Power County Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in American Falls, Idaho.
- Location
- 510 Roosevelt Street, American Falls, Idaho 83211
- CMS Provider Number
- 135066
- Inspections on file
- 14
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Power County Skilled Nursing Facility during CMS and state inspections, most recent first.
The facility did not complete and transmit required MDS assessments within the mandated timeframe for several residents with complex medical conditions, resulting in overdue assessments and delayed reporting to CMS. The DON acknowledged the backlog and lack of timely reporting.
Several residents with complex medical, behavioral, and safety needs did not have individualized care plans that reflected their current conditions, physician orders, or observed behaviors. For example, residents on psychotropic medications were not monitored for side effects as required, and behaviors such as aggression, sadness, and fall risks were not documented in care plans despite being tracked elsewhere. Staff acknowledged these omissions during interviews.
The facility did not have a certified dietary manager overseeing food and nutrition services. The current dietary manager was not yet certified and was supervised by a Registered Dietitian who visited weekly, not full-time. This affected all residents receiving meals from the kitchen.
Kitchen staff did not consistently wear hair restraints as required, with one aide observed having hair exposed while working. Inspections also revealed several expired or undated food items, including syrups, tortillas, and seasonings, which remained in storage despite being past their best by or expiration dates. The dietary manager confirmed these practices did not meet food safety standards.
The QAA committee did not effectively identify or resolve systemic issues, as it lacked a method to measure or track improvements in performance improvement plans. The DON was unable to provide evidence of improved outcomes, relying only on incident counts, which led to failures in reporting resident assessments and comprehensive care planning for all residents.
Four residents were inaccurately assessed as using bedrails as restraints in their MDS documentation, despite care plans and assessments indicating the bedrails were used for mobility or independence. Staff interviews confirmed that the MDS coding did not match the actual use of bedrails, leading to inaccurate resident assessments.
A resident with Huntington's disease was exposed during wound care when an LPN left the window blinds open, resulting in a failure to maintain privacy as required. The LPN later acknowledged the oversight.
A resident with Alzheimer's disease and apraxia experienced two unwitnessed falls, after which a tab alarm was recommended and put in place for safety. Despite this intervention, the resident's care plan was not updated to include the use of the tab alarm, as confirmed by the DON during review.
A resident with SIADH and a physician-ordered fluid restriction was not properly monitored, resulting in repeated instances of fluid intake exceeding the prescribed daily limit. Despite a care plan and staff awareness of the restriction, intake records showed multiple days where the resident consumed more fluids than allowed, and the DON confirmed that monitoring was insufficient.
Three residents with complex medical histories were found to have bed rails in use without proper assessment, documentation, or informed consent as required by facility policy. Staff confirmed that assessments were either missing or incorrectly completed, and there was no evidence of quarterly reassessment or risk/benefit review with residents or their representatives.
A pharmacist recommended that a physician document the dose of citalopram for a resident with dementia, UTI, and chronic pain. The physician signed the report but did not provide the requested dosage information, and this omission was not identified by staff during a medication review meeting.
A resident receiving Apixaban and Aspirin for DVT prevention was not monitored for bruising or bleeding, as required for anticoagulant therapy. The DON confirmed that no daily assessments for bleeding were performed by licensed nurses, and the resident's record lacked documentation of monitoring for adverse outcomes.
Two residents experienced significant medication errors when a Med-Tech without documented insulin competency administered the wrong insulin to a diabetic resident, and another resident with chronic pain did not receive a prescribed dose of Oxycodone-Acetaminophen. Both incidents involved failures in verifying the MAR and following the five rights of medication administration.
A Novolog insulin pen remained in the medication cart past its expiration date and was administered by an LPN to a resident after it had expired. The expired medication was not removed from the cart as required.
A resident with osteoporosis and fractures did not receive a timely evaluation or provision of an appropriate wheelchair after a physician's order. The resident continued to use an ill-fitting wheelchair, and staff interviews revealed delays in arranging for a vendor evaluation and lack of documentation of the required assessment.
An LPN did not apply a mask or gown while administering a nasal medication to a resident on enhanced barrier precautions for MRSA, despite facility protocols requiring these PPE measures. The DON confirmed that a mask and gown should have been used.
