Lincoln County Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shoshone, Idaho.
- Location
- 511 East Fourth Street, Shoshone, Idaho 83352
- CMS Provider Number
- 135056
- Inspections on file
- 16
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Lincoln County Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one room, the wall behind a bed had multiple strips of missing paint and numerous holes, and the ceiling near the curtain track had exposed sheetrock. Another room had a damaged windowsill with exposed rebar. In common areas, a dining room vent was covered with a black substance, and a large light fixture above the nurse’s station lacked a cover and had long, thick cobwebs. The Maintenance Supervisor reported difficulty repairing concrete walls, noted that a resident had recently moved into one of the damaged rooms, and stated that housekeeping should have cleaned the cobwebs and vent.
Surveyors identified multiple failures in medication labeling, dating, and storage, including an illegible lorazepam label in the refrigerator, an opened tuberculin vial and a Hepatitis B vaccine syringe improperly stored, and a non–permanently affixed locked box containing insulin and narcotics in the medication refrigerator. In a medication cart, loose unlabeled pills and various identified tablets were found in drawers, and a bottle of glucose test strips in use lacked an open date despite manufacturer instructions. An unattended medication cart was also observed with a pill on the floor nearby, which an LPN later admitted she had dropped and not properly located and destroyed.
The facility did not obtain informed consent before starting antidepressant therapy for two residents. One resident with heart failure and anxiety received Citalopram without any signed informed consent on file. Another resident with a lumbar fracture, depression, and repeated falls received Sertraline before an informed consent form was signed, with the consent only completed several days after the medication was ordered. The RNC confirmed that, per facility policy, informed consent for antidepressant use should have been obtained prior to administration in both cases.
The facility failed to follow its self-administration of medications policy by not obtaining an IDT assessment or documenting approval before allowing a resident to keep and use Calcitonin nasal spray in their room. The policy required that residents may self-administer medications only if the IDT determines it is clinically appropriate and safe, with this decision documented in the medical record and care plan. However, a resident was observed with Calcitonin nasal spray on the overbed table and reported self-administering it as needed, while record review showed no IDT assessment or care plan authorization. A Regional Nurse Consultant confirmed the resident should not have had the medication in the room and had not been assessed for self-administration.
Surveyors found that staff failed to keep call lights within reach for two residents, contrary to facility policy requiring accessible call lights to ensure timely responses to needs. One resident with COPD and dementia was in bed with the call light hanging under the foot of the bed, out of reach. Another resident with a lumbar fracture and history of repeated falls was seated in a recliner while the call light was draped over an overbed table pushed against the bed on the opposite side of the room, also out of reach. A CNA and the RNC both acknowledged that call lights should have been within reach and were not in these cases.
The facility failed to ensure accurate MDS assessments when two residents were incorrectly coded as having daily physical restraints in section P0100, despite observations showing no restraints in their beds or wheelchairs. One resident with epilepsy and dementia was seen in a wheelchair without restraints, while another resident with diabetes and an above-the-knee amputation was observed in bed using only a trapeze bar for repositioning. The DON and MDS coordinator later acknowledged that the restraint coding on both MDS assessments was incorrect.
A resident with COPD, bipolar disorder, PTSD, and other serious mental illnesses was admitted and care planned as meeting PASRR Level II criteria, but the facility did not complete a PASRR Level I screen until more than eight months after admission. That Level I identified multiple major mental illnesses and instructed that the case be forwarded to the state-designated authority for a PASRR Level II evaluation. At the time of survey, there was no documentation of a completed PASRR Level II, and the RNC confirmed that the facility lacked the required Level II evaluation despite policy and federal requirements that such screenings occur prior to admission and be used in assessment and care planning.
The facility did not follow its baseline care plan policy requiring that a written summary of the baseline care plan be given to the resident and/or representative and that this be documented in the medical record. For three newly admitted or readmitted residents with conditions including muscle wasting with respiratory failure, Parkinson’s disease with prostate cancer, and a stable lumbar fracture with repeated falls, there was no documentation that a baseline care plan was provided or discussed. During interview, the RNC acknowledged that there was no record showing these residents or their representatives had received copies of their baseline care plans.
