Life Care Center Of Sandpoint
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandpoint, Idaho.
- Location
- 1125 North Division Avenue, Sandpoint, Idaho 83864
- CMS Provider Number
- 135127
- Inspections on file
- 19
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Life Care Center Of Sandpoint during CMS and state inspections, most recent first.
Surveyors identified failures in maintaining kitchen and food storage cleanliness, including water and ice accumulation in the freezer, dust in the refrigerator, and black residue in the ice machine. Staff food was also found stored with resident food, and cleaning schedules were not adequately followed, as confirmed by staff interviews.
During a COVID-19 outbreak, the facility did not conduct facility-wide testing as directed by the local Health Department, failed to ensure proper PPE use and hand hygiene among staff, and did not follow isolation protocols for residents with or exposed to COVID-19. Residents were observed leaving isolation without masks, using shared water fountains, and eating in communal areas without staff intervention. Medical equipment was also stored unsafely, and infection control policies were not consistently followed.
The facility did not have policies and procedures in place for administering flu and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
The facility did not consistently offer, administer, or re-offer COVID-19 vaccinations to eligible residents, as shown by missing documentation of vaccine offers, re-offers after refusal, and administration after consent. Staff interviews confirmed there was no set process for re-offering the vaccine and no recent vaccine clinics, resulting in lapses in vaccination practices for several residents with significant health conditions.
A resident with paralysis, diabetes, and dysphagia was not served breakfast at the same time as others at the same table, leading to the resident leaving the dining room before eventually receiving his meal. Staff interviews confirmed this was due to the way fried egg orders were prepared, and facility policy required residents at the same table to be served together.
A resident with multiple complex medical conditions was found living in a room that was soiled and unkept, with pooled liquid on the floor, overflowing trash, and untidy bedding. Staff interviews confirmed that housekeeping had not yet cleaned the room after lunch, despite the room's known need for more frequent cleaning due to food debris left by a roommate.
Two residents with serious mental health diagnoses had their MDS assessments inaccurately coded regarding PASRR Level II status, despite documentation confirming their evaluations. The MDS Coordinator acknowledged that the assessments should have indicated completed PASRR Level II screenings.
A resident with diagnoses of PTSD and anxiety was not referred for a PASRR Level II evaluation as required. The initial PASRR Level I screening and admission MDS assessment both failed to identify the resident's mental health conditions, and no further PASRR evaluations were completed. Staff later acknowledged the oversight and the need for an updated evaluation.
The facility did not update the care plan for a resident after a positive COVID-19 diagnosis and failed to hold or document required care conferences for two residents with complex medical conditions, as confirmed by staff and record review.
A resident with chronic pain and multiple diagnoses received PRN Oxycodone at inconsistent dosages due to physician orders lacking clear parameters for each dose. Nursing staff administered 5 mg, 10 mg, and 15 mg doses for overlapping pain levels, and the ADON confirmed that staff did not seek clarification from the physician, resulting in inconsistent pain management practices.
A resident with complex medical needs was observed to have an empty humidifier reservoir, incorrectly stored nebulizer tubing, and undated oxygen tubing. Staff interviews confirmed that required procedures for monitoring and replacing respiratory equipment were not followed.
A resident with a history of Wegener's Granulomatosis and renal involvement did not have required post-dialysis assessments and documentation completed by staff. Facility policy required immediate monitoring and documentation of the access site and vital signs after dialysis, but these were not recorded on multiple occasions, as confirmed by the ADON.
Three residents received incorrect medication dosages when staff failed to follow physician orders for pain and blood pressure medications, resulting in administration of higher doses of Oxycodone and inappropriate administration of Midodrine despite blood pressure parameters. These errors were confirmed by nursing leadership upon review.
A resident was administered Sevelamer Carbonate by an LPN according to a revised physician's order for one tablet, but the pharmacy label still indicated a previous order for two tablets before meals and at bedtime. Both the LPN and DON confirmed the label had not been updated to match the current order.
A resident with COPD and diabetes had outdated physician orders in their medical record regarding insulin administration. The record was not updated to reflect the current use of long-acting insulin after the resident refused sliding scale injections, as confirmed by the DON.
The facility failed to ensure a qualified dietary manager was in place, as the Dietary Manager (DM) had not completed certification requirements despite being in the role for over a year. The DM admitted to not scheduling the certification test and was unable to provide documentation of a Serve Safe certificate. The Registered Dietician (RD) was assisting with assessments weekly, but the deficiency in the DM's qualifications remained unaddressed.
