Orchards Of Cascadia, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Nampa, Idaho.
- Location
- 404 North Horton Street, Nampa, Idaho 83651
- CMS Provider Number
- 135019
- Inspections on file
- 21
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Orchards Of Cascadia, The during CMS and state inspections, most recent first.
A cognitively intact resident with chronic respiratory failure and depression reported that a roommate threatened to "kick" him, leading staff to move the resident to another room for the night. Documentation showed there was a verbal altercation with no physical contact, and the resident later stated he felt safe and not threatened. The facility’s policy required a timely, thorough abuse investigation and follow-up report, but the Administrator, though notified and having spoken with the resident, did not ensure the incident was reported or fully investigated. The CRN confirmed that a thorough investigation was not completed, resulting in a failure to properly respond to an alleged resident-to-resident abuse incident.
Multiple residents reported ongoing issues with excessive nighttime noise from staff activities and roommate televisions, as well as concerns about staff conduct, but their grievances were not investigated or resolved in a timely manner. The facility failed to document or follow up on several complaints, including those related to verbal abuse, and did not communicate outcomes to the affected residents.
A resident with Parkinson's disease reported that a CNA caused pain by pulling a shirt that caught on the resident's hernia, and the incident was not reported to the Administrator or State within the required timeframe. The delay occurred because the Administrator was not informed immediately and only learned of the allegation after receiving a grievance form several days later, resulting in late reporting of the suspected abuse.
A resident with a history of surgical amputation and end stage renal disease received a whole 4 mg hydromorphone tablet on 14 occasions instead of the prescribed 2 mg dose after a physician's order was changed. The error was not detected due to failures in communication between the pharmacy and facility, lack of proper auditing, and staff not following the updated order, resulting in significant medication errors.
Surveyors found that medication and vaccine storage practices were not followed, including an open and undated vial of Tuberculin Skin Testing Solution in a medication room refrigerator and missing temperature logs for both medication and immunization refrigerators. The DON confirmed that required monitoring and labeling procedures were not in place.
Staff failed to follow enhanced barrier precautions and hand hygiene protocols while providing care to a resident with a nephrostomy and other complex conditions. An LPN did not wear a gown or perform hand hygiene after glove removal when emptying a nephrostomy bag, and a CNA did not change gloves or perform hand hygiene between cleaning the resident and handling clean supplies. Both staff acknowledged the lapses, and the Infection Preventionist confirmed the expected procedures.
A resident with ESRD and a central venous catheter for hemodialysis experienced a bleeding emergency when her catheter began leaking blood. An LPN clamped the line but left to get a cap, during which time the clamp became unclipped and bleeding resumed. The resident was escorted by a CNA without continuous licensed nurse supervision, and was later found unresponsive with ongoing bleeding. CPR was initiated, but the resident was pronounced deceased at the hospital. The facility lacked evidence of staff training or competency in managing dialysis access emergencies, and staff did not follow best practices or facility policy.
A resident, identified as a fall risk, fell during a transfer due to inadequate supervision by a CNA, resulting in a hematoma and chest pain. The resident was on anticoagulants, raising concerns about internal bleeding. The incident was not immediately reported, and discrepancies were noted in the accounts of the fall. The facility failed to follow the care plan and provide timely notification.
A resident's right to self-determination was not honored when a CNA repositioned the resident's bed without consent, despite the resident's preference for the bed to be against the wall. The resident, who was cognitively intact and had multiple health issues, felt insecure about falling out of bed in its new position. Interviews with staff, including an LPN, SSD, and DON, confirmed that residents have the right to determine their personal space arrangement, and staff should not alter it without consent.
The facility failed to adhere to its smoking policy, which prohibited storing smoking materials in resident rooms. Two residents were found with smoking materials in their rooms, contrary to their care plans. Staff interviews revealed inconsistencies in policy understanding, and the newly hired Administrator and DON were unfamiliar with the policy.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation was completed following an allegation of resident-to-resident abuse involving one cognitively intact resident with chronic respiratory failure and depression. According to the facility’s abuse policy, a follow-up report summarizing investigation findings and corrective actions must be submitted within five working days of an incident, including any new or revised information. In this case, a resident reported to the nurse’s station during the night that he "can't take it anymore" and that his roommate was "threatening to kick my ass." The resident was offered a temporary room change for the night, initially declined due to concern about losing his room, but later agreed after further discussion and slept peacefully in another room. Progress notes documented that the resident reported there was no physical altercation, that both individuals remained on their own sides of the room during the verbal altercation, and that although the roommate stated, "once I get out of bed, I am going to kick your ass," the resident indicated he did not feel threatened and felt safe in the facility. During an interview, the Administrator stated he was notified of the situation by phone, was informed the residents were separated, and that he personally spoke with the resident and ruled out physical and psychosocial harm. When asked by surveyors why the incident was not reported and whether an investigation was conducted, the Administrator stated he ruled out harm and did not answer regarding an investigation, and the CRN acknowledged that the facility did not complete a thorough investigation, resulting in a failure to respond appropriately to the alleged abuse in accordance with facility policy.
