Madison Carriage Cove Short Stay Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Rexburg, Idaho.
- Location
- 410 West 1st North, Rexburg, Idaho 83440
- CMS Provider Number
- 135140
- Inspections on file
- 16
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Madison Carriage Cove Short Stay Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that kitchen staff did not follow required food safety standards for storage, labeling, and dating of food items. In the walk-in freezer, an open box of frozen French bread dough and an open bag of frozen chicken breast were not sealed or dated, and a loaf of sliced bread was found on the floor between the wall and shelving. In the walk-in refrigerator, a container of heavy cream was stored past its best-by date. These practices did not comply with FDA Food Code requirements or the facility’s food safety policy for inspecting, properly storing, labeling, dating, and covering food items.
The facility failed to maintain infection prevention and control practices in both food service and insulin administration. During meal service, the kitchen supervisor and dietary staff repeatedly moved between the tray line, storage areas, and resident meal delivery without performing required hand hygiene, and some staff had uncovered ponytails hanging out from under hats instead of using hairnets as required by policy. In a separate incident, a resident with diabetes receiving ordered subcutaneous insulin had the insulin syringe placed directly on the bed surface while the LPN cleaned the injection site, after which the same syringe was used for administration.
The facility did not complete a required PASARR Level I screening before admitting a resident with multiple medical diagnoses, including kidney failure and cancer. Facility policy required all applicants to have a PASARR Level I pre-screening for serious mental disorders or intellectual disabilities prior to admission, but the screening for this resident was not obtained until several days after admission. Record review confirmed the delay, and the ADON stated she had not requested or received the PASARR Level I before admission and only requested it later from the hospital.
A resident with chronic respiratory failure using CPAP and supplemental O2 did not receive respiratory care consistent with CPAP manufacturer guidelines. Surveyors observed the CPAP device turned off while O2 at 2 L/min continued to be bled into the device, and the required in-line pressure valve to prevent O2 backflow was not present. The Administrator acknowledged that the O2 should have been shut off when the CPAP was turned off but was not.
The facility did not maintain daily nurse staffing sheets for the required 18-month period. The DON reported that only staffing records from the time she started in August 2025 were available, and the Administrator could not account for missing staffing sheets from earlier months. This resulted in a lack of accessible historical nurse staffing information for residents, their representatives, and visitors who might request to review staffing levels.
Surveyors identified that controlled medications on one medication cart were not properly tracked when narcotic accountability sheets showed only one nurse signature on a specific date instead of the required two. An LPN and the DON both acknowledged that two nurses should sign the narcotic sheet when accepting or releasing the cart, but this did not occur, affecting all residents receiving controlled medications from that cart.
A resident with diabetes and anxiety had physician orders for Basaglar (insulin glargine) 15 units SQ and insulin lispro per sliding scale. An LPN was observed preparing the glargine insulin pen by dialing it directly to 15 units and administering it without first priming the pen with 2 units, contrary to facility expectations. The LPN later acknowledged that she did not prime the pen on that occasion and only sometimes primed insulin pens before use, while the DON confirmed that insulin pens should be primed with 2 units prior to administering the ordered dose.
Surveyors found that the facility did not follow its own policy for destruction and removal of unused and expired medications. During a medication cart audit, an LPN had a bottle of Gas Relief on the cart that was past its manufacturer expiration date and acknowledged it should have been discarded. In a medication storage room audit, an LPN had two tubes of barrier cream, each bearing prescription labels for residents who had already been discharged, still kept among supplies available for resident use. The DON confirmed that expired and unused medications should have been removed from the cart and storage room but were not.
A resident with multiple diagnoses, including surgical aftercare and septicemia, experienced multiple falls due to inadequate supervision and lack of updated fall interventions. The resident, who had a wound vacuum and Foley catheter, suffered significant injuries, including a hip fracture and brain bleed, after tripping on medical tubing and falling out of bed. The facility failed to update the care plan with new interventions after each incident.
