Life Care Center Of Idaho Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Idaho Falls, Idaho.
- Location
- 2725 East 17th Street, Idaho Falls, Idaho 83406
- CMS Provider Number
- 135091
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Life Care Center Of Idaho Falls during CMS and state inspections, most recent first.
The facility did not follow its policy requiring an IDT assessment before allowing a resident to self-administer medications. A resident with multiple myeloma and diabetes was observed independently instilling eye drops, with a bottle of Refresh Tears at the bedside. Record review showed no MD order for the eye drops and no documented IDT self-administration assessment. The DON confirmed the resident had not been assessed for self-administration and should not have had the eye drops at the bedside.
The facility did not follow its policy to provide all residents or their responsible parties with information and assistance to formulate advance directives upon admission. Record review and staff interviews showed that four residents with significant medical conditions, including polyneuropathy, diabetes, dementia, stroke-related hemiplegia, cancer, hypertension, and lumbar spinal stenosis, had no healthcare advance directives in their records and no documentation that they were informed of their right to create one. The Social Services Director and DON confirmed these residents only had financial or general POA documents and were not offered the opportunity to establish a healthcare advance directive.
The facility did not follow its own policies requiring daily toilet cleaning and twice-daily shower/bath area cleaning, resulting in a resident room and multiple shower rooms with thick black and brown debris, staining, and missing caulking. Surveyors observed a resident room toilet with a heavy black ring above the water line and under the rim, and a sink with heavy brown residue. In two hall shower rooms, they found blackened debris on floors and tiles, toilets with black/brown debris at the water line and under the rim, rusty discoloration in bowls and around bases, discolored toilet seats, missing caulking, and black debris along floor and wall lines. The Maintenance Director acknowledged the showers did not appear to have been cleaned, and the Housekeeping Manager reported that CNAs were supposed to wipe down showers between use and housekeeping was to check them at day’s end, but confirmed the shower rooms had not been cleaned as required, creating potential for diminished quality of life and resident safety including infection and cross-contamination.
Surveyors found that the facility did not follow its own discharge and bed-hold policy requiring written notice of transfer, reasons for the move, and bed-hold information before hospital transfers. Record review showed that two residents with complex medical conditions, including stage IV pressure ulcers, diabetes, spinal cord injury, cancer, hypertension, and lumbar spinal stenosis, were transferred to the hospital without any documented Notice of Transfer or Bed Hold Policy in their charts. In an interview, the DON confirmed that the facility did not have the required transfer and bed-hold documentation for these residents.
A deficiency was cited when a resident’s comprehensive care plan included an intervention for high-risk medication management of insulin "per MD order" for diabetes, despite the absence of any physician order for insulin in the medical record. Facility policy required person-centered care plans with interventions aligned to each resident’s physical and psychosocial needs and updated with each MDS assessment. Record review showed the care plan had not been updated to remove the incorrect insulin intervention, and the DON confirmed the resident had never had an insulin order and that insulin should not have been listed on the care plan.
A resident with multiple chronic conditions had standing PRN orders for a bowel protocol, including Senna, Bisacodyl (oral and suppository), and a Fleet enema, to be used based on specific time intervals without a BM and to notify the MD if there was no response. Record review showed the resident went more than five days without a BM, with no documentation that the ordered bowel medications were administered during part of this period and no documentation that the physician was contacted after more than 96 hours without a BM. The ED acknowledged that nursing staff should have notified the physician and did not.
Two residents were affected when the facility failed to prevent environmental hazards and to timely document a fall. One resident with respiratory failure and diabetes was found using a multi-outlet extension cord in her room to power a bed, power wheelchair, and cellphone, contrary to guidance that extension cords not replace permanent wiring and be used for only one device. Another resident with hemiplegia and hemiparesis reported left shoulder pain to therapy staff and a physician after falling from a wheelchair, with imaging later indicating osteoporosis and a likely acute clavicle fracture. An LPN assessed the resident after the fall and instructed another LPN to enter the event into the risk management system, but this documentation was not completed, and the ED reported he did not become aware of the fall until much later during an internal investigation.
A resident with chronic respiratory failure with hypoxia and a history of stroke had a physician order and care plan for continuous oxygen at 1 L/min via nasal cannula, with the MAR reflecting administration at that rate. However, surveyors observed the resident’s oxygen concentrator set at 2 L/min on one occasion and 2.5 L/min on another, and the resident reported being on 2 L/min. An RN acknowledged the oxygen should have been set at 1 L/min but was not, and the DON stated that staff should check the concentrator liter flow at least every shift but had not done so, creating the potential for increased fatigue and low O2 levels.
A resident with hypothyroidism and dementia was observed on multiple occasions with bilateral upper side rails in the up position, but the facility failed to follow its bed rail policy. The record lacked an assessment for bed rail use, documentation of alternatives attempted and how they failed, the intended purpose of the rails, a physician order, and a documented risks/benefits discussion with signed consent. The DON confirmed that none of these required steps had been completed, creating potential for injury, entrapment, and/or death.
The facility failed to accurately post required daily nurse staffing information, including the number of CNAs present and their hours worked on one date, and RN hours worked for all shifts on another date. Federal regulations require posting of the facility name, date, total number and actual hours worked by RNs, LPNs/LVNs, and CNAs per shift, along with the resident census. Surveyors observed missing CNA and RN data on the posted staffing sheets, and the Executive Director acknowledged that these staffing details should have been documented but were not.
