Meadow View Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Nampa, Idaho.
- Location
- 46 North Midland Boulevard, Nampa, Idaho 83651
- CMS Provider Number
- 135076
- Inspections on file
- 22
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Meadow View Nursing And Rehabilitation during CMS and state inspections, most recent first.
A CNA was observed entering a resident's room without knocking and waiting for acknowledgment, despite facility policy requiring this practice. The resident, who had a history of stroke and muscle weakness, stated she expected staff to wait for an invitation before entering. Both the CNA and DON confirmed that staff are expected to knock and wait before entering rooms.
The facility did not provide or document assistance to three residents with significant medical conditions in formulating Advance Directives, instead relying solely on POST forms and failing to follow up or distinguish between the two, as revealed by staff interviews and record review.
Two residents were not given timely or properly completed Advance Beneficiary Notice (ABN) forms before being billed for care, with one signing the form several days after services began and the other signing an undated form. The DON confirmed that ABNs should have been signed and dated before care was provided.
A resident with cerebral palsy and COPD was allegedly subjected to rough handling by a CNA, which was witnessed by another CNA. The incident was not reported to the Administrator until nearly two days later, and the Administrator failed to notify the State Survey Agency within the required two-hour timeframe, as mandated by facility policy.
A resident reported excessively hot sink water in their room, and multiple temperature checks confirmed water temperatures between 122 and 124°F, exceeding the facility's maximum limit of 115°F. Both the DON and maintenance staff acknowledged the temperature should not be above 115°F, and the deficiency was confirmed through direct observation and interviews.
A resident with Parkinson's disease and COPD did not receive oxygen therapy as ordered, resulting in observed lethargy and unresponsiveness while off oxygen. The oxygen equipment was not in use, and the resident's SpO2 was found to be 81% on room air before oxygen was reapplied and adjusted by an LPN. Staff confirmed that assessment for low oxygen saturation had not been performed when the resident showed symptoms.
Two residents did not receive appropriate pain management monitoring and documentation. In one case, a MAC administered hydrocodone-acetaminophen for a pain level of 5 without a required LN pain assessment. In another case, oxycodone was given to a resident for pain scores of zero, despite orders to administer only for moderate to severe pain. The DON confirmed that pain assessments and documentation were not properly completed prior to medication administration.
The facility did not accurately post daily nurse staffing information for each shift, as required, because actual hours worked by nursing staff were not documented when they differed from scheduled hours. The Human Resource Manager was unaware of the requirement to post actual hours worked for both licensed and unlicensed nurse staff.
Narcotic counts were not consistently verified and documented by both off-going and oncoming nurses for all medication carts, as required by facility policy. Audit records showed missing signatures, and staff interviews confirmed that nurses forgot to sign or signed in the wrong place after performing the counts. The DON stated that both nurses are expected to perform and sign for the narcotic count at each shift change.
Surveyors observed that the narcotic storage refrigerator was left unlocked and unmonitored, and the narcotic box inside was not permanently affixed as required. Staff confirmed that both the refrigerator and the narcotic box should have been secured to prevent unauthorized access.
Surveyors found that staff did not consistently follow food safety standards, including a dietary manager not wearing a required beard net, improper labeling of opened food items, and expired food and beverages being available and served to residents. Nursing and dietary staff acknowledged that these practices did not meet required standards.
Clean clothing was observed stored in unsealed plastic bags placed directly on the laundry room floor after being returned from an outside laundromat. Laundry staff confirmed the clothing was clean and acknowledged it should not have been placed on the floor. The Executive Director noted that the use of outside laundry services due to broken washing machines contributed to the situation.
A facility failed to ensure resident safety during a mechanical lift transfer, resulting in a fall and spinal fracture, and did not prevent a cognitively impaired resident from accessing the parking lot unsupervised. The first incident involved a resident with intellectual disabilities who fell due to unsecured loops during a lift transfer. The second incident involved a resident with wandering behaviors who was found in the parking lot without staff supervision. Staff interviews revealed a lack of awareness and training regarding elopement protocols.