The facility failed to properly store, label, and serve food according to professional standards, as observed during an inspection. Unlabeled and undated food items were found in the walk-in refrigerator and freezer, and expired spices were noted in the dry storage area. The CFM acknowledged these issues, which posed a risk of contamination and adverse health outcomes for residents.
A facility failed to assess a resident for the ability to safely self-administer medications, as required by policy. The resident, with multiple diagnoses including metabolic encephalopathy, was using a pain pump with hydromorphone and bupivacaine. Despite care plan and physician orders allowing self-administration, no assessment was conducted, creating potential for adverse effects.
The facility failed to assist residents in formulating advance directives, leading to incomplete or conflicting documentation for three residents. One resident had inconsistent resuscitation status documents, while two others lacked documentation of advance directives or assistance offered by the facility. The CCO acknowledged these deficiencies.
A facility failed to provide necessary health information to a hospital during the transfer of a resident with respiratory failure and hypercapnia. Despite the facility's policy requiring detailed medical information to be sent, the resident's records lacked documentation of such information during two hospital transfers due to changes in condition. This deficiency was confirmed by the ADON.
The facility failed to provide bed hold notices to two residents upon their transfer to the hospital, as required by policy. One resident was transferred twice due to changes in condition, and another was transferred three times due to medical issues, with no documentation of bed hold notices provided. The ADON confirmed the lack of documentation, indicating non-compliance with the facility's policy.
A facility failed to develop and review a baseline care plan with a resident who was admitted with multiple diagnoses, including osteomyelitis and PTSD. The facility's policy required the care plan to be completed and reviewed within 48 hours of admission, but there was no documentation that this was done. The CCO confirmed the oversight.
The facility failed to complete, review, and update comprehensive care plans for residents, leading to potential risks. A resident's care plan was not reviewed within the required timeframe, another's care plan was not updated to reflect a change in medication dosage, and a third resident's care plan was not updated with new fall interventions after multiple falls. These deficiencies were confirmed by facility staff.
The facility failed to ensure proper labeling, dating, and storage of medications. Loose pills were found in a medication cart, and a Tubersol solution vial lacked an opened date. The emergency narcotic kit was not permanently affixed, and a medication cart was left unlocked without a nurse present, contrary to facility policy.
The facility failed to maintain infection control practices during meal service and resident care. A dietary aide did not assist or encourage hand hygiene before meals, and two CNAs did not follow hand hygiene protocols during catheter care for a resident with hemiplegia and kidney failure. Additionally, staff did not wear PPE gowns during a resident transfer, contrary to the care plan requirements.
A facility failed to maintain an effective Antibiotic Stewardship Program, as evidenced by a resident's prescription for erythromycin eye ointment lacking a specified duration or end date. The Infection Preventionist was not notified of the antibiotic order, leading to the oversight. This failure to adhere to the facility's policy and CDC guidelines could result in unnecessary antibiotic use.
The facility failed to follow professional standards of practice for insulin administration for a resident with type 2 diabetes mellitus. The resident had multiple low blood glucose readings, but the hypoglycemic protocol was not followed, and the physician was not notified as required.
The facility failed to ensure expired medications and wound care supplies were not available for administration to residents. Expired items were found in both the south and north side medication storage rooms, including normal saline, Hibiclens, Solosite Hydrogel, Preparation H suppositories, Fiber Good gummies, a Glucagon emergency kit, lubricating gel, Bacitracin, nighttime cold & flu medicine, and nicotine gum. The LPNs present verified the expiration dates and acknowledged the oversight.