The facility failed to follow its policy requiring two nurses to count and document controlled substances at each shift change, resulting in missing nurse signatures on narcotic count sheets for both medication carts reviewed. During audits of two halls, surveyors found multiple dates where only one or no licensed nurse signatures were recorded on Narcotic Card Item Count sheets, despite the expectation that two nurses sign when accepting or releasing the cart. An LPN on each hall and the DON confirmed that two signatures were required but not consistently obtained, affecting all residents receiving controlled medications.
A resident with acute osteomyelitis of the left ankle and foot had PRN orders for acetaminophen for mild pain and Percocet for moderate to severe pain. Documentation showed acetaminophen was given only once for a pain level of 4 and then not administered for several days, while Percocet was administered multiple times for documented pain levels of 3, below the ordered indication for moderate to severe pain. The facility’s pain management policy required pain assessment every shift with documentation of the pain scale and type of pain, and the DON reported that physicians had moved away from relying on the numeric pain scale because residents might underreport their pain.
Surveyors found that glucose control solutions used for blood glucose testing were not dated when opened, despite manufacturer instructions and facility policy requiring documentation of an open date and three-month discard date. Review of blood glucose logs showed the same undated solutions were used over several months, and staff acknowledged they should have been dated and limited to three months of use. In addition, a medication cart on one hall was observed left unlocked and unattended, contrary to facility policy requiring carts to be locked when out of sight, and both an RN and the DON confirmed the cart should not have been left unlocked.
Surveyors found that the facility failed to follow its IPCP requirements for appropriate storage and handling of medical equipment when a resident’s power wheelchair, with personal items and a Hoyer sling, along with a resident lounge shower chair, a Hoyer lift, and a bariatric shower chair, were stored in an Out of Order shower room that was visibly soiled with a dirty toilet, brown substances on floors and walls, and used paper towels on surfaces. The Infection Preventionist acknowledged that staff should not be storing resident equipment in this Out of Order shower room.
A resident with chronic kidney disease and diabetes was found unresponsive, and despite clear DNR/DNI orders in the medical record and care plan, an LPN mistakenly initiated CPR after referencing a POST document for another resident. CPR was discontinued only after the correct code status was confirmed by emergency responders.
A medication cart review revealed that the narcotic accountability record was missing a required nurse signature, with only one instead of two signatures documented. Both an RN and the Admissions Nurse confirmed that two nurses should have signed the record when accepting or releasing the cart, indicating a failure to properly track and secure controlled medications.
A resident with a DNR/DNI order was resuscitated and intubated by facility staff and EMS without verification of her code status. Despite having a POST indicating DNR/DNI, staff initiated CPR and used an AED, and EMS was not informed of her status until after intubation. The resident's family confirmed her wishes, and she later expired at the hospital.
The facility failed to store food safely and sanitarily, with expired yogurts, unlabeled salad, and undated chicken found during inspections. Ants were also observed on a food prep table, despite recent pest control. The Food Service Director acknowledged these issues, highlighting risks of food contamination.
The facility failed to ensure accurate MDS assessments for multiple residents, leading to potential negative outcomes. A resident with Cerebral Palsy was incorrectly documented as not receiving tube feeding, while another with schizophrenia was not marked for major mental illness. Similar inaccuracies were found in assessments for residents with bipolar disorder, schizoaffective disorder, and those requiring feeding tubes, highlighting a significant deficiency in resident assessments.
The facility failed to update care plans for four residents, leading to discrepancies between documented care and current needs. A resident's care plan inaccurately listed clostridium difficile, another's did not include self-administration of Biofreeze, a third's omitted treatment for excoriation, and a fourth's incorrectly documented a discontinued Dobhoff tube. Staff acknowledged these oversights.
The facility failed to ensure a safe, clean, and homelike environment, with water temperatures exceeding safe limits and various cleanliness and maintenance issues in resident rooms and common areas. Observations included high water temperatures, missing drawer fronts, black substances in showers, and dust on kitchen ceilings and vents.
The facility failed to complete PASARR Level II evaluations for residents with major mental illnesses, including those with bipolar disorder, PTSD, and borderline personality disorder. This oversight involved four residents, where necessary screenings and referrals were not conducted, potentially impacting the provision of specialized mental health services.
A facility failed to follow a resident's care plan requiring two staff members for bed mobility due to fragile bones. Despite the care plan's directive, documentation showed that only one CNA or NA assisted the resident on multiple occasions. The DON confirmed the need for adherence to the care plan.
A resident with kidney disease and bladder pain refused a prescribed Nicotine Transdermal Patch 11 out of 12 times. The facility's policy required notifying the physician after three refusals, but there was no documentation of such notification. The DON confirmed the physician should have been informed, indicating a failure to adhere to professional standards.
The facility failed to follow professional nursing standards for two residents. A resident with wounds on her knee lacked documented wound care orders, and an LPN treated the wounds without proper orders. Another resident with emphysema was using oxygen without documented orders in his electronic medical records, despite standing orders being present in paper records. Nurses did not document the completion of these orders.
A resident with atrial fibrillation using sequential compression devices had the compressor plugged into a power strip, contrary to safety guidelines. The State Operations Manual specifies that power strips should not be used for medical devices in patient care areas. The Maintenance Director acknowledged the error, highlighting a failure to follow safety protocols.