A resident with intact cognition reported an aggressive incident with a CNA during a smoke break, where the CNA grabbed her arm to extinguish a cigarette, resulting in a burn. Another resident corroborated the aggressive nature of the CNA's actions. The facility's policy requires immediate reporting and investigation of such incidents, which was conducted, leading to the CNA's termination.
The facility failed to investigate an injury of unknown origin for a resident with no cognitive impairment, as well as an allegation of sexual abuse involving two residents, one of whom had severe cognitive impairment. The documentation was incomplete, and the facility did not conduct thorough investigations as required by their policy, placing other residents at risk.
A resident with a history of wandering and exit-seeking behaviors accessed the facility parking lot unsupervised due to the facility's failure to implement a care plan. Despite being identified as an elopement risk, no interventions were in place prior to the incident. Interviews revealed the interdisciplinary team was aware of the resident's behaviors, but the facility's policies on care planning and elopement prevention were not followed.
The facility failed to follow professional standards in two cases: a resident with diabetes had their blood sugar checked incorrectly by an LPN who used a dirty alcohol pad, and another resident with COPD received a nebulizer treatment with residual liquid in the chamber. The DON confirmed the lack of a policy for blood sugar checks and emphasized the need for clean respiratory equipment.
Failure to Knock and Wait for Acknowledgment Before Entering Resident Rooms
Penalty
Summary
Staff failed to honor residents' rights to dignity and respect by not following the facility's policy requiring staff to knock and wait for acknowledgment before entering residents' rooms. Specifically, a Certified Nursing Assistant (CNA) was observed saying 'knock, knock' while approaching a resident's room but entered without waiting for an invitation. The resident, who had a history of stroke and muscle weakness, expressed that she expected staff to knock and wait before entering. The CNA acknowledged not following the correct procedure, and the Director of Nursing confirmed that staff are expected to knock and wait for acknowledgment before entering resident rooms.
Failure to Assist Residents with Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an Advance Directive. For three residents reviewed, documentation showed that while each had a POST (Physician Orders for Scope of Treatment) form on file, there was no evidence that information about Advance Directives was provided or that discussions regarding Advance Directives took place as required. In each case, the admission documentation indicated the resident did not wish to create an Advance Directive at that time, but there was no follow-up or further documentation regarding their wishes or any subsequent discussion. Staff interviews revealed that social services staff misunderstood the difference between a POST and an Advance Directive, believing them to be the same. As a result, they did not follow up with the residents or their representatives about formulating an Advance Directive, nor did they document any such discussions. This lack of action and documentation was consistent across the three residents, each of whom had significant medical conditions such as stroke, diabetes, chronic respiratory failure, chronic pain, cerebral infarction, and dementia.
Failure to Provide Timely and Properly Completed ABN Forms
Penalty
Summary
The facility failed to provide timely and properly completed Advance Beneficiary Notice (ABN) forms to two residents who were reviewed for beneficiary protection notification. One resident, with diagnoses including amputation aftercare and malnutrition, was required to pay out of pocket for care starting on 5/20/25, but did not sign the ABN form until 9 days after services began. Another resident, with a history of left femur fracture and pulmonary fibrosis, signed the ABN form, but the form was not dated, making it unclear when the notification was provided. According to the Director of Nursing, ABNs should have been signed and dated by both residents prior to the provision of any care for which they could be billed.
Failure to Timely Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of potential abuse to the State Survey Agency within the required two-hour timeframe. According to facility policy, any alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made if the event involves abuse or results in serious bodily injury. In this case, a certified nursing assistant (CNA) observed another CNA roughly slam a resident into the wall while turning her in bed. The observing CNA reported the incident to the hall nurse and texted the nurse manager, but did not inform the Administrator until nearly two days later. The Administrator did not report the alleged abuse to the state survey agency or enter it into the Bureau of Facility Standards (BFS) portal as required. The resident involved had multiple diagnoses, including cerebral palsy and chronic obstructive pulmonary disease. During an interview, the Administrator acknowledged that the incident was not reported within the mandated two-hour window. This lapse in timely reporting was identified through policy review, record review, BFS portal review, and staff interviews.
