionally, the Registered Dietitian (RD), who was present at the facility two days a week, acknowledged the DM's lack of certification and emphasized the importance of certification for managing the kitchen for long-term residents. The RD stated that she was responsible for completing resident assessments but did not manage the kitchen.
Inadequate Staffing and Training in Dietary Department
Penalty
Summary
The facility failed to ensure sufficient staffing with appropriate competencies and training in the dietary department, affecting the ability to safely and effectively carry out food and nutrition services for 81 of 82 residents. The dietary schedule revealed inadequate staffing, with only two employees scheduled to prepare, serve, and clean up the dinner meal for most days, and only one employee on Tuesdays. Observations confirmed that during the evening, only two staff members were present in the kitchen. Interviews with the Dietary Manager (DM) and other staff highlighted severe understaffing, lack of training, and the absence of in-service training since December 2022. The DM, who had been working without a day off for six months, admitted to not having time for certification or staff training. The Registered Dietitian (RD) was unaware of any training provided to the kitchen staff and noted that her suggestions during kitchen audits were not addressed by the DM. The RD also identified a failure to update a resident's diet tray ticket, which was supposed to reflect a change to a diet limiting tomatoes and potatoes. Staff interviews further revealed that the lack of adequate staffing led to rushed work and mistakes, with many staff members leaving the job due to the conditions. The DM acknowledged the need for additional staff and training but was not involved in the recruitment process, which was handled by the main office.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitation and food handling practices, as observed during a survey. In the kitchen, a black mold-like substance was found on the plastic lining inside the ice machine, which had not been cleaned since July, despite the facility's policy requiring regular maintenance. Additionally, food items such as health shakes and soda were improperly stored on the floor in both the walk-in freezer and dry storage area, contrary to professional standards. Cook1 acknowledged that these items had been delivered days prior and should not have been left on the ground. Further observations during the tray line service revealed that Cook2 handled plates and food with bare hands, placing his thumb on the center of the plates and arranging food without gloves. Cook2 also wiped his hands on his pants multiple times during service. The Dietary Manager admitted that the cook was newly hired and required more training. The Registered Dietitian confirmed that kitchen audits were conducted, but her recommendations were not being followed, emphasizing the need for adherence to the sanitation policy.
Failure to Serve Meals Consecutively Affects Resident Dignity
Penalty
Summary
The facility failed to serve residents consecutively at five of the seven tables during meal service, affecting the dignity and meal satisfaction of residents. The policy titled 'Resident Dining Services' required that residents seated together be served in consecutive order so they could eat at the same time. However, during a lunch meal observation, meals were served in a non-consecutive manner across different tables, leading to delays for some residents. For instance, meals were served at different times to residents at tables one, two, three, four, five, six, and seven, with the final meal being served at 11:49 AM, which was 12 minutes after the first meal was served. Resident 48, who was seated at table four, expressed dissatisfaction, stating that meals were served in this manner daily, and they often had to wait. The resident attributed this to having only one server. Interviews with Cook1 and the Dietary Manager revealed a lack of awareness regarding the policy requirement to serve all residents at a table before moving to the next. Cook1 mentioned serving plates as they came off the tray line, while the Dietary Manager admitted not knowing that residents were not being served consecutively at each table.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% during the observation of 26 medication administration opportunities. This deficiency was identified in two residents out of a sample of 29. For one resident, the facility did not adhere to the prescribed timing for administering Lantus Solostar insulin. The insulin was ordered to be administered at 8:00 AM, but it was observed being administered at 9:59 AM, which is beyond the one-hour window allowed by the physician's order. The registered nurse confirmed the late administration during an interview. Another resident received multiple medications through a PEG tube in a manner that did not comply with the facility's policy. The policy required each medication to be administered separately, but the nurse crushed several medications and mixed them with water before administering them together through the PEG tube. This action was confirmed by the nurse during an interview, indicating a deviation from the facility's established medication administration procedures.
Inadequate Documentation of Diabetes Management
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with diabetes, specifically regarding the treatment of high and low blood sugar levels. The resident, who had moderately impaired cognition, was on insulin therapy and had a history of blood sugar issues. On one occasion, the resident's blood sugar dropped to 50, but there was no documentation of the actions taken to address this hypoglycemic event, such as administering carbohydrates or notifying a physician, as required by the facility's protocol. The Licensed Practical Nurse (LPN) involved admitted to not documenting the incident, despite administering glucose and glucagon injections. In another instance, the resident's blood sugar was recorded at 566, but the Registered Nurse (RN) did not document administering the prescribed insulin or rechecking the blood sugar within the specified time frame. The RN claimed to have followed the physician's instructions and administered insulin, but there was no progress note to confirm this. The lack of documentation raised concerns about the accuracy of the resident's medical records and the adequacy of their diabetes management. Interviews with the Resident Care Manager and the Director of Nursing confirmed the absence of necessary documentation in the resident's medical records. The facility's policy required all medical record entries to be authenticated and documented by credentialed individuals, but this was not adhered to in the cases of both hypoglycemia and hyperglycemia incidents. This deficiency in record-keeping created the potential for inadequate treatment of the resident's diabetes.
Failure to Implement Proper Infection Control Procedures
Penalty
Summary
The facility failed to implement proper infection control procedures for a resident who required enhanced barrier precautions (EBP) due to having an invasive device, such as a feeding tube. The resident had diagnoses including stroke and diabetes and was admitted with orders for tube feeding and medication administration through a percutaneous endoscopic gastric (PEG) tube. Despite the requirement for staff to wear protective gowns during high-contact care activities, a registered nurse (RN) was observed administering medications to the resident via the PEG tube while only wearing gloves and not a protective gown. The RN confirmed the resident was under EBP and acknowledged the failure to don a gown prior to accessing the PEG tube for medication administration.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents, R140 and R18, from sexual abuse by another resident, R139. R139, who was cognitively intact, was observed placing R140's hand on his genitals and later placing his hand on R18's groin. R140 had a severely impaired cognition with a BIMS score of six, indicating she could not consent to sexual activity. Despite being educated about R140's inability to consent, R139 continued to engage in inappropriate behavior. The facility's policy on abuse prevention was not effectively implemented to prevent these incidents. R139's behavior was documented in the Facility Reported Incident (FRI) investigations. The first incident involved R140, who had a diagnosis of dementia and was severely impaired cognitively. R139 was observed by a CNA engaging in inappropriate contact with R140, who was unable to consent. The facility's response included separating the residents and placing them under supervision, but R139's care plan was not updated until several months later. R139 was eventually discharged to an all-male unit due to his behavior. The second incident involved R18, who had moderately impaired cognition. R139 was observed by CNA3 touching R18 inappropriately in the dayroom. Despite being placed on one-to-one supervision, R139 continued to seek out female residents with cognitive impairments. The facility's response included reporting the incident and placing R139 under observation, but the care plan interventions were not sufficient to prevent further incidents. The facility's failure to protect these residents from sexual abuse resulted in a deficiency in their care.
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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