A facility failed to ensure licensed nurses followed standing orders for oxygen administration, as evidenced by multiple instances where a resident with low SpO2 levels did not receive the required intervention. Despite having standing orders to titrate supplemental oxygen for SpO2 below 88%, the nursing staff did not document any follow-up actions or notify the physician, as confirmed by interviews with an LPN and the DON.
The facility failed to store medications and supplies appropriately for two residents, leading to potential safety risks. One resident had medication left on the bedside table without a self-administration assessment or care plan, while another had wound care supplies left out in the room. Staff confirmed these practices were against facility policy.
The facility failed to employ a qualified director of food and nutrition services, as required by regulations. The current Food Service Director did not meet the necessary qualifications, such as certification or relevant experience and education. This deficiency had the potential to affect all residents receiving meals prepared in the facility's kitchen.
The facility failed to maintain infection control practices, with issues in oxygen equipment storage, catheter bag placement, and glucometer cleaning. Oxygen supplies were improperly stored, catheter bags were found on the floor, and glucometers were not cleaned per protocol, risking cross-contamination.
The facility failed to consistently perform glucometer solution tests for two medication carts, Hall 300 and Hall 400, as required by the Assure Prism Blood Glucose Monitoring System manual. The tests were not done consistently from December 2024 to January 2025 for Hall 400 and in January 2025 for Hall 300. An LPN confirmed that these tests should have been conducted daily by the night shift.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident’s ability to self-administer medications in accordance with its Self-Administration of Medication policy, which requires that any resident requesting to self-administer medications be evaluated by the interdisciplinary team (IDT) and that the assessment be documented in the electronic medication record and reviewed with the resident and/or responsible party. The resident, who had multiple diagnoses including multiple myeloma and diabetes, was observed sitting in his room placing eye drops in his eyes, and a bottle of Refresh Tears was seen on his bedside table. Review of the resident’s medical record showed no physician order for Refresh Tears and no IDT self-administration assessment. The DON stated that the resident should not have had the Refresh Tears at his bedside and confirmed that the resident had not been assessed by the IDT for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident.
Failure to Assist Residents With Formulating Healthcare Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advance directive, as required by the facility’s Advance Directives policy. That policy, last reviewed on 12/1/25, stated that all residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the formation of advance directives upon admission. Record review showed that four residents admitted with multiple medical diagnoses did not have an advance directive for healthcare in their medical records, nor documentation that they were provided information on their right to formulate one. One resident with polyneuropathy and diabetes, another with a left femur fracture and dementia, another with hemiplegia and hemiparesis following a stroke, and another with cancer, hypertension, and lumbar spinal stenosis all lacked healthcare advance directives or documentation of being informed of their right to create one. The Social Services Director and the DON confirmed that these residents only had financial or general powers of attorney on file and did not have a Durable Power of Attorney for Healthcare or other healthcare advance directive, and that they were not offered the opportunity to formulate one.
Failure to Maintain Clean and Homelike Resident Room and Shower Areas
Penalty
Summary
The facility failed to honor residents' right to a safe, clean, comfortable, and homelike environment as required by its own policies for daily room and shower cleaning. The Daily Room Cleaning policy required that resident bathroom toilets be cleaned daily, and the Housekeeping Services policy required that resident shower/bath areas be cleaned twice daily. Despite these policies, surveyors observed one resident room with a toilet that had a thick black ring of debris above the bowl water line and under the rim, and a room sink that was heavily stained with brown residue. Additional observations in common shower areas showed similar failures to maintain cleanliness. In one hall shower room, surveyors observed blackened thick debris on floors and tiles, a toilet with a black/brown debris line around the water line and rusty brown discoloration in the bowl, black debris around the wall and floor line, and a rusty brown area between tiles and the wall under the sink. In another hall shower room, there was blackened thick debris on floors and tiles, a toilet with black/brown debris at the water line and under the rim, a discolored toilet seat, a rusty brown and black ring around the entire toilet base, missing caulking at the floor and wall line, and black debris at the floor and wall line extending up two tiles on the wall. The Maintenance Director acknowledged that the showers did not appear to have been cleaned as they should have been, and the Housekeeping Manager stated that CNAs were expected to wipe down showers between resident use and housekeeping was to check shower rooms at the end of the day, but confirmed the shower rooms had not been cleaned as required. The report states this deficient practice created the potential for diminished quality of life and resident safety including infection and cross-contamination.
Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to residents or their representatives when residents were transferred to the hospital. Policy review showed the facility’s "Discharge Process and Bed Holds" policy, reviewed 12/1/25, required that before a transfer or discharge, the facility must notify the resident and representative in writing, in a language and manner they understand, of the transfer or discharge and the reasons for the move. The policy also required that before a resident is transferred to a hospital or goes on therapeutic leave, the facility must provide written information specifying the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence. Record review revealed that one resident with multiple diagnoses including stage IV pressure ulcers, diabetes, and spinal cord injury was transferred from the facility and admitted to the hospital on two occasions, and there was no documentation that he was provided with a Notice of Transfer or Bed Hold Policy prior to either transfer. Another resident with multiple diagnoses including cancer, hypertension, and lumbar spinal stenosis was transferred and admitted to the hospital, and her medical record also lacked documentation that she was provided with a Notice of Transfer or Bed Hold Policy prior to transfer. During an interview on 3/18/26 at 1:40 PM, the DON stated they did not have the Notice of Transfer or Bed Hold documentation for these two residents.