Unsafe Water Temperatures in Resident Room
Penalty
Summary
The facility failed to provide a safe, homelike environment by not ensuring that the water temperature in a resident's room remained within safe limits. During interviews and observations, a resident reported that the sink water became very hot. Subsequent temperature checks of the sink water in the resident's room revealed readings of 122, 123, and 124 degrees Fahrenheit, all above the facility's stated maximum of 115 degrees Fahrenheit. Both the DON and assistant maintenance director confirmed that water temperatures should not exceed 115 degrees Fahrenheit. The State Operations Manual notes that water at these temperatures can cause third-degree burns within minutes. The deficiency was identified through direct observation, resident interview, and verification of temperature readings by both the surveyor and facility staff.
Failure to Provide Physician-Ordered Respiratory Services
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for a resident with multiple diagnoses, including Parkinson's disease and chronic obstructive pulmonary disease. The resident had active physician orders for oxygen therapy, specifying use of oxygen via nasal cannula at 2-4 Lpm if oxygen saturation was less than 90%, and 2 Lpm at bedtime. During observation, the resident was found sitting in a wheelchair without the oxygen cannula in place, while the oxygen concentrator was running and the tubing was stored in a plastic bag. The resident appeared lethargic and was not responding to most questions or prompts from the CNA assisting with activities of daily living. The CNA stated she would reapply the oxygen after completing morning care. An LPN later confirmed the resident had required oxygen during the day over the weekend due to shortness of breath and low oxygen saturation, and acknowledged the resident was acting confused and lethargic, which can indicate low oxygen levels. Upon assessment, the resident's oxygen saturation was found to be 81% on room air, prompting the LPN to apply oxygen at 2 Lpm and increase it to 4 Lpm to achieve a saturation above 90%. The LPN instructed the CNA to notify licensed nursing staff if residents exhibit lethargy or unresponsiveness. The DON confirmed that residents showing such symptoms should be assessed for low oxygen saturation, which had not occurred in this instance.
Failure to Ensure Proper Pain Management and Documentation
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of pain management for two residents. For one resident with diagnoses including myositis and dyspnea, a physician ordered hydrocodone-acetaminophen to be administered as needed for pain. On a specific date and time, the Medication Administration Record (MAR) showed that a Medication Aide Certified (MAC) documented a pain level of 5 and administered the medication, but there was no licensed nurse (LN) assessment of pain documented prior to administration, as required. The Director of Nursing (DON) confirmed that a licensed nurse should have documented the pain assessment before the medication was given, but this did not occur. For another resident with chronic respiratory failure, diabetes, and chronic pain, the care plan required pain assessments every shift and administration of analgesics as ordered. Physician orders specified that oxycodone should be given only for moderate to severe pain (pain rating of 4 or higher). However, the MAR showed that oxycodone was administered on multiple occasions when the resident's pain assessment was documented as zero. The DON confirmed that the medication should only have been administered for pain ratings of 4 or higher and that documentation was insufficient when administering as-needed pain medications.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted for each shift, as required. Review of the posted staffing records from March 20, 2025, to September 20, 2025, revealed that there were no adjustments made to reflect actual hours worked when they differed from scheduled hours. During an interview, the Human Resource Manager stated she was not aware that the actual hours worked by nursing staff needed to be documented on the daily postings for both licensed and unlicensed nurse staff. This deficiency was identified through observation, review of records, and staff interview, and had the potential to affect all residents, their representatives, visitors, and others who may wish to review current staffing levels.