A resident was found to be self-administering an over-the-counter supplement without an assessment or physician's order, contrary to facility policy. The resident, who had multiple health conditions, was observed with the supplement in her room, and staff were unaware of her self-administration. The facility's policy required an assessment by the Interdisciplinary Team and a physician's order before allowing self-administration, which was not conducted.
A facility failed to accurately assess a resident's MDS, documenting adequate hearing and clear speech despite the resident's chronic hearing impairment and garbled speech. Observations showed the resident used a whiteboard for communication. Interviews with the MDS Coordinator and DON confirmed the assessments were incorrect, as the resident was deaf and used alternative communication methods.
A resident with Parkinson's Disease and other conditions experienced a delay in receiving toileting assistance, resulting in a urine incontinent episode. The resident waited 1.5 hours for help, which was only provided after her son intervened. The delay led to feelings of anger and shame for the resident.
A resident with specific dietary preferences, including no meat and no carrots, was not accommodated by the facility, leading to dissatisfaction and potential nutritional issues. The resident was repeatedly served meals that did not align with her preferences, and staff interviews revealed a lack of communication and awareness regarding her dietary needs.
A facility failed to ensure an ongoing activity program for a resident with Alzheimer's and dementia, lacking a care plan for activities despite documented preferences. The resident's admission assessment was completed five months late, and staff confirmed the absence of a necessary care plan focus on activities.
A resident with hemiplegia required two-person assistance for transfers, as per her care plan. However, a CNA transferred her alone, resulting in the resident's knee hitting the bed and causing increased pain. The resident required more frequent pain medication following the incident. The DON confirmed the care plan was not followed, leading to a deficiency in accident prevention.
Deficiencies in Food Storage, Cleanliness, and Staff-Resident Food Separation
Penalty
Summary
Surveyors observed multiple deficiencies related to food storage, cleanliness, and separation of staff and resident food. During inspections, the walk-in freezer was found to have water droplets on the ceiling, some frozen and some dripping, with a layer of ice on open boxes of ice cream sandwiches and other closed boxes of food. Ice had accumulated on the floor, and maintenance had been attempting to fix the condenser for a month without resolution. The walk-in refrigerator was also noted to have dust particles blowing from the fan covers and hanging from the ceiling, with maintenance having missed cleaning certain areas despite recent filter replacement. The main ice machine contained an accumulation of black residue on the inner upper area, even though it had reportedly been cleaned the previous month. Additionally, the LTC resident refrigerator's freezer area had visible food residue, and the Housekeeping Supervisor was unable to confirm when it was last cleaned. Further, staff food was found stored in the LTC resident refrigerator, specifically leftover fried chicken in a refrigerator drawer, contrary to facility policy. The RCM confirmed that staff food should not be stored with resident food. These findings were based on direct observation and staff interviews, and they reflect failures to maintain proper food storage, cleanliness, and separation of staff and resident food as required by FDA Food Code standards.
Failure to Implement Comprehensive Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, resulting in multiple deficiencies. Surveyors found that the facility did not conduct facility-wide COVID-19 testing as advised by the local Health Department during an outbreak. Only residents and staff in one section (Team 3) were tested, while those in another section (Team 4) were not, and only symptomatic or exposed staff were tested. The facility leadership stated they did not review the Health Department's email with the testing guidance until after the surveyors' inquiry. Observations revealed improper use of personal protective equipment (PPE) by staff, including a housekeeper who did not fully secure her gown, failed to change gowns and masks between isolation rooms, and did not perform hand hygiene when changing gloves. Additionally, residents were not offered hand hygiene before meals in the dining hall, contrary to facility policy. Medical equipment, such as a nebulizer mask, was found stored unsanitarily next to a soiled urinal in a resident's room. Several residents with COVID-19 or exposed to COVID-19 were not properly isolated or encouraged to follow infection control protocols. One resident with a positive COVID-19 test was observed leaving her room without a mask and using a community water fountain, while her room door was left open despite care plan instructions. Another resident, who was a roommate of a COVID-19 positive individual, was allowed to eat in the dining room without a mask and without staff intervention. Staff confirmed that care plans and infection control measures were not consistently followed.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Failure to Offer, Administer, and Document COVID-19 Vaccinations for Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccinations were consistently offered, administered, and re-offered to eligible residents, as required by CDC guidance. Record review and interviews revealed that for four residents over the age of 65 with multiple comorbidities, there was either no documentation of the vaccine being offered, no documentation of re-offering after initial refusal, or no documentation of vaccine administration after consent was obtained. Specifically, one resident refused the vaccine, but there was no record of it being re-offered; another had no documentation of the vaccine being offered or consent obtained; a third refused the vaccine, but again, there was no record of a re-offer; and a fourth had consent provided by a POA, but there was no documentation of vaccine administration. Interviews with facility staff, including the Infection Preventionist (IP) and MDS Coordinator, confirmed gaps in the process, such as the absence of a set schedule for re-offering the vaccine and lack of recent vaccine clinics. The last documented COVID-19 vaccine clinic was held in 2022-2023, and there was no evidence of ongoing efforts to ensure residents remained up to date with current vaccine recommendations. These findings were based on record review, CDC guidance, and staff interviews.