Inaccurate Diabetes Care Plan Intervention Without Corresponding Insulin Order
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a person-centered comprehensive care plan consistent with the resident’s actual medical orders and needs. The facility’s policy required development and implementation of a comprehensive person-centered care plan for each resident, including identification and implementation of interventions and treatments to address physical, functional, and psychosocial needs, and updating the care plan with each MDS assessment and periodically. Record review for one resident with multiple diagnoses, including hypertensive heart and chronic kidney disease and diabetes, showed the last care plan review was completed on 12/21/25 and included an endocrine/diabetes care plan with an intervention for “High Risk Medications: Insulin per MD order,” initiated on 12/15/25. However, review of the resident’s medical record on 3/17/26 showed there was no physician’s order for insulin during the resident’s stay, and the DON confirmed the resident had not had an insulin order and that insulin should not have been documented on the care plan. This discrepancy between the documented care plan intervention and the absence of a corresponding physician order demonstrated that the facility did not maintain an accurate, person-centered comprehensive care plan for the resident, as required by its own care planning policy.
Failure to Follow Bowel Protocol and Physician Orders for Constipation Management
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own bowel protocol policy for a resident requiring bowel management. The facility’s Bowel Protocol policy, reviewed on 9/15/25, stated that the facility, in coordination with the attending practitioner, would implement standing orders to address a lack of bowel movement. Resident #13 was admitted with multiple diagnoses including hypertensive heart and chronic kidney disease and respiratory failure. The resident’s medication administration record contained standing PRN orders dated 1/22/26 for Senna tablets to be given if there was no bowel movement (BM) in 72 hours, Bisacodyl delayed-release tablets if no BM in 96 hours, a Bisacodyl suppository if there was no BM by 10:00 the day after oral Bisacodyl, and a Fleet enema if there was no result two hours after the suppository, with instructions to call the MD if there was no BM within two hours of the enema. Record review on 3/18/26 at 2:01 PM showed that the resident had a BM on 2/21/26 at 03:56 and then not again until 2/26/26 at 22:39, a gap of over 120 hours. During this period, there was no documentation that any of the ordered bowel management medications were administered between 2/24/26 and 2/26/26, despite the standing orders tied to specific time intervals without a BM. Further review at 2:07 PM on 3/18/26 showed no nursing progress note documentation that the physician had been contacted on 2/25/26 through 2/26/26 regarding the absence of a BM for over 96 hours. In an interview at 2:20 PM on 3/18/26, the Executive Director stated that nursing staff should have contacted the physician after 96 hours without a BM and had not done so.
Failure to Prevent Environmental Hazards and Timely Document Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision, as evidenced by issues involving two residents. For one resident with respiratory failure and diabetes, surveyors observed an extension cord in the room with the bed electrical cord, wheelchair electrical cord, and cellphone electrical cord all plugged into it. The resident stated she had purchased the extension cord herself and used it for these devices. The Maintenance Director stated that medical devices should not have been plugged into an extension cord in the room, and the Executive Director stated he was unaware the resident had an extension cord and that medical devices should not have been plugged into it. The State Operations Manual, Appendix PP, specifies that extension cords should not be used in place of adequate wiring and should be connected to only one device to prevent overloading. The deficiency also includes the facility’s failure to timely document and report a fall for another resident with hemiplegia and hemiparesis following a stroke. Therapy notes on multiple dates documented the resident’s reports of left shoulder pain due to a fall from his wheelchair, including mention of hearing a pop at the time of the fall. A physician progress note later documented increased left shoulder pain since a fall, and an x-ray report showed osteoporosis, mild to moderate shoulder osteoarthritis, and a likely acute distal clavicular fracture. Subsequent physician documentation referenced the need for further imaging and screening for osteoporosis. The facility’s later investigation determined that the resident had fallen out of his wheelchair onto the grass in front of the facility, was assessed by an LPN, and assisted back into the wheelchair. The investigation documented that the LPN instructed another LPN to enter the fall into the Risk Management system on the day of the incident, but this was not done because the second LPN forgot, and the Executive Director stated he did not learn of the fall until weeks later when the investigation was initiated.
Failure to Follow Ordered Oxygen Liter Flow Settings
Penalty
Summary
Surveyors found that the facility failed to provide respiratory services as ordered by the physician for one resident with chronic respiratory failure with hypoxia and a history of stroke. The facility’s Oxygen Administration policy required oxygen orders to include a specific liter flow, and the physician’s order for this resident, dated 11/12/23, specified oxygen at 1 liter per minute via nasal cannula continuously. The resident’s care plan directed staff to provide supplemental oxygen per the medical order, and the MAR documented that oxygen was administered at 1 liter per minute on specified dates and shifts. However, on 3/16/26 at 1:29 PM, the resident was observed in bed with a nasal cannula in place while the oxygen concentrator was set at 2 liters per minute, and the resident stated she was on 2 liters per minute of oxygen. On 3/17/26 at 9:04 AM, the oxygen concentrator was again observed, this time set at 2.5 liters per minute. At 9:08 AM, an RN acknowledged that the oxygen should have been set at 1 liter per minute and had not been. On 3/18/26 at 9:28 AM, the DON stated that the resident’s oxygen concentrator liter flow setting should be checked often or at least every shift by nursing staff and that this had not been done. The report stated this failure created the potential for residents to experience increased fatigue and low oxygen levels.