Failure to Consistently Verify and Document Narcotic Counts at Shift Change
Penalty
Summary
The facility failed to ensure that narcotic counts were consistently verified and documented by both the off-going and oncoming nurses for all three medication carts reviewed. According to the facility's policy, two licensed nurses are required to conduct and document a reconciliation or physical inventory of all controlled medications at each shift change. However, review of the narcotic count sheets revealed missing signatures in the designated spaces for both off-going and oncoming nurses on multiple occasions. Specifically, the C-Hallway and Special Care Unit medication carts had blank signature spaces for the oncoming nurse, while the A-Hallway cart had a blank space for the off-going nurse, with staff confirming that signatures were omitted due to forgetfulness or signing in the wrong spot. Staff interviews confirmed that the required documentation was not completed as per policy, with nurses acknowledging that they forgot to sign the narcotic count logs after performing the counts. The Director of Nursing stated that the expectation is for both the off-going and oncoming nurses to perform the narcotic count and sign the log at each shift change. These lapses in documentation were observed and verified during the survey process.
Failure to Secure Controlled Drugs in Medication Storage Room
Penalty
Summary
The facility failed to ensure that medications, specifically controlled drugs, were properly secured and inaccessible to unauthorized staff and residents. During an observation in the C Hallway medication storage room, it was found that the narcotic storage refrigerator was left unlocked and unmonitored. Additionally, a black metal box labeled as the Hall C Narcotic Box, which contained narcotics, was not permanently affixed inside the refrigerator as required. Staff interviews confirmed that the refrigerator should have been locked and the narcotic box should have been securely attached inside the refrigerator, in accordance with facility policy and procedures.
Failure to Follow Food Safety Standards and Proper Food Labeling
Penalty
Summary
Surveyors observed multiple failures in food safety practices within the facility's kitchen and dining areas. The assistant dietary manager was seen working in the kitchen food preparation area without a beard cover, despite having facial hair, in violation of the Idaho Food Code requirements for hair restraints. When questioned, the assistant dietary manager stated he did not believe a beard cover was necessary due to the short length of his facial hair. Additionally, an opened bottle of red food coloring was found without a label indicating the date it was opened, and the assistant dietary manager acknowledged that food items should be labeled with both opened and use by dates, which was not being done. Further observations revealed that expired food items were available and being served to residents. A carafe of cranberry juice with a use by date that had already passed was being served in the Bistro dining room, and three containers of dry cereal with expired use by dates were accessible to residents in another dining area. When asked, both an RN and an LPN confirmed that food should not be used past its use by date. The expired cereal was subsequently removed after being brought to the attention of staff.
Improper Storage of Clean Laundry in Laundry Room
Penalty
Summary
The facility failed to ensure that clean clothing was stored on a clean surface in the laundry area, as required by its Infection Prevention and Control Program. During observations on two separate occasions, multiple clear unsealed plastic bags containing folded clean clothing were found placed directly on the floor near the washing machines in the laundry room. Interviews with laundry staff confirmed that the clothing in the bags was clean and acknowledged that the bags should not have been placed on the floor. The Executive Director stated that due to non-functioning washing machines, the facility had been using outside laundry services, which resulted in additional work for staff as they managed the return and sorting of clean laundry.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident during a mechanical lift transfer, resulting in the resident falling and sustaining a spinal fracture. The resident, who had profound intellectual disabilities and was nonverbal, required two staff members for transfers using a mechanical lift. However, during the transfer, the loop at the resident's right hip came undone, causing the resident to slide feet first onto the floor. The Licensed Practical Nurse (LPN) involved did not physically check the loops before the transfer, which was identified as the cause of the fall. The Director of Nursing (DON) confirmed that the loops were not secured, leading to the incident. Another deficiency involved a cognitively impaired resident with wandering and exit-seeking behaviors who managed to access the parking lot without supervision. The resident had a history of attempts to leave the facility unattended and was identified as an elopement risk. Despite this, there were no interventions in place to prevent the resident from leaving the facility. On one occasion, the resident was found in the parking lot, about 20 feet from a main road, without staff supervision. The facility did not have documentation related to this incident, and it was not reported or investigated as an elopement. Interviews with staff revealed a lack of awareness and training regarding elopement protocols. The LPN involved in the parking lot incident was unsure of the facility's elopement protocol and could not recall when the last training occurred. The Assistant Director of Nursing (ADON) confirmed that a wander guard was placed on the resident after the incident, but there was no clear understanding of how the resident managed to leave the facility. The DON acknowledged that the interdisciplinary team was aware of the resident's wandering behaviors but failed to implement preventive measures.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. The incident involved a resident with intact cognition, who reported an aggressive interaction with a CNA during a smoke break. The resident alleged that the CNA grabbed her arm and wrist aggressively to extinguish her cigarette, resulting in a burn to both the resident and the CNA. This account was corroborated by another resident who witnessed the event and confirmed the aggressive nature of the CNA's actions. The facility's policy on abuse prevention and prohibition requires immediate reporting and investigation of such incidents. The resident filed a grievance with social services, and the Director of Nursing was informed. The administrator conducted an investigation and confirmed the incident through interviews with the involved resident and a witness. The CNA involved was placed on leave and subsequently terminated following the investigation.