Resident Not Served Meal Concurrently with Tablemates
Penalty
Summary
A deficiency was identified when a resident with right side paralysis, diabetes, and dysphagia was not served his meal at the same time as other residents seated at his table during a dining observation. While two other residents at the table received their meals at 8:22 AM, the resident in question was not served at that time. He was observed looking at the meals of the other residents, turning his wheelchair to observe others eating, shaking his head, and leaving the dining room before eventually returning to receive his meal at 8:43 AM. Staff interviews revealed that the dietary manager prepared fried egg orders together, resulting in this resident consistently receiving his meal after others at the table had already been served. The executive director confirmed that it was not facility policy to serve residents at the same table at different times and acknowledged that the resident should have been served concurrently with the others. This failure to serve the meal in a timely and dignified manner was found to be inconsistent with the facility's dignity policy.
Failure to Maintain a Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was observed to be soiled and unkept, failing to provide a safe, clean, comfortable, and homelike environment as required by facility policy. During an observation with the Resident Care Manager (RCM), liquid was found pooled on the floor between the beds, an overflowing trashcan with wadded tissues was present, and a wadded tissue was seen on the floor near the liquid. Additionally, the resident's bedding was wadded up and piled at the end of the bed. The RCM confirmed that housekeeping had not yet cleaned the room at the time of observation and acknowledged that the bedding should not have been left in that condition. The resident involved had multiple diagnoses, including protein-calorie malnutrition, right-sided paralysis following a stroke, failure to thrive, and dementia. The RCM noted that the resident's roommate frequently puts food on the ground, and housekeeping is aware that the room requires more frequent cleaning. The Housekeeping Manager stated that all rooms are cleaned daily, but this particular room is scheduled for cleaning twice per day due to its tendency to become dirty after meals. However, at the time of the surveyor's observation, housekeeping had not yet cleaned the room after lunch, resulting in the unsanitary and unhomelike conditions observed.
Inaccurate MDS Assessments for PASRR Level II Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected their PASRR (Preadmission Screening and Resident Review) Level II status, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with diagnoses including schizophrenia, anxiety, and depression, the PASRR Level II screening documented a primary diagnosis of schizophrenia with medication management. However, the resident's Annual MDS assessment incorrectly indicated that a PASRR Level II had not been completed. The MDS Coordinator confirmed that this was inaccurate and that the assessment should have been marked as completed. Similarly, another resident with diagnoses of bipolar disorder and depression had a PASRR Level II screening confirming these conditions and ongoing medication management. Despite this, the resident's Annual MDS assessment was also inaccurately coded as not having a PASRR Level II evaluation. The MDS Coordinator acknowledged the error upon review. These inaccuracies were identified through record review and staff interviews.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with diagnosed mental disorders, including PTSD and anxiety, to the appropriate state-designated authority for a PASRR Level II evaluation. Upon admission, the resident's PASRR Level I screening inaccurately documented that the resident did not have any mental illnesses, despite medical records indicating otherwise. The admission MDS assessment also reflected that the resident did not have a major mental illness, and no further PASRR evaluations were found in the medical record. Staff confirmed that the PASRR Level I was inaccurate and should have been updated at the time of admission, and acknowledged that a PASRR Level II evaluation should have been completed.
Failure to Update Care Plans and Hold Timely Care Conferences
Penalty
Summary
The facility failed to update care plans and conduct timely care conferences for two residents. For one resident with a history of brain injury, brain bleeding, and right-side paralysis, the care plan was not updated to reflect a new diagnosis of COVID-19, despite the resident testing positive and this being verified by the DON and IP. Staff confirmed that the care plan should have been updated to include the respiratory infection but was not. Another resident with diagnoses including duodenal cancer and heart failure reported not recalling any care plan conference meetings. Record review showed that care conferences were only documented twice within a 16-month period, with no conferences held for over seven months. The DON acknowledged that additional care conferences should have occurred and could not provide documentation for the missing meetings.