Improper Food Storage, Labeling, and Dating in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and dating of food items, contrary to FDA Food Code 2022 and the facility’s own Food Safety Requirements policy. The FDA Food Code requires refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours to be clearly date-marked and used or discarded within seven days at 41°F or less. The facility’s policy required staff to inspect all food upon delivery for safe transport and quality, ensure timely and proper storage, label and date refrigerated foods (including leftovers) so they are used by their use-by date or frozen/discarded, and keep foods covered or in tight containers. During an early morning kitchen tour with the Food Service Manager (FSM), surveyors observed multiple violations. In the walk-in freezer, there was an open box of frozen French bread dough that was not covered, sealed, or dated, and an open bag of frozen chicken breast that was not sealed or dated. Additionally, a loaf of sliced bread in a bag was found lying on the floor between the wall and shelving. In the walk-in refrigerator, surveyors found a container of heavy cream with a best-by date that had already passed. The FSM acknowledged that the bread must have fallen from the shelf, that the French bread and chicken breast should have been sealed and dated, and that the heavy cream had been recently ordered without noticing its expired best-by date.
Infection Control Failures in Dietary Services and Insulin Administration
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices in both the dietary department and during insulin administration. Facility policies required dietary employees to perform hand hygiene before food preparation, when changing tasks, after contact with unsanitary items or body parts, and as often as necessary to prevent cross contamination, as well as to wear hairnets when cooking, preparing, or assembling food. During a meal service observation, the Kitchen Supervisor left the tray line to enter the walk-in refrigerator and dry storage areas and then returned to continue prepping plates without performing hand hygiene. A dietary aide pureed resident food items without performing hand hygiene, and another dietary aide prepped plates, left the kitchen to deliver trays, and returned to prep more plates without washing hands. The Food Service Manager and a dietary aide had their hair pulled back in ponytails under baseball-type hats, with the ponytails hanging out and not restrained by hairnets. The Kitchen Supervisor later stated he was probably not seen washing his hands as much as he should have because one of the handwashing sinks was out of order, and the Food Service Manager stated she believed hairnets were not required if staff wore hats and that handwashing was only needed when hands were visibly dirty and when changing tasks. The deficiency also includes improper infection control practices during insulin administration to a resident with diabetes and anxiety. The resident had physician orders for subcutaneous insulin glargine and insulin lispro per sliding scale. During an observation, an LPN placed a syringe containing insulin glargine on the resident’s bed next to the resident while cleaning the injection site, then picked up the syringe from the bed and administered the insulin. The LPN later acknowledged she should not have placed the insulin syringe on the resident’s bed. The Infection Preventionist stated that the LPN should have placed resident medications on a protective cover on top of the bedside table rather than in the bed.
Failure to Obtain PASARR Level I Screening Prior to Admission
Penalty
Summary
The facility failed to ensure completion of a Pre-admission Screening and Resident Review (PASARR) Level I prior to admitting a resident, as required by its policy and state Medicaid rules. The facility’s policy dated 12/24/25 stated that all applicants would be screened for serious mental disorders or intellectual disabilities through a PASARR Level I pre-screening completed before admission. One resident, identified as Resident #32, was admitted with multiple diagnoses including kidney failure and cancer, but the PASARR Level I, dated 12/16/25, was not received by the facility until four days after the resident’s admission. Record review on 1/28/26 confirmed the PASARR I was not on file at the time of admission, and during an interview, the ADON acknowledged she had not requested or received the PASARR I prior to admission and only realized it was missing on 12/16/25, at which time she requested it from the hospital. This failure created the potential for harm if residents required but did not receive specialized services for mental health while residing in the facility.