A resident with ESRD and diabetes who received hemodialysis three times weekly had a care plan requiring hemodialysis and administration of medications as ordered, but the facility failed to maintain complete dialysis communication documentation and to update an antihypertensive order per dialysis instructions. Dialysis documentation indicated the resident’s Amlodipine dose should be decreased to 5 mg daily, yet the medical record continued to reflect a 10 mg dose on specific days with hold parameters, and the change was never entered. Dialysis communication forms for two treatment dates were also missing, and both the DON and Regional Nurse Consultant confirmed the Amlodipine dose in the record was incorrect and that the dialysis communication sheets were not present.
The facility did not ensure that daily postings of nurse staffing accurately reflected the actual hours worked by licensed and unlicensed nursing staff. Although facility policy required posting direct care daily staffing numbers for each shift, surveyors found that posted staffing information over several months was not adjusted when scheduled hours differed from actual hours worked. The RNC and DON acknowledged that they did not update the posted staffing with actual hours, only the internal daily assignment sheets, resulting in inaccurate publicly posted staffing information for all shifts.
Surveyors found that meals were not consistently palatable, attractive, or maintained at safe and appetizing temperatures. Residents reported that food was often cold, tasteless, and not nutritious, and that trays, particularly those delivered to rooms, lacked condiments, with dinner described as the worst meal. Observation of a lunch service showed discrepancies between the posted menu and the food actually served, absence of garnishes or condiments, and a test tray with bland scalloped potatoes and gravy, under-temperature green beans, and no beverage. The Dietary Manager stated that frozen foods were used and often lacked flavor, and that only one staff member was scheduled for the dinner meal service each day.
Surveyors found that kitchen staff failed to follow professional standards for food storage, labeling, and distribution, including opened refrigerated and frozen items without proper use-by dates and undated baked goods in the pantry. Dietary trays delivered to resident rooms contained uncovered food items such as gelatin and sliced cake, and the dietary manager acknowledged not being aware that all tray food must be covered. Inspectors also noted that the same daily cleaning log was reused and marked completed for an entire week instead of being replaced, as confirmed by the dietary aide and dietary manager.
Surveyors found that residents were served meals in the dining room without being offered required hand hygiene before eating, despite facility policy mandating handwashing or alcohol-based hand rub use before handling food. A CNA and the DON both acknowledged that residents’ hands should have been sanitized prior to meals. Additional observations showed a housekeeper transporting clean gowns uncovered in a hallway and significant visible buildup of white and grey fuzzy substances on pipes, wires, equipment, and chemical buckets in the laundry area, with the housekeeper stating there was no formal cleaning schedule in place.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, as required by the facility’s Homelike Environment policy revised in February 2021. Observations showed multiple areas of disrepair and uncleanliness in resident rooms and common areas. In one resident room, the wall behind the bed had four strips of missing paint with four holes in each strip, along with multiple additional small holes. The ceiling near the curtain railing in the same room had two areas of missing sheetrock paper measuring approximately 1 x 2 inches and 1 x 3 inches. In another resident room, part of the bottom right corner of the windowsill, approximately 1.5 x 2.5 inches, was missing, exposing the lower part of the rebar. Additional observations in common areas included a dining room vent covered with a black substance and a large light fixture above the nurse’s station that lacked a cover and had two long, thick cobwebs hanging from the light fixture frame. During an interview, the Maintenance Supervisor stated that the walls are concrete and difficult to repair around the window when beds break pieces off, and that the resident in one of the affected rooms had just moved in and he had not yet had time to fix the wall behind the bed. He also stated that housekeeping should have cleaned the cobwebs on the light at the nurse’s station and the vent in the dining room.