Failure to Investigate Injury and Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was re-admitted with a diagnosis of mild cognitive communication deficit. The resident had a BIMS score indicating no cognitive impairment. An x-ray revealed acute oblique fractures in the resident's toes, but the nurse on duty was unsure if she reported the fractures to a supervisor, and there was no documentation of such a report. The Director of Nursing (DON) stated an investigation was conducted, but only a paper with five questions was provided, lacking any additional documentation or evidence of a thorough investigation. The facility also failed to properly investigate an allegation of sexual abuse involving two residents. One resident, with severe cognitive impairment, was found in a situation with another resident who had a history of unwelcome sexual behaviors. The incident was reported, but the documentation was incomplete, lacking specific details such as the date and time of the report. The DON provided a summary of the incident but did not have documented evidence of interviews conducted with residents or staff. The facility's policy required thorough and prompt investigations, which were not evident in this case. The Administrator was unaware of the care plan entry documenting the resident's history of inappropriate behaviors. Measures to prevent further incidents were discussed but not effectively implemented, as evidenced by inconsistent monitoring checks. The facility's failure to investigate these incidents thoroughly and promptly placed other residents at risk of abuse or neglect, as per the facility's policy on abuse reporting and investigation.
Failure to Implement Care Plan for Elopement Risk
Penalty
Summary
The facility failed to implement a care plan for a resident with a known history of wandering and exit-seeking behaviors, resulting in the resident gaining access to the facility parking lot without staff supervision or knowledge. The resident, identified as R95, had been re-admitted to the facility with diagnoses including attention and concentration deficit, aphasia, and memory deficit. Despite being identified as an elopement risk due to a history of attempts to leave the facility unattended, the care plan dated 03/18/24 did not include specific interventions to address these behaviors. Interviews with the Director of Nursing and the Former Social Worker revealed that the interdisciplinary team was aware of the resident's wandering behaviors and desire to leave the facility. However, no interventions were put in place prior to the incident on 03/16/24 when the resident was found in the parking lot. The facility's policy on comprehensive person-centered care planning and the course transcript on wandering and elopement emphasized the need for developing a care plan with measurable objectives and prevention strategies for residents identified as high risk for elopement, which was not adhered to in this case.
Failure to Adhere to Professional Standards in Diabetes and COPD Care
Penalty
Summary
The facility failed to adhere to professional standards of practice in two separate incidents involving residents with specific medical needs. In the first incident, a resident with type two diabetes mellitus and chronic kidney disease had their blood sugar checked incorrectly. The LPN used a dirty alcohol pad to wipe away the first drop of blood instead of using a clean alcohol pad or a dry cotton ball/gauze, as acknowledged by the LPN and confirmed by the Director of Nursing (DON). The DON admitted there was no policy in place for properly checking blood sugar, and the facility relied on physician orders. In the second incident, a resident with chronic obstructive pulmonary disease (COPD) received a nebulizer treatment incorrectly. The LPN administering the treatment failed to notice residual liquid in the medication chamber before adding the current dose of medication. The DON stated that respiratory equipment should be checked to ensure it is clean and free of debris or liquids before use. The facility's guidelines, as referenced from an external source, indicated that nebulizer parts should be washed, rinsed, and stored properly after each use, which was not followed in this case.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