Failure to Follow CPAP Manufacturer Guidelines for Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with CPAP manufacturer warning guidelines and professional standards of practice for one resident whose respiratory equipment was observed. The CPAP manufacturer’s warnings specified that oxygen supports combustion and should not be used while smoking or near open flame, that when using supplemental oxygen with the CPAP the device must be turned on before the oxygen is turned on and the oxygen must be turned off before the device is turned off to prevent oxygen accumulation in the device, and that a specific pressure valve must be placed in-line between the device and the oxygen source to prevent backflow of oxygen into the device when it is off. The manufacturer’s explanation stated that if oxygen flow is left on while the device is not operating, oxygen may accumulate within the device enclosure, creating a risk of fire, and that failure to use the pressure valve could result in a fire hazard. The resident involved had multiple diagnoses, including a left femur fracture and chronic respiratory failure with hypoxia. On observation in the resident’s room, the CPAP machine was turned off while supplemental oxygen at 2 L/min was still turned on and being bled into the CPAP device, contrary to the manufacturer’s instructions. A subsequent observation with the Administrator confirmed that the resident’s supplemental oxygen continued to be bled into the CPAP while the CPAP was not turned on, and that the required Respironics pressure valve was not installed in the circuit between the device and the oxygen source. The Administrator stated that the oxygen in the resident’s room should have been shut off when the CPAP was turned off and was not.
Failure to Maintain Required Daily Nurse Staffing Records
Penalty
Summary
The facility failed to maintain daily nurse staffing sheets for the required minimum of 18 months. During the survey, the DON reported that she only had access to daily staffing sheets dating back to when she began employment in August 2025. The Administrator stated he was unsure what happened to the daily staffing sheets covering the period from January 2025 through July 2025. This failure affected the facility’s ability to provide historical nurse staffing information for that seven-month period to residents, their representatives, visitors, or others who wished to review the facility’s staffing levels.
Failure to Maintain Dual-Nurse Narcotic Accountability on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications on one of two medication carts reviewed. During an audit of the North Hall medication cart, narcotic accountability sheets dated from 1/1/26 to 1/27/26 were observed with only one licensed nurse signature documented for 1/21/26, instead of the required two signatures. An LPN stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart, and the DON confirmed that two nurses were expected to sign the narcotic accountability sheet at those times. This deficiency involved the process for documenting controlled medication accountability rather than a specific resident, and it affected all residents who received controlled medications in the facility, as the lack of dual signatures meant controlled medications on that cart were not properly tracked for that date.
Failure to Properly Prime Insulin Pen Before Administration
Penalty
Summary
Surveyors identified a deficiency in medication preparation and administration involving insulin for Resident #2. The resident, who had multiple diagnoses including diabetes and anxiety, had physician orders for Basaglar (insulin glargine) 15 units subcutaneously and insulin lispro per sliding scale. On 1/27/26 at 8:27 AM, an LPN was observed removing the glargine insulin pen from the medication cart and dialing it directly to 15 units without first priming the pen with 2 units, as required. At 8:32 AM, the LPN administered the unprimed glargine insulin dose to the resident. At 8:37 AM, the LPN acknowledged she had not primed the insulin pen on that occasion and stated she only sometimes primed the pen before administration. On 1/28/26 at 4:18 PM, the DON confirmed that insulin pens should be primed with 2 units prior to administering the ordered insulin dosage. This failure to consistently prime the insulin pen before dialing and administering the ordered dose resulted in the resident not being ensured freedom from significant medication preparation and administration errors and placed the resident at risk for not receiving the prescribed medication dosage and other adverse outcomes, as stated in the report.
Failure to Remove Expired and Unused Medications From Storage and Use Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of medications, including failure to ensure medications were properly stored, not expired, and appropriately disposed of when unused. The facility’s policy titled “Destruction of Unused Drugs” dated 12/29/25 stated that unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. During a medication cart audit on 1/28/26 at 8:52 AM on the South Hall with an LPN present, surveyors observed one bottle of Gas Relief on the cart with a manufacturer expiration date of 7/25 printed on the bottle, and the LPN acknowledged the bottle should have been discarded and had not been. Later that day at 2:01 PM, during an audit of the North Hall medication storage room with another LPN present, surveyors observed one tube of barrier cream labeled for a resident discharged on 10/3/25 and another tube of barrier cream labeled for a resident discharged on 11/18/25 among available supplies for resident use. At 4:38 PM, the DON stated that expired and unused medications should have been removed from the medication cart and storage room and had not been, confirming the failure to follow the facility’s medication storage and disposal policy. No specific medical histories or current clinical conditions of the residents for whom the labeled barrier creams were prescribed are provided in the report.