Improper Medication Labeling, Dating, and Storage in Medication Room and Cart
Penalty
Summary
The deficiency involves failure to ensure medications and biologicals were properly labeled, dated, and stored in accordance with facility policy and professional standards in both the medication room and a medication cart. In the medication room, surveyors observed a bottle of liquid lorazepam in the refrigerator with an illegible label on both the bottle and box, and the LPN present was unsure whether it should be refrigerated. A vial of tuberculin purified protein derivative was found with an open date of 11/24/25, and the LPN did not know how long it remained usable after opening. A Hepatitis B vaccine syringe with an expiration date of 7/7/25 was also stored in the refrigerator, and the LPN acknowledged it should not have been there. A metal box containing insulin and narcotics from the pharmacy was found in the refrigerator; it was locked but not permanently affixed, and staff stated the narcotics could not be moved to the refrigerator’s lock box due to pharmacy key and assignment issues. The DON later confirmed the narcotics box should have been permanently attached to the refrigerator. In the west hall medication cart, surveyors found multiple loose, unlabeled pills in drawers, including three small round white pills and several identified tablets (duloxetine, Lasix, atorvastatin in multiple strengths, divalproex, pantoprazole, and quetiapine), and the LPN acknowledged these loose pills should not have been in the cart. A bottle of Evencare ProView glucose test strips in use for a resident’s blood sugar check lacked an open date, and the RN using them stated the bottle should have had an open date but was unsure how long the strips were good after opening, despite the operator’s manual specifying dating and discard timeframes. Additionally, an unattended medication cart was observed near the nurses’ station with a round white pill on the floor nearby; the LPN later stated she had dropped the medication earlier, could not find it, and admitted she should have moved the cart to locate and destroy the medication but had not done so.
Failure to Obtain Informed Consent Before Initiating Antidepressant Medications
Penalty
Summary
The facility failed to obtain informed consent prior to initiating psychotropic (antidepressant) medications for two residents reviewed for unnecessary medications. The facility’s Medication Therapy policy required that each resident’s medication regimen include only necessary medications and that medication use be consistent with the individual’s condition, prognosis, values, wishes, and responses to treatment. Resident #1, admitted and later readmitted with multiple diagnoses including heart failure and anxiety, had a physician order dated 3/1/26 for Citalopram Hydrobromide 20 mg by mouth once daily, but the Resident Nurse Coordinator (RNC) confirmed on 4/13/26 that there was no signed Informed Consent for Use of Antidepressant Medications for this order. Resident #35, admitted and later readmitted with multiple diagnoses including a stable lumbar vertebra fracture, depression, and repeated falls, had a physician order dated 4/1/26 for Sertraline HCl 200 mg by mouth at bedtime; the medical record contained an informed consent for use of antidepressant medication signed and dated 4/10/26, and on 4/13/26 the RNC stated that this informed consent should have been signed before the resident received the medication but was not.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that residents were initially assessed by the interdisciplinary team (IDT) to determine if they were safe to self-administer medications, as required by facility policy, for one resident. The facility’s Self-Administration of Medications policy, revised February 2021, stated that residents have the right to self-administer medications only if the IDT determines it is clinically appropriate and safe, and that such determinations must be documented in the medical record and care plan. During observation, a surveyor noted that Resident #35 had Calcitonin nasal spray on her overbed table; the resident reported that she kept it in her room for use when she needed it and that she had used it before coming to the facility. Review of the resident’s medical record and care plan showed no documentation of an IDT assessment or authorization for self-administration of medications. The Regional Nurse Consultant confirmed that the resident should not have had the Calcitonin nasal spray in her room and that no IDT assessment for self-administration had been completed.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents’ call lights were within reach, as required by the facility’s “Answering the Call Light” policy, version 1.3, which states that call lights must be accessible to residents to ensure timely responses to their requests and needs. For one resident with COPD and dementia, the resident was observed lying in bed with the call light plugged into the wall and hanging down the wall under the foot of the bed, not within the resident’s reach. The resident was unable to independently reach the call light. A CNA later confirmed that this resident’s call light should have been within reach and had not been. Another resident, with a history including a stable lumbar vertebra fracture and repeated falls, was observed sitting in a recliner with the call light draped over an overbed table that had been pushed against the bed on the other side of the room, making it inaccessible. This resident reported that staff had pushed the table against the bed after removing the breakfast tray and that the call light could not be reached. The same CNA confirmed that this resident’s call light should have been within reach and was not. The RNC also stated that residents’ call lights should be within reach and acknowledged that they had not been in these instances.