Failure to Follow Professional Standards for PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for a resident with multiple diagnoses, including diabetes, right hip fracture, and cognitive communication deficit, who experienced chronic pain. The resident's care plan documented ongoing pain and a goal for pain relief, but physician orders for Oxycodone were written for three different dosages (5 mg, 10 mg, and 15 mg) every four hours as needed, without specifying parameters for when each dose should be administered. Medication administration records showed that nurses gave varying doses of Oxycodone for overlapping pain levels, with 5 mg given for a pain level of 5, 10 mg for pain levels 4-6, and 15 mg for pain levels 2-8. The ADON confirmed that nurses were inconsistent in administering the medication and had not contacted the physician to clarify the dosing parameters.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide appropriate respiratory care for a resident with multiple diagnoses, including aortic dissection, asthma, and dementia. During observation, the resident's humidifier reservoir was found empty, the nebulizer tubing was not stored correctly, and the oxygen tubing was not dated. Staff interviews revealed that oxygen tubing should be replaced and dated weekly, but it was unclear when this had last occurred. Additionally, the humidifier reservoir was supposed to be monitored every shift and should not have been empty, and the nebulizer tubing should have been stored in a plastic bag, which was not done.
Failure to Complete Post-Dialysis Assessments and Documentation
Penalty
Summary
The facility failed to ensure that post-dialysis assessments were completed and accurately documented for a resident who required dialysis services. According to the facility's policy, staff were required to immediately monitor and document the status of the resident's access site, including vital signs and assessment for complications such as bleeding, redness, or edema, upon the resident's return from dialysis. Record review showed that for multiple dates, the post-dialysis section of the Pre/Post Dialysis Communication Form was not completed, and there was no documentation of the required assessments. The Assistant Director of Nursing confirmed that staff did not complete the necessary documentation, which should have included vital signs and the condition of the access site. The resident involved had a history of Wegener's Granulomatosis with renal involvement and morbid obesity.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by the administration of incorrect medication dosages to three residents. For one resident with a right femur fracture and cognitive communication deficit, the MAR showed that Oxycodone was administered at a higher dose than ordered for the reported pain level on multiple occasions, contrary to the physician's specific instructions regarding pain scale and dosage. Another resident with orthopedic aftercare, diabetes, and cognitive communication deficit received Oxycodone at a higher dose than prescribed for their documented pain level, again not following the physician's order for pain management. A third resident, diagnosed with Wegener’s Granulomatosis with renal involvement and morbid obesity, was prescribed Midodrine to be held if systolic blood pressure exceeded 120. Despite this, the MAR documented multiple instances where the medication was administered when the resident's systolic blood pressure was above the specified threshold. These actions were confirmed by facility nursing leadership upon review of the records, indicating that the physician's orders were not followed in these cases.
Medication Labeling Discrepancy Identified
Penalty
Summary
The facility failed to ensure that the pharmacy label for a resident's medication matched the current physician's order. During medication administration, an LPN was observed giving one tablet of Sevelamer Carbonate to a resident, while the pharmacy label on the medication bottle indicated a dosage of two tablets before meals and at bedtime. The LPN confirmed that the physician's order had been changed to one tablet, but the label had not been updated to reflect this change. The Director of Nursing also acknowledged that the label should have been changed to match the physician's order. This discrepancy was identified through observation and staff interviews.
Failure to Maintain Accurate Clinical Records for Insulin Administration
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident with multiple diagnoses, including COPD and diabetes. The resident's medical record contained outdated physician orders, specifically regarding insulin administration. Although the resident was no longer receiving sliding scale insulin due to refusal of injections and had been placed on long-acting insulin, the clinical record was not updated to reflect the current physician's order. The Director of Nursing confirmed that the record should have been updated to match the resident's current treatment regimen.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to ensure that there was a qualified dietary manager, which could potentially affect all residents consuming food prepared in the facility's kitchen. The job description for the Food Service Director - Certified Dietary Manager required completion of a Certified Dietary Manager (CDM) or state-approved course in food services, current certification as a CDM, and maintenance of active certification in good standing. Additionally, the position required one year of experience in post-acute food service and a minimum of two years of supervisory experience. However, during an interview, the Dietary Manager (DM) admitted to completing the coursework for certification but had not scheduled the test, indicating a lack of certification for over a year since moving from the position of cook to manager of the facility's dietary services. Further interviews revealed that the Registered Dietician (RD) was employed on a weekly basis to assist with assessments until a new dietician started, visiting the facility once a week and checking the kitchen once a month. The Administrator confirmed the DM's lack of certification and acknowledged the need to schedule the test. Additionally, the DM mentioned having a Serve Safe certificate but was unable to locate it, and online records indicated the need to retake the test. A review of the DM's personnel file did not include documentation of a Serve Safe certificate, further highlighting the deficiency in meeting the required qualifications for the position.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a resident was assessed for safety to self-administer an over-the-counter supplement medication. This deficiency was identified for a resident who was cognitively intact and had multiple diagnoses, including diabetes, paroxysmal atrial fibrillation, chronic kidney disease, heart failure, and muscle weakness. The resident was observed with a bottle of Chanca [NAME] on her bedside table, which she stated she used daily for pain management. However, there was no physician's order, medication administration record, or comprehensive care plan documenting the resident's self-administration of this supplement. Interviews with facility staff revealed a lack of awareness regarding residents self-administering medications. A CNA and an LPN both stated they were not aware of any residents self-administering medications or having over-the-counter medications in their rooms. The LPN subsequently removed the supplement from the resident's room and secured it in the medication storage room. The facility's policy required an assessment by the Interdisciplinary Team and a physician's order before allowing self-administration, which was not followed in this case.