Failure to Implement Fall Interventions Leads to Resident Harm
Penalty
Summary
The facility failed to ensure adequate supervision and implement necessary interventions to prevent falls for a resident, resulting in harm. The resident, who had multiple diagnoses including surgical aftercare and septicemia, returned from the hospital with a wound vacuum and a Foley catheter. On one occasion, the resident was found on the floor after apparently tripping on the tubing of the wound vacuum or Foley catheter while attempting to get out of bed. This incident led to a right hip fracture, subdural hematoma, and UTI. Despite the fall, the resident's care plan was not updated with new fall interventions. Subsequent incidents occurred where the resident rolled out of bed and sustained an abrasion, and later was found disoriented and confused on the floor with a skin tear and bruising. The resident was again transferred to the hospital with a traumatic subarachnoid hemorrhage and UTI. The Director of Nursing acknowledged that new fall interventions were not implemented after these incidents, and the care plan was not updated accordingly, highlighting a failure in the facility's responsibility to provide adequate supervision and prevent accidents.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food storage, labeling, and serving standards as outlined in the Idaho Food Code and the facility's own Food Safety Requirements policy. During an inspection, several deficiencies were observed in the kitchen area, including unlabeled and undated containers of tomato juice, lemonade, shredded cheese, and lunch meat in the walk-in refrigerator. Additionally, a bag of ham was improperly stored on top of an open bag of lettuce, and a tray of sliced tomato, onion, and pickles was undated. In the walk-in freezer, a large bag of cubed carrots was found open to the air and not sealed correctly. Expired onion and garlic powder were also found in the dry food storage area. Further observations revealed a bag of lettuce in the refrigerator that was not sealed correctly, and in the grill area, a liquid butter alternative container and a squirt bottle were not dated or labeled. The Certified Food Manager (CFM) acknowledged these issues, stating that the opened, non-dated food items should have been dated and sealed correctly, and the bag of meat should not have been stored on top of the lettuce. These practices placed residents at risk for potential contamination and adverse health outcomes, including food-borne illnesses.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for their ability to safely self-administer medications, as required by their policy. This deficiency was identified during a review of Resident #13, who was admitted with multiple diagnoses including metabolic encephalopathy, pneumonia, and a UTI. The facility's policy, dated 12/16/24, mandates that an interdisciplinary team assess and determine if self-administration of medication is clinically appropriate for a resident, with results recorded on the Medication Self-Administration Safety Evaluation. However, Resident #13 did not have such an assessment completed. Resident #13's care plan and physician orders included instructions for the use of a pain pump with hydromorphone and bupivacaine for pain management, allowing the resident to self-administer doses under certain conditions. Despite these instructions, the Chief Clinical Officer (CCO) confirmed that no assessment had been conducted to determine if Resident #13 was safe to self-administer medication. This oversight created the potential for adverse effects if the resident self-administered medications inappropriately.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advance directive. This deficiency was identified for three residents whose records were reviewed. Resident #7's medical record contained conflicting documents regarding their resuscitation status, with some documents indicating a full code status and others indicating a Do Not Resuscitate (DNR) status. This inconsistency was acknowledged by the facility's chief clinical officer, who stated that the documents were confusing and needed clarification. For Residents #185 and #186, the facility did not document whether they had advance directives, whether the facility offered assistance in formulating one, or if the residents declined to formulate an advance directive. The care plan conference documents for these residents were incomplete, with sections regarding advance directives left blank. The chief clinical officer confirmed that the advance directives should have been completed for these residents, indicating a lapse in the facility's adherence to its policy on supporting residents' rights to formulate advance directives.