Inaccurate MDS Coding of Physical Restraints for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ actual status, resulting in incorrect documentation of physical restraints for two residents. One resident with epilepsy and dementia, observed in a wheelchair on 4/12/26 with no restraints in the wheelchair or bed, had a quarterly MDS that coded in section P0100 “Physical Restraints, Other used daily” for restraint use. Another resident with diabetes and an above-the-knee left leg amputation, observed in bed with a trapeze bar used to assist with repositioning and with no restraints in the bed or wheelchair, had an admission MDS that also coded in section P0100 “Physical Restraints, Other used daily” for restraint use. On 4/13/26, the DON and MDS coordinator stated that these MDS assessments were coded incorrectly and confirmed that neither resident had restraints, indicating that the inaccurate coding stemmed from staff error in completing the MDS.
Failure to Obtain Required PASRR Level II Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to coordinate required PASRR evaluations for a resident with major mental illness in accordance with its own policy and federal guidance. The facility’s Resident Assessments PASRR Screening Coordination policy required that PASRR Level I and Level II screenings, when needed, be conducted prior to admission, and that Level II evaluation reports be used when conducting assessments and developing care plans. The State Operations Manual, Appendix PP, specified that a positive Level I screen requires an in-depth Level II evaluation by the state-designated authority prior to admission. Despite these requirements, the facility did not ensure that the appropriate PASRR process was completed. Resident #4 was admitted with multiple diagnoses, including COPD, Bipolar Disorder, and PTSD. The resident’s care plan documented that the resident met PASRR Level II determination secondary to serious mental illness diagnoses, including anxiety and bipolar disorder, and a long-term care stay. However, the medical record showed that a PASRR Level I screening was not completed until more than eight months after admission, and that this Level I identified major mental illnesses (depressive, anxiety, bipolar, and PTSD) and directed that the screening be forwarded to the state-designated authority for a PASRR Level II evaluation. As of the surveyor’s review, there was no documentation that a PASRR Level II evaluation had been completed, and the RNC confirmed that the facility did not have a PASRR Level II for this resident and should have had one.
Failure to Provide and Document Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to provide baseline care plans to residents or their representatives and to document this provision in the medical record for three of five residents reviewed. Facility policy "Care Plans - Baseline," version 1.2, required that the resident and/or representative be provided a written summary of the baseline care plan in an understandable language and that provision of this summary be documented in the medical record. For a resident admitted with muscle wasting and respiratory failure, there was no documentation that a baseline care plan was provided or discussed with the resident or representative. For a second resident admitted with Parkinson’s disease and malignant neoplasm of the prostate, the medical record likewise lacked documentation that a baseline care plan was provided or discussed. For a third resident, initially admitted and later readmitted with a stable lumbar vertebral fracture and repeated falls, there was also no documentation that a baseline care plan was provided or discussed. On interview, the RNC confirmed there was no documentation that these residents or their representatives had received copies of their baseline care plans. This deficiency centers on the facility’s noncompliance with its own baseline care plan policy and the absence of required documentation in the medical records for multiple residents with significant medical conditions.
Failure to Implement Dialysis Communication and Updated Antihypertensive Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related care and medication management according to professional standards for a resident with end stage renal disease and diabetes who required hemodialysis three times weekly. The resident’s care plan noted the need for hemodialysis and listed interventions such as administering medications as ordered and encouraging attendance at scheduled dialysis sessions. However, review of the medical record showed that dialysis communication forms were missing for two dialysis dates, and the existing dialysis communication form documented a change in the resident’s Amlodipine dosage from 10 mg to 5 mg daily that was not implemented in the medical record. The physician’s order in the chart continued to show Amlodipine 10 mg by mouth on specific days with hold parameters, and there was no documentation of the decreased 5 mg daily dose as communicated by dialysis. The DON and Regional Nurse Consultant acknowledged that the Amlodipine dose in the record was incorrect, that the dose should have been 5 mg every day, and that dialysis communication sheets for two dates were missing.