Failure to Assess and Obtain Consent Prior to Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for the safe and effective use of bed rails for one resident. The facility’s policy, reviewed on 9/3/25, required that residents be assessed upon admission, readmission, or upon initiation of bed rail use using the Evaluation for Use of Bed Rails Assessment, that alternatives to bed rails be tried and evaluated, and that the risks and benefits of bed rail use be reviewed with the resident or representative and consent obtained prior to installation. Surveyors observed a resident with multiple diagnoses including hypothyroidism and dementia using bilateral upper side rails in the up position on three consecutive days. On review of the resident’s medical record, surveyors found no documentation of an evaluation of alternatives attempted, no documentation of the purpose or intended use of the side rails, and no documented discussion of risks and benefits with a signed consent for bed rail use. Additionally, there was no physician order for the bed rails. The DON confirmed that the resident had not been assessed for the use of bed rails and that the medical record lacked the required documentation of alternatives, intended purpose, physician order, and consent, despite the facility’s policy requirements. This failure created the potential for harm due to the risk for injury, entrapment, and/or death.
Incomplete Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted on a daily basis for each shift, as required by 42 CFR §483.35(g). The State Operations Manual, Appendix PP, specifies that facilities must post the facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, and CNAs directly responsible for resident care per shift, as well as the resident census. On 3/17/26 at 12:31 PM, surveyors observed that the daily staffing sheet for 1/20/26 was missing the CNA number of staff present and their hours worked. Later that same day at 12:45 PM, surveyors observed that the daily staffing sheet for 2/15/25 was missing RN hours worked for the day, evening, and night shifts. On 3/18/26 at 9:30 AM, the Executive Director confirmed that the CNA and RN worked hours and staff present data should have been documented on the daily staffing sheets for those dates and had not been. 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, because the posted information was incomplete and did not fully reflect the required nurse staffing data.
Failure to Properly Document Controlled Substance Counts on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure controlled medications were consistently tracked and secured in accordance with its own policy and procedures. The facility’s “Inventory Control of Controlled Substances” policy, revised 08/01/24, required incoming and outgoing nurses to count all Schedule II controlled substances and other medications with a risk of abuse or diversion at each shift change and document the results on a Controlled Substance Count Verification/Shift Change Sheet. The policy also required staff to count all Schedule III–IV controlled substances in accordance with facility policy and applicable law. During a medication cart audit on Hall 2 on 3/18/26 at 8:17 AM, surveyors observed Narcotic Card Item Count sheets dated 1/1/26 to 1/15/26, 2/1/26 to 2/15/26, and 3/1/26 to 3/15/26 that were missing one of the required licensed nurse signatures on 1/1/26, 2/3/26, 2/10/26, 2/11/26, and 3/10/26. During a medication cart audit on Hall 4 on 3/18/26 at 8:50 AM, surveyors observed a Narcotic Card Item Count sheet dated 3/11/26 to 3/21/26 that was missing one licensed nurse signature on 3/12/26. An LPN interviewed at 8:19 AM stated that two nurses should have signed the Narcotic Card Item Count sheet and had not. Another LPN interviewed at 8:55 AM similarly stated that two nurses should have signed the Narcotic Card Item Count sheet when they accepted or released the medication cart. At 10:16 AM, the DON confirmed that two nurses were expected to sign the Narcotic Card Item Count sheet when accepting or releasing the medication cart and acknowledged that this had not occurred. These findings were true for 2 of 2 medication carts reviewed and affected all residents receiving controlled medications in the facility.
Inadequate Assessment and Indication for Opioid Pain Medication
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when the facility failed to ensure appropriate assessment and indications for opioid pain medication use for one resident with other acute osteomyelitis of the left ankle and foot. The facility’s Pain Management policy dated 12/2/25 required that pain be assessed every shift, recorded on the eMAR, with the pain scale used and the type of pain documented, and that pain management be consistent with professional standards of practice and the resident’s care plan, goals, and preferences. For this resident, there was a physician order for acetaminophen 325 mg, two tablets by mouth every 8 hours as needed for mild acute pain, not to exceed 3000 mg/day. The record showed acetaminophen was administered once on March 8 at 0837 for a pain level of 4, with no further documented administration of acetaminophen from March 9 through March 16. The same resident also had a physician order for Percocet 5-325 mg (oxycodone with acetaminophen), one tablet by mouth every 4 hours as needed for moderate to severe acute pain related to the osteomyelitis diagnosis. However, the medical record documented that Percocet was administered on three occasions—March 13 at 0707, March 15 at 0621, and March 16 at 0625—each time for a documented pain level of 3, which is below the ordered indication of moderate to severe pain. During an interview on March 17 at 12:58 PM, the DON stated that physicians had moved away from using the pain intensity number scale because some residents might report a pain level of 3 when it is really a 6 or 7, indicating a discrepancy between the documented pain scores and the ordered criteria for opioid use.