Failure to Timely Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to investigate and resolve resident grievances in a timely manner for multiple residents, as evidenced by interviews, record reviews, and policy review. Residents repeatedly raised concerns about excessive noise at night, particularly from staff activities and roommate televisions, during several resident council meetings. Despite these ongoing complaints, residents reported that no resolution had been communicated to them, and the noise disturbances persisted. The facility's grievance log did not reflect timely documentation or follow-up on these issues, and some grievances were not logged until months after the initial complaint. Several residents with varying cognitive abilities, including those with moderate impairment and those who were cognitively intact, described being disturbed at night by staff entering rooms, knocking loudly, turning on lights, and offering services such as ice water or trash removal during early morning hours. Residents also reported that staff responses to their complaints were inadequate, with some staff members being described as rude or dismissive. In cases where residents complained about roommate behavior, such as loud televisions, staff acknowledged the issue but did not provide a timely or effective resolution, and the facility lacked a clear policy regarding television use at night. Additionally, the facility did not complete or document grievances related to allegations of verbal abuse by staff, as identified during a facility-reported incident investigation. Residents reported instances of staff yelling, using negative language, and making inappropriate comments, but these grievances were not entered into the grievance log or investigated according to facility policy. Interviews with the Social Services Director and Administrator confirmed that some grievances had not been completed or addressed, and there was a lack of consistent follow-up and communication with residents regarding the outcomes of their complaints.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported in a timely manner to both the Administrator and the State, as required by facility policy. The policy specifies that allegations of abuse or serious bodily injury must be reported to the CEO and the state agency within two hours, and within 24 hours if the event did not involve abuse or serious bodily injury. In this case, a resident with Parkinson's disease and impaired upper extremity range of motion reported to the Unit Manager that a CNA caused pain by pulling a shirt that caught on the resident's umbilical hernia. The resident stated that the CNA continued to pull on the shirt despite being told to stop, causing further discomfort. The incident was initially reported by the resident to the Unit Manager, who documented the event as a late entry in the medical record. The resident also submitted a grievance form describing the incident and alleged that attempts to report the event to other CNAs were unsuccessful. The Administrator became aware of the incident only after the grievance form was placed under his door and did not see it until several days after the initial report. The Administrator stated that the initial report did not meet the threshold for abuse and therefore was not reported immediately. The facility did not report the allegation to the State until four days after the resident's initial report, exceeding the required reporting timeframe. The Administrator confirmed that staff are expected to report abuse allegations to him immediately, but this did not occur in this instance. The delay in reporting the incident constituted a failure to follow the facility's abuse reporting policy and regulatory requirements.
Resident Received Incorrect Dose of Hydromorphone
Penalty
Summary
A resident with a history of surgical amputation and end stage renal disease was admitted to the facility and had a physician's order for hydromorphone oral tablets. Initially, the order was for four milligrams (mg) every six hours for pain, but it was later changed to 0.5 tablet (2 mg) every six hours. Despite this change, review of the controlled drug record revealed that the resident received a whole 4 mg tablet on 14 occasions instead of the prescribed 2 mg dose. This error was confirmed through interviews with facility staff, including a registered pharmacist and an LPN, both of whom acknowledged that the medication was administered at the incorrect dose and that the physician's order was not followed. The facility's policy required regular audits of controlled substance inventory records, but the error was not detected until after multiple incorrect doses had been administered. The pharmacist noted that the interface between the pharmacy and the facility did not communicate narcotic orders effectively, and that a hard copy of the order was required. The LPN involved confirmed that she had given a whole pill instead of half, and the DON agreed that the medication was not administered as ordered. The failure to follow the physician's order resulted in significant medication errors for the resident.
Failure to Properly Store and Monitor Medications and Vaccines
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and vaccine supplies in one of its medication rooms. During an observation with the DON, an open and undated vial of Tuberculin Skin Testing Solution was found in one of the medication room refrigerators. The packaging indicated the solution had been dispensed from the pharmacy, but there was no indication of when it was opened, as required by the manufacturer's instructions and facility policy. The instructions specified that the solution must be discarded 30 days after opening or by the expiration date, whichever comes first, and must be stored refrigerated and protected from light. Additionally, temperature logs for both refrigerators in the medication room, one used for medications and the other for immunization materials, could not be located at the time of the survey. The facility's policy required daily monitoring of medication refrigerator temperatures and twice-daily monitoring for vaccine storage. When a log was later provided, it was unclear which refrigerator it pertained to, and the logs were not posted on the refrigerator doors as expected. The DON confirmed that both refrigerators were supposed to be monitored and labeled appropriately, but this was not being done at the time of the survey.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed for a resident with a nephrostomy and other complex medical conditions. During care, an LPN emptied the resident's nephrostomy bag while wearing only gloves, without donning a gown as required under enhanced barrier precautions (EBP) for residents with indwelling medical devices. After emptying the bag and disposing of the contents, the LPN removed her gloves and immediately donned a new pair without performing hand hygiene, contrary to facility policy and physician orders that specify hand hygiene before and after glove use. Additionally, a CNA providing incontinence care to the same resident did not change gloves or perform hand hygiene between cleaning the resident and handling clean supplies, such as picking up clean incontinence briefs. Both staff members acknowledged during interviews that they should have performed hand hygiene and changed gloves as required. The Infection Preventionist confirmed that the expectation is for staff to wash hands before starting care and to use gowns and gloves appropriately when providing high-contact care to residents on EBP.