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurate and posted daily for each shift, as required by its own policy. The facility’s “Staffing, Sufficient and Competent Nursing” policy, revised April 2025, stated that direct care daily staffing numbers for each shift must be posted in the facility. On 4/13/26, surveyors reviewed the daily postings of licensed and unlicensed nurse staffing for the period 11/1/25 through 4/11/26 and found there were no adjustments made to the posted staffing when the scheduled hours did not match the actual hours worked. During an interview on 4/13/26 at 11:37 AM, the RNC and DON confirmed that the facility does not update the daily posted staffing with actual hours worked and instead only adjusts the time on the daily assignment sheets. This practice resulted in posted staffing information that did not reflect the actual direct care nursing personnel responsible for resident care for each shift, affecting all residents, their representatives, visitors, and others who might review the facility’s staffing levels.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were palatable, attractive, and maintained at safe and appetizing temperatures for residents consuming food prepared in the kitchen. During a Resident Council meeting, all 6 residents present reported that food was often cold, tasteless, and not nutritious, and that meal trays, especially those delivered to rooms, lacked condiments. They also stated that the dinner meal was usually the worst meal of the day. The 2022 FDA Food Code standard that hot food be maintained at 135°F or above and cold food at 41°F or below was cited as the applicable guideline. During observation of a lunch meal service, the posted menu listed roast beef with gravy, scalloped potatoes, seasoned green beans, a roll with margarine, coconut cake, and a beverage, but the meal actually served was roasted pork with gravy, scalloped potatoes, green beans, a roll with margarine, white cake, and a beverage, with no garnishes or condiments provided. When the last tray from the meal cart was tested, the scalloped potatoes were 135°F but tasted bland, the gravy was bland and tasteless, and the green beans were 128°F instead of the expected 135°F, and were described as bland and mushy; no beverage was present on the tray. The Dietary Manager stated that the facility used frozen food that often lacked flavor, confirmed the green beans should have been at 135°F, and reported that only one staff member was scheduled for the dinner meal service each day.
Improper Food Storage, Labeling, Tray Coverage, and Cleaning Log Documentation
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and distribution of food, as well as incomplete documentation of cleaning activities. Based on the FDA Food Code 2022, they observed in the walk-in refrigerator a large opened package of provolone cheese without a use-by date. In the pantry, they found three bags of cookies dated 4/8/26 with a use-by date of 4/11/26 and one bag of sliced cake that was not dated. In the walk-in freezer, they observed an opened box of enchiladas dated 3/24/26 with no use-by date. These items were not clearly marked in accordance with date-marking requirements for refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours. Surveyors also observed that food on dietary trays delivered to resident rooms was not consistently covered. At one time, trays included an uncovered bowl of gelatin dessert, and at another time, trays included an uncovered plate of sliced cake. When interviewed, the dietary manager stated she was not aware that all food on dietary trays delivered to resident rooms must be covered. Additionally, the daily cleaning log was observed to be marked as completed for every day of the week, and the dietary aide reported she did not have a new cleaning log and therefore continued to use the same one. The dietary manager confirmed that the daily cleaning log should have been replaced with a new log for the current week and that it had not been replaced.
Inadequate Hand Hygiene and Environmental Cleaning in Infection Control Program
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to hand hygiene and maintaining a clean, sanitary environment. The facility’s Handwashing/Hand Hygiene Policy, revised March 2022, required use of alcohol-based hand rub or soap and water before and after eating or handling food. During a meal service observed at 12:04 PM on 4/12/26, 14 residents were served meals in the dining room without being offered hand hygiene before eating. At 12:12 PM, a CNA acknowledged that residents’ hands should have been sanitized before they started eating, and on 4/13/26 at 2:44 PM, the DON confirmed that residents in the dining room should have been offered hand hygiene using hand sanitizer from a bottle before meals. Additional infection control concerns were observed regarding environmental cleanliness and handling of clean items. On 4/14/26 at 6:53 AM, a housekeeper was seen carrying clean gowns down the hallway uncovered, and at 6:56 AM the housekeeper stated the gowns should have been covered. Later that morning at 8:36 AM, with the housekeeper present, surveyors observed multiple areas of visible buildup and residue in the laundry room, including a white hard substance and grey fuzzy substance on pipes behind a small washing machine, a tube of wires covered with grey fuzzy substance near the entrance, teal-colored and grey fuzzy substances on water pipes behind a large washing machine, a layer of white substance on the chemical dispenser cover, and grey fuzzy buildup on chemical buckets and nearby walls. At 8:41 AM, the housekeeper reported there was no cleaning schedule for the laundry room, although sweeping was done daily.
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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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