Improper Labeling of Glucose Control Solutions and Unlocked Medication Cart
Penalty
Summary
The deficiency involves failure to ensure biologicals were labeled when opened and to store medications in locked compartments as required by facility policy and manufacturer instructions. The facility’s policy on storage and expiration dating of medications and biologicals required that once any medication or biological package was opened, manufacturer guidelines for expiration dates be followed. The Assure Prism Blood Glucose Monitoring System QA/QC manual specified that when a control solution bottle is first opened, the discard date (date opened plus three months) must be recorded on the label. Surveyors observed one set of Assure Prism glucose test solutions (CSYF24BN and CSYM26AM) that were not dated when opened and had no expiration date written on the label. An RN stated she did not know how long the test solutions had been opened and used. Review of blood glucose testing logs showed these same solutions were documented as opened and used for testing over multiple months, and the Infection Preventionist confirmed they should be dated when opened and used only for three months. The deficiency also includes failure to keep a medication cart locked when unattended, contrary to the facility’s General Dose Preparation and Medication Administration policy, which required medication carts to be locked when out of sight or unattended. Surveyors observed a Hall 2 medication cart left unlocked and unattended by the medication nurse. Shortly thereafter, an RN was seen pushing a Hoyer lift down the hall toward the medication room and stated the medication cart should have been locked when left unattended. The DON also stated the medication cart should have been locked when not attended by the nurse and acknowledged that it had not been.
Improper Storage of DME and Lift Equipment in Contaminated Out-of-Order Shower Room
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the storage and handling of residents’ durable medical equipment (DME). The facility’s Infection Prevention and Control Program and Plan, revised 6/2/25, required appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipment to reduce risks associated with procedures, medical equipment, and medical devices. Resident #71, admitted with multiple diagnoses including atrial fibrillation, heart failure, and hypertension, was observed on 3/16/26 operating her power wheelchair on the 200 Hall. Later that morning, the 200 Hall shower room, which was marked Out of Order, was observed to have a thick dirty black ring inside the toilet bowl, a dirty brown substance on the floor and walls, and used paper towels on the back of the toilet and on the sink. In this same Out of Order shower room, Resident #71’s power wheelchair was stored, with an open box of cereal in the bag attached to the back of the wheelchair and a Hoyer lift sling placed in the seat, along with a resident lounge shower chair. On subsequent observations, a Hoyer lift and a bariatric shower chair were also found stored in this Out of Order shower room on the 200 Hall. On 3/19/26, the Infection Preventionist stated that staff should not be storing resident equipment in the Out of Order shower room on Hall 200. These observations demonstrated that the facility did not follow its own IPCP requirement for appropriate storage and handling of DME and related equipment, as resident mobility devices and shared lift and shower equipment were stored in a visibly dirty, Out of Order shower room, contrary to the facility’s stated infection control methods.
Failure to Honor DNR/DNI Orders Due to Staff Error
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders. The resident, who had multiple diagnoses including chronic kidney disease and diabetes, was found unresponsive by CNA staff. Nursing staff assessed the resident and determined the code status was DNR. However, an LPN entered the room with a Physician Orders for Scope of Treatment (POST) document, incorrectly identifying the resident as a full code, and initiated CPR. The POST document was later found to belong to a different resident. CPR was stopped only after the ambulance crew arrived and the correct DNR status was confirmed. The resident's physician order, POST, and care plan all documented DNR status, and staff interviews confirmed that CPR should not have been started.
Failure to Properly Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by a missing licensed nurse signature on the narcotic accountability record for one medication cart during a review. The narcotic accountability record, covering a specific period, was found to have only one nurse's signature instead of the required two. Both an RN and the Admissions Nurse confirmed that two nurses should have signed the record when accepting or releasing the medication cart. This lapse was identified during a medication cart review and was limited to one cart, but had the potential to affect all residents receiving controlled medications.
Failure to Honor DNR/DNI Orders
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, resulting in a deficiency. The resident, who had multiple diagnoses including a C2 level cervical spinal cord lesion and chronic kidney disease, was found with agonal respirations and subsequently lost her pulse. Despite having a Physician Orders for Scope of Treatment (POST) in her medical record indicating DNR/DNI status, facility staff initiated CPR and connected her to an automated external defibrillator (AED) without verifying her code status. CPR was continued for 13 minutes until EMS arrived, who then intubated the resident without being informed of her DNR/DNI status. The deficiency was further compounded by the lack of communication among facility staff regarding the resident's code status. The Medical Director and Director of Nursing (DON) were unaware of the resident's DNR/DNI status until after she was transferred to the hospital. The hospital emergency department report confirmed that EMS was not notified of the resident's code status until after intubation and transport. The resident's family later confirmed her DNR/DNI status, stating she should have been allowed to pass naturally. The resident ultimately expired at the hospital.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner, as observed during an initial kitchen inspection. In the walk-in refrigerator, eight individual yogurts were found with expired dates, a sandwich was wrapped in cellophane without a clear label, and an open bag of salad was unlabeled. A dietary aide acknowledged that the expired yogurts should have been discarded and was unaware of the sandwich's intended recipient or the reason for the salad's lack of labeling. During a subsequent inspection, the walk-in freezer contained an opened package of chicken breast and a package of chicken tenders, both undated and sealed with a binder clip, which the Food Service Director confirmed should have been dated. Additionally, multiple ants were observed on the food preparation table, under a dish towel, and inside a logbook. The Food Service Director noted that pest control had been conducted a couple of weeks prior, and the Maintenance Director confirmed that pest control services are provided monthly and as needed. The presence of expired and improperly stored food, along with pest issues, posed a risk of food contamination.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for eight residents, leading to potential negative outcomes due to inaccurate assessments. Resident #4, who was admitted with a diagnosis of Cerebral Palsy, had a physician's order indicating nutrition through a feeding tube, but the MDS assessment incorrectly documented that she did not receive nutrition this way. Similarly, Resident #6, diagnosed with schizophrenia, had a PASRR Level II indicating a major mental illness, but the MDS assessment failed to document this condition. Resident #12, admitted with bipolar disorder and PTSD, had a care plan and PASRR I indicating a major mental illness, yet the MDS assessment incorrectly marked 'No' for serious mental illness. Resident #29, with multiple diagnoses including schizoaffective disorder, had a PASRR II in her medical chart, but the MDS assessment did not reflect this. Resident #40's MDS assessment inaccurately documented the presence of a catheter, which was confirmed not to be in place. Resident #54's MDS assessment failed to document a PASRR II despite its presence in her medical chart. Resident #58, diagnosed with bipolar disease, had a PASRR Level II indicating a serious mental illness, but this was not documented in the MDS assessment. Lastly, Resident #65, with a Dobhoff tube for enteral feedings, had an MDS assessment incorrectly marked for parenteral/IV feeding instead of a feeding tube. These inaccuracies in MDS assessments highlight the facility's failure to ensure accurate resident assessments, potentially impacting resident care and monitoring.