Inaccurate MDS Assessment for Resident with Hearing Impairment
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including diabetes, COPD, hearing loss, and hemiplegia and paraplegia following a stroke, was inaccurately documented in quarterly MDS assessments as having adequate hearing and clear speech. However, the resident's care plan indicated a chronic hearing impairment, and observations revealed that the resident was unable to hear when called and communicated using a whiteboard due to garbled speech. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the MDS assessments were incorrectly coded, as the resident was deaf and relied on alternative communication methods.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance and incontinence care to a resident, leading to a deficiency in the care provided for activities of daily living. The resident, who was admitted with multiple diagnoses including Parkinson's Disease, scoliosis, and muscle weakness, required assistance for toileting as documented in her care plan. Despite being cognitively intact and independent with toileting hygiene, the resident experienced a significant delay in receiving assistance, which resulted in a urine incontinent episode. The incident occurred when the resident activated her call light for assistance, but it took staff one and a half hours to respond. The delay was only addressed after the resident's son called the nurse's station to report the need for assistance. During an interview, the resident expressed feelings of anger, disgust, and shame due to the prolonged wait and subsequent incontinence. A CNA confirmed the delay, stating that she responded to the call after being informed by the resident's son, finding the resident flustered and wet in bed.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences, leading to dissatisfaction and potential nutritional issues. Resident #21, who was cognitively intact and had specific dietary preferences of no meat, no orange juice, and no carrots, was repeatedly served meals that did not align with these preferences. On multiple occasions, the resident was offered scrambled eggs as a substitute for meat, and was served carrots despite her preference against them. The facility's policy stated that residents' preferences should be followed to promote food acceptance, but this was not adhered to in the case of Resident #21. Interviews with staff revealed a lack of communication and awareness regarding the resident's dietary needs. The Registered Dietitian (RD) was unaware of the resident's preference for not eating meat, and the cook admitted to overlooking the resident's diet card. The Dietary Manager acknowledged the need for better communication and education among the staff regarding non-meat meal options. The administrator also recognized the communication failure concerning the resident's food choices and the lack of appropriate protein substitutes being provided.
Failure to Provide Individualized Activity Program for Resident with Dementia
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to meet the interests and support the physical, mental, and psychosocial well-being of each resident, specifically for a resident with Alzheimer's Disease and dementia. The resident, who was admitted with multiple diagnoses including cognitive communication deficit, did not have a care plan that included documentation or interventions for participation in activities. The resident's admission activities assessment, completed five months after admission, indicated preferences for activities such as pets/animals, arts and crafts, and board games, but there was no documentation of participation in these activities or acknowledgment of the resident's preferred nickname. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed the absence of a care plan focused on activities for the resident, which should have been in place, especially for a resident with dementia. Additionally, the admission assessment was completed significantly late, five months after the resident's admission, rather than during the initial admission process. This oversight in care planning and assessment completion contributed to the deficiency in meeting the resident's activity needs.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident's care plan was followed, resulting in a deficiency related to accident prevention. Resident #24, who had multiple diagnoses including hemiplegia and hemiparesis following a stroke, required two-person assistance for transfers as documented in her care plan. However, during a transfer, a CNA attempted to transfer Resident #24 alone using a pivot method, which was against the care plan's directive for two-person assistance with a Hoyer mechanical lift. This improper transfer led to Resident #24's left knee hitting the metal side of the bed, causing increased pain and swelling. Following the incident, Resident #24 experienced heightened pain levels, requiring more frequent administration of pain medication. The CNA involved admitted to transferring the resident alone and acknowledged the care plan requirement for two-person assistance. The Director of Nursing confirmed that the care plan was not followed, and the incident was documented as a soft tissue injury, with no fractures identified. The failure to adhere to the care plan resulted in the potential for more than minimal harm to Resident #24.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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