Failure to Provide Appropriate Emergency Response for Dialysis Catheter Bleed
Penalty
Summary
The facility failed to provide appropriate monitoring, emergency response, and staff intervention for a resident receiving hemodialysis, resulting in actual harm. The resident, who had end stage renal disease and a central venous catheter (CVC) for dialysis, was found by an LPN with her catheter leaking blood from the red port, with blood flowing onto the floor and down her chest. The LPN clamped the line but left to obtain a cap, during which time the clamp became unclipped and bleeding resumed. The resident was then escorted down the hallway by a CNA without continuous licensed nurse supervision of the access site. Subsequently, the resident was found in her room slumped on the bed, with blood continuing to leak from the catheter, followed by loss of consciousness, absent respirations, and pulse. CPR was initiated, and EMS was called, but the resident was later pronounced deceased at the hospital after extensive interventions. The investigation revealed that the facility did not provide evidence of staff training or competency in responding to dialysis access emergencies. The Director of Clinical Services confirmed that no such training had been provided and that staff were expected to rely on their initial licensing preparation. The nurse involved did not apply a hemostat when the clamp failed and did not replace the cap on the CVC, contrary to best practices and facility policy. These failures were inconsistent with professional standards of practice, the resident's care plan, and the facility's own policies regarding monitoring and responding to changes in condition.
Inadequate Supervision During Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and intervention during a resident's transfer, resulting in a fall and subsequent injury. The resident, who was cognitively intact and required extensive assistance for transfers, was identified as a fall risk due to multiple factors including impaired mobility and medication use. On the day of the incident, a CNA was assisting the resident when she began to slide out of bed. The CNA attempted to assist, but the resident fell forward, sustaining a hematoma on her face and experiencing chest pain. The incident report noted discrepancies in the accounts of the fall between the CNA and the resident. The resident's husband reported a delay in the notification of the fall, and the resident was sent to the hospital due to concerns about internal bleeding from anticoagulant use. A CT scan revealed a hematoma and soft tissue swelling, but no fractures. Interviews with staff indicated that the CNA did not immediately report the fall, and the resident was seen with facial bruising when brought to the dining room. The facility's response included educating the CNA on proper procedures, but the report highlights the initial failure to follow the care plan and provide timely notification of the incident.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination, specifically regarding the resident's preference for bed placement. Resident #63, who was cognitively intact and had multiple diagnoses including morbid obesity, a pressure ulcer, spinal disc degeneration, and major depressive disorder, expressed a preference for her bed to be positioned against the wall. This preference was not honored by CNA #1, who repositioned the bed without the resident's consent, citing ease of care as the reason. The resident reported feeling insecure about potentially falling out of bed due to the new position and communicated her concerns to another CNA. Interviews with facility staff, including an LPN, the SSD, and the DON, confirmed that residents have the right to determine the arrangement of their personal space, and staff should not alter it without consent. The LPN was unaware of the reason for the bed's repositioning and stated that it should be returned to the resident's preferred position. The SSD and DON both acknowledged the resident's right to self-determination and emphasized the importance of staff explaining any risks to the resident and their family.
Failure to Implement Smoking Material Storage Policy
Penalty
Summary
The facility failed to implement proper storage of resident smoking materials as directed by the residents' care plans, which was identified during a survey. The facility's Smoking Policy, dated 10/15/22, clearly stated that smoking paraphernalia, including e-cigarettes and vaping devices/materials, was not permitted to be stored in the resident's room. However, for two residents whose care plans were reviewed, this policy was not followed. Resident #57, who was cognitively intact, had his smoking materials stored in his room, contrary to the care plan that stated they should be stored in the nurse's cart. Similarly, Resident #67, who was moderately cognitively impaired, kept his smoking materials in his room, despite his care plan indicating they should be stored at the nursing station or in a locked box outdoors. Interviews with various staff members revealed inconsistencies in the understanding and implementation of the smoking policy. Some staff members believed residents could keep smoking materials in their rooms if deemed safe, while others stated that smoking materials were not allowed in resident rooms and should be stored at the nurses' station. The facility Administrator and DON, both recently hired, were not familiar with the facility's smoking policy, acknowledging that the policy and residents' care plans should be adhered to. This lack of adherence to the smoking policy placed residents at risk of negative outcomes due to unsafe storage of smoking materials.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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