Care Plan Revisions Not Updated for Residents
Penalty
Summary
The facility failed to ensure that residents' care plans were revised to reflect their current needs and interventions, as evidenced by the review of care plans for four residents. Resident #12, who was initially admitted with multiple diagnoses including bipolar disorder and PTSD, had a care plan that inaccurately documented a condition of clostridium difficile, which she no longer had. The Director of Nursing acknowledged that the care plan should have been updated. Resident #23, with diagnoses including heart failure and kidney disease, was observed with Biofreeze at her bedside, but her care plan did not document self-administration of this medication, despite having a physician's order for it. LPN #1 confirmed that the care plan should have included this information. Resident #59, admitted with a history of stroke and benign prostatic hyperplasia, had a physician's order for Calmoseptine Ointment for excoriation, but his care plan did not document this condition or its treatment. LPN #1 stated that the care plan should have included the wounds and treatment orders. Resident #65, with diagnoses including dysphagia and emphysema, had a care plan that inaccurately documented the presence of a Dobhoff tube for enteral feedings, even though it had been discontinued according to a physician's order. The Director of Nursing confirmed that the care plan should have been updated to reflect the discontinuation of the Dobhoff tube.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by several observations of deficiencies in resident rooms and common areas. Specifically, the water temperature in one resident's room was found to be as high as 124 degrees F, exceeding the state regulation range of 105 to 120 degrees F, which poses a risk of burns. Despite rechecks, the temperature remained inconsistent, indicating a failure to maintain safe water temperatures. Additionally, the maintenance director acknowledged that water temperatures should be maintained below 118 degrees F. Further observations revealed multiple issues compromising the cleanliness and homeliness of the environment. These included missing drawer fronts, black substances and hair in showers, missing drywall and baseboards, and light brown splattering on ceilings in resident rooms. In the kitchen, dust and gray substances were found on the ceiling and vents. Similar issues were noted in common areas, with gray fuzzy substances on light fixtures and vents. The maintenance director and administrator acknowledged these issues, indicating a lapse in routine cleaning and maintenance procedures.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to refer residents for further evaluation when diagnosed with major mental illnesses, as required by the Pre-Admission Screening and Resident Review (PASARR) process. This deficiency was identified in four out of seven residents reviewed. Resident #12, diagnosed with bipolar disorder and PTSD, did not have a PASARR Level II evaluation completed despite a positive Level I screen indicating the need for further assessment. Similarly, Resident #51, with a new diagnosis of borderline personality disorder, lacked a PASARR Level II evaluation upon admission and after the new diagnosis. The Director of Nursing (DON) acknowledged these oversights. Resident #60, admitted with Myasthenia Gravis, anxiety, and PTSD, exceeded a 30-day stay without a new Level I PASARR screening or a referral for a Level II evaluation, contrary to the State Operations Manual Appendix PP requirements. Additionally, Resident #219, with schizoaffective disorder, had an incomplete PASARR I that should have triggered a Level II evaluation. The MDS coordinator and DON confirmed the PASARR I was not properly completed or submitted for state review. These failures in the PASARR process could potentially result in residents not receiving necessary specialized mental health services.
Failure to Follow Care Plan for Resident's Bed Mobility
Penalty
Summary
The facility failed to adhere to a comprehensive person-centered care plan for a resident with multiple diagnoses, including hemiplegia, hemiparesis, and seizures. The care plan, dated 11/27/24, specified that the resident required assistance from two staff members for bed mobility due to fragile bones. However, documentation from the resident's medical chart revealed that on multiple occasions, only one CNA or NA assisted the resident with bed mobility. This occurred on several dates, including 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/2/25, 1/5/25, and 1/8/25. On 1/9/25, the Director of Nursing confirmed that the CNAs and NAs should have been following the care plan by using two staff members for assistance.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice, specifically for one resident who was observed during medication administration. The resident, admitted with diagnoses including kidney disease and bladder pain, had a physician's order for a Nicotine Transdermal Patch 14mg to be administered once daily for tobacco use. However, the resident refused the nicotine patch 11 out of 12 times since admission. Despite the facility's policy requiring physician notification after three refusals, there was no documentation that the physician was informed of these refusals. The Director of Nursing confirmed that the physician should have been notified after three refusals, indicating a lapse in following the facility's policy and professional standards of practice.