Failure to Provide Pertinent Health Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that pertinent health information was provided to the receiving hospital during the transfer of a resident. The facility's Transfer and Discharge policy requires that specific information, such as contact information of the resident's practitioner, resident representative information, advance directives, and all necessary medical details, be provided to the receiving provider. However, for Resident #14, who was transferred to the hospital on two occasions due to changes in condition, there was no documentation in the medical record indicating that this information was sent to the hospital. Resident #14, who had multiple diagnoses including respiratory failure and hypercapnia, was initially admitted to the facility and later readmitted. On two separate occasions, the resident was transferred to the hospital due to a change in condition, specifically weakness and lethargy. Despite the facility's policy, the medical records did not contain documentation of the pertinent medical information that should have been provided to the hospital, as confirmed by the Assistant Director of Nursing (ADON). This lack of documentation could potentially result in adverse outcomes if the resident was not treated in a timely manner due to missing information.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives upon transfer to the hospital, as required by their policy. This deficiency was identified for two residents who were reviewed for transfers. The facility's policy, dated 12/2/24, mandates that written information regarding bed hold policies be provided prior to transferring a resident to the hospital. However, for Resident #14, who was transferred to the hospital on two occasions due to changes in condition, there was no documentation of a bed hold notice being provided. Similarly, Resident #24, who was transferred to the hospital on three separate occasions due to medical issues, also did not have documentation of a bed hold notice being provided. The absence of bed hold notices for these residents was confirmed through staff interviews. The Assistant Director of Nursing (ADON) acknowledged the lack of documentation for both residents, indicating that the facility did not adhere to its policy. This oversight created the potential for harm, as residents were not informed of their right to return to their former bed or room within a specified time frame, as outlined in the facility's policy.
Failure to Implement Baseline Care Plan
Penalty
Summary
The facility failed to develop, review with the resident, and implement a baseline care plan for one of the residents whose care plans were reviewed. This deficiency was identified for a resident who was admitted and later readmitted with multiple diagnoses, including osteomyelitis of the vertebra, sacral and sacrococcygeal region, chronic post-traumatic stress disorder, and nutritional deficiency. The facility's policy required that the baseline care plan be completed within 48 hours of admission, reviewed with the resident or their representative, and a copy provided to them. However, there was no documentation in the resident's medical record indicating that the baseline care plan had been reviewed with or given to the resident or their representative. The Chief Clinical Officer confirmed that the baseline care plan should have been completed and shared with the resident but was not.
Failure to Update and Review Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were completed, reviewed, and updated for residents, as required. For Resident #7, there was no documentation that the comprehensive care plan had been reviewed with the resident or their representative within 21 days of admission, as confirmed by the Chief Clinical Officer (CCO). Resident #13's care plan was not revised to reflect an updated physician order that increased the dosage of hydromorphone and bupivacaine, which was a deviation from the documented care plan dated 9/24/24. Resident #24 experienced multiple falls resulting in serious injuries, including a right hip fracture and a traumatic subarachnoid hemorrhage. Despite these incidents, the care plan was not updated with new fall interventions after each fall, as acknowledged by the Director of Nursing (DON). These deficiencies in care planning placed residents at risk of adverse outcomes due to the lack of timely updates and reviews of their care plans in response to changes in their conditions.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of medications, as observed during an inspection of the south side medication cart and medication room. In the medication cart, two small white pills and one oval white pill were found loose in the second drawer, with the RN present unable to identify them. The ADON later confirmed that the medication carts are cleaned weekly, and the pills should not have been loose. Additionally, a Tubersol solution vial in the medication refrigerator lacked an opened date, which was confirmed by the RN and acknowledged by the ADON as a failure to follow proper dating procedures. Further inspection revealed that the emergency narcotic kit in the medication storage refrigerator was not permanently affixed, contrary to the facility's policy for storing Schedule II controlled medications. The ADON admitted to being unaware of the requirement for the narcotic box to be permanently affixed. Additionally, the south medication cart was found unlocked with no nurse present, which was acknowledged by RN #2, who stated the cart should have been locked. The DON confirmed that nursing staff are required to lock medication carts when not in attendance.