Deficiencies in Nursing Practice and Documentation
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed for two residents, leading to deficiencies in their care. Resident #12, who was admitted with multiple diagnoses including bipolar disorder and PTSD, was observed with wounds on her left knee. Despite the presence of these wounds, there were no documented physician orders for wound care in her medical record. An LPN observed and treated the wounds without proper orders, acknowledging that there should have been wound care orders documented. Resident #65, admitted with diagnoses including dysphagia and emphysema, was observed using an oxygen concentrator set to 2 liters per minute without wearing his nasal cannula. Although his progress notes indicated continuous oxygen use, there were no documented orders for oxygen in his electronic medical records. Standing orders for oxygen were found in his paper records, but they were not transferred to the electronic system, and nurses failed to document the completion of these orders. An LPN confirmed that the standing orders should have been in the electronic records and documented accordingly.
Improper Use of Power Strip for Medical Device
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards, as observed in the case of a resident with atrial fibrillation who was using sequential compression devices for lymphedema management. A power strip was found in the resident's room, with the compressor for the compression device plugged into it. This practice was against the guidelines documented in the State Operations Manual, which states that power strips should not be used as a substitute for adequate electrical outlets and are not designed for use with medical devices in patient care areas. The Maintenance Director confirmed that the medical device should not have been plugged into a power strip, indicating a lapse in adherence to safety protocols.
Failure to Follow Oxygen Administration Standing Orders
Penalty
Summary
The facility failed to ensure that licensed nurses performed tasks for which they had the necessary knowledge, skills, and competencies, as evidenced by the failure to follow standing orders for oxygen administration. This deficiency was observed in three out of four licensed nurses. The facility's standing orders required that supplemental oxygen be titrated for oxygen saturations below 88%. However, for Resident #41, who had multiple diagnoses including hemiplegia, hemiparesis, and seizures, there were multiple instances of low SpO2 readings (ranging from 85% to 86%) recorded over several days without any documented follow-up or intervention by the nursing staff. Interviews with LPN #1 and the DON confirmed that the nursing staff did not follow the standing orders or notify the physician regarding the low SpO2 levels.
Medication and Supply Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately for two residents, leading to potential risks. Resident #51, who has multiple diagnoses including diabetes and post-traumatic stress disorder, was observed with medication cups containing tablets left on her bedside table. The resident stated that the nurse left the medication for her to take later. However, there was no documentation of a self-administration assessment or care plan allowing for self-administration of medications. The Director of Nursing confirmed that medications should not have been left at the bedside without proper assessment and care planning. Resident #58, diagnosed with paraplegia, malnutrition, and bipolar disease, was found with stoma powder, ostomy/wound supplies, and wound scissors left out in the room. The resident mentioned that nurses regularly leave these items out. The wound nurse acknowledged that these supplies should not have been left in the resident's room. These observations indicate a failure to adhere to the facility's policy on medication and supply storage, potentially compromising resident safety.
Unqualified Food Service Director in Facility
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as required by the State Operations Manual Appendix PP. The manual specifies that the director must meet certain qualifications, such as being a Certified Dietary Manager, a Certified Food Service Manager, or having similar national certification. Alternatively, the director could have an associate's or higher degree in food service management or hospitality, or have two or more years of experience in the position within a nursing facility setting, along with a completed course of study in food safety and management by a specified date. On January 9, 2024, it was confirmed through interviews with the Food Service Director and the Registered Dietician that the current Food Service Director did not meet these regulatory requirements. This deficiency had the potential to affect all residents receiving meals prepared in the facility's kitchen.
Infection Control Deficiencies in Equipment and Catheter Management
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by several observations. For oxygen and respiratory equipment, Resident #51's oxygen concentrator was found with a white substance and fuzz on the filter, and Resident #22's nebulizer mouthpiece and tubing were left uncovered on a bedside table. These observations were contrary to the facility's policy, which requires oxygen supplies to be stored in a labeled bag when not in use and concentrators to be cleaned weekly. Additionally, the external filter should be checked daily and cleaned weekly, which was not adhered to in these cases. Further deficiencies were noted in the management of indwelling urinary catheters and glucometer cleaning. Resident #59 and Resident #222 had catheter bags resting on the floor, violating the facility's policy that prohibits such practice. In terms of glucometer cleaning, LPN #3 and RN #2 did not follow the proper cleaning protocol, which requires using two towelettes for cleaning and disinfecting, ensuring the surface remains wet for the recommended contact time. Both staff members used only one towelette and did not adhere to the required cleaning procedure, as confirmed by their statements and the Director of Nursing's acknowledgment.
Inconsistent Glucometer Calibration
Penalty
Summary
The facility failed to ensure the proper calibration of glucometers, which is essential for maintaining the accuracy of blood glucose test results. Specifically, the glucometer solution tests were not consistently performed for two medication carts, Hall 300 and Hall 400, as required by the Assure Prism Blood Glucose Monitoring System manual. The manual specifies that control solution tests should be conducted under various circumstances, including when using the meter for the first time, when opening a new bottle or box of test strips, if the meter or test strips do not function properly, if the resident's symptoms are inconsistent with test results, or if the meter is dropped or damaged. Upon review on January 8, 2025, it was found that the Hall 400 glucometer solution test was not consistently done from December 2024 to January 2025, and the Hall 300 glucometer solution test was not consistently done for January 2025. An LPN confirmed that these tests should have been conducted daily by the night shift.
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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