Infection Control Deficiencies in Meal Service and Resident Care
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as observed during meal service and resident care activities. During breakfast service, a dietary aide did not assist or encourage residents to perform hand hygiene before meals, despite the facility's policy requiring such actions. This oversight was acknowledged by the dietary aide, who admitted to not offering hand hygiene assistance to the residents. In another instance, two CNAs provided catheter care to a resident with multiple diagnoses, including hemiplegia and kidney failure, without adhering to proper hand hygiene protocols. The CNAs failed to perform hand hygiene between glove changes and placed soiled linens on the floor, contrary to the facility's policies. Additionally, the CNAs did not change the resident's bed linens despite visible contamination. Furthermore, during a transfer using a Hoyer lift, the CNAs and an occupational therapist did not wear PPE gowns as required by the resident's care plan for high-contact activities, which was later confirmed as a lapse by the staff involved.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (IPCP) that included a functional Antibiotic Stewardship Program. This deficiency was identified during a review of the medical records of a resident who was prescribed erythromycin eye ointment. The prescription lacked a specified duration or end date for use, which is a requirement under the facility's Antibiotic Stewardship Program policy. The policy mandates that all antibiotic prescriptions specify the dose, duration, and indications for use, and the McGeer Criteria may be used to determine whether to treat an infection with antibiotics. The issue was further compounded by the Infection Preventionist (IP) not being notified of the antibiotic order through the electronic medical records system, which is the usual protocol. As a result, the lack of a duration date for the erythromycin prescription was not identified and addressed. This oversight had the potential to lead to the unnecessary use of antibiotics, as the facility's policy and CDC guidelines emphasize the importance of monitoring antibiotic use to ensure compliance with prescribing policies.
Failure to Follow Hypoglycemic Protocol for Insulin Administration
Penalty
Summary
The facility failed to follow professional standards of practice for insulin administration for a resident with type 2 diabetes mellitus. The resident had multiple low blood glucose readings on three separate occasions, but the hypoglycemic protocol was not followed. Specifically, the resident's blood glucose levels were recorded as 58 mg/dL, 52 mg/dL, and 67 mg/dL on different days, but there was no documentation of follow-up blood glucose checks or notification of the resident's physician as required by the facility's hypoglycemia management policy. During an interview with the Director of Nursing (DON) and the Clinical Resource Nurse (CRN), it was confirmed that the resident's physician was not notified, and the hypoglycemic protocol was not adhered to on the specified dates. This failure to follow the protocol created the potential for harm to the resident, as adverse outcomes from low blood sugar were not properly managed according to the established guidelines.
Expired Medications and Supplies Found in Storage Rooms
Penalty
Summary
The facility failed to ensure expired medications and wound care supplies were not available for administration to residents. During an inspection of the south side medication storage room, several expired items were found, including five bottles of normal saline, one bottle of Hibiclens, two tubes of Solosite Hydrogel, and one box of Preparation H suppositories. The LPN present verified the expiration dates and acknowledged that these items should not have been available for use. The DON stated that nurses were responsible for checking the dates of medications and wound care supplies before use and disposing of expired supplies. In the north side medication storage room, additional expired items were discovered, including 30 bottles of Hibiclens, Fiber Good gummies, another box of Preparation H suppositories, a Glucagon emergency kit, a tray of lubricating gel, a tray of Bacitracin, a bottle of nighttime cold & flu medicine, and a box of nicotine gum. The LPN present was unsure whose responsibility it was to check for expired medications and mentioned that the pharmacy randomly checked the medication room and carts for expired items. The facility's failure to remove expired medications and wound care supplies from the storage rooms was evident.
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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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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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