A resident with a history of breast cancer was not offered or administered the pneumococcal vaccine according to CDC recommendations, as there was no documentation of the vaccine being offered upon admission and her immunization history was unknown. Staff only offered the vaccine months later after unsuccessful attempts to obtain her records, resulting in a deficiency related to timely and appropriate immunization practices.
A resident with dementia and anxiety reported missing laundry, but the facility failed to document the grievance or notify residents on how to file grievances. The DON and ADON were unaware of the issue, as grievances were only documented if unresolved.
The facility failed to employ sufficient staff with the necessary competencies in food and nutrition services, affecting 20 residents needing medical nutrition therapy. The DM lacked certification and an appropriate degree, and responsibilities were shared with the RD. The Food Services Manager had an engineering degree, not a nutrition-related one.
The facility failed to maintain proper hand hygiene, food storage, and cleaning practices in the kitchen. Staff did not wash hands appropriately, shelves were improperly placed on the floor, and personal food items were stored in the resident's refrigerator. Additionally, there was significant ice buildup in the freezer, dust on the refrigerator fan, and multiple food items were open and undated.
The facility did not meet the minimum member requirement for its QAPI committee because the Medical Director did not attend the meetings. This was identified during a review of the QAPI meeting minutes, and the DON confirmed the Medical Director's absence and her lack of awareness of the attendance requirement.
The facility did not provide timely meal assistance to two residents, affecting their dignity and dining experience. One resident waited 11 minutes for help with her meal, while another's tray was delayed due to random placement in the food cart. An LPN confirmed this practice, which led to the observed delays.
A resident with dementia and COPD was observed managing her oxygen supply independently without an assessment for self-administration, contrary to the facility's policy. The resident's care plan required continuous oxygen, but no evaluation for self-administration was documented, despite a previous determination that the resident was not a candidate for self-administration of medications. Staff acknowledged the oversight.
A facility failed to notify the State LTC Ombudsman of a resident's hospital transfer, as required by policy. The resident, with multiple diagnoses, was discharged to a hospital and later readmitted. The resident's record lacked documentation of the required notification. A social services employee admitted to not knowing about the notification requirement.
A facility failed to complete an annual comprehensive MDS assessment for a resident with multiple diagnoses, including shortness of breath and diabetes, before the required deadline. The DON confirmed that a quarterly assessment was submitted late, and an annual assessment was mistakenly not completed.
The facility failed to maintain comprehensive care plans for several residents, leading to potential risks. A resident with COPD was observed without oxygen, and her care plan lacked an assessment for self-administration. Another resident's dementia diagnosis was missing from her care plan. A third resident's care plan did not document side rail use, despite a preference for them. A resident with Huntington's disease was without a call light in the TV room, and her care plan did not address this need. Lastly, a resident's care plan did not reflect a hospice order for oxygen use or the discontinuation of CPAP use. The DON admitted the care plans were not updated as required.
The facility failed to update care plans for three residents, including those with Huntington's disease, Alzheimer's, and COPD, as required by their policy. The care plans were overdue for review, and the DON acknowledged the oversight, placing residents at risk of adverse outcomes.
A facility failed to obtain a physician's order to discontinue CPAP use for a resident. The resident had a physician's order for nightly CPAP use, but the MAR showed CPAP care was stopped without an order. The DON confirmed the resident no longer used CPAP and acknowledged the lack of a discontinuation order, despite discussions in an IDT meeting.
The facility failed to ensure medications were not expired, as observed in a medication storage room and cart. Expired vaccines and an Antacid liquid were found, with an LPN acknowledging the oversight and uncertainty about handling expired medications. The DON indicated that expired medications should be removed for destruction.
The facility failed to maintain infection control and prevention practices, including improper cleaning of resident equipment, inadequate hand hygiene by an LPN, and incorrect storage of oxygen supplies. Additionally, inappropriate detergent was used for residents' laundry, posing a risk of cross-contamination and infection.
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and transmitted to the State within the required 7-day timeframe for 7 out of 9 residents reviewed. Record review, staff interviews, and reference to the RAI manual revealed that multiple MDS assessments, including Admission, Quarterly, and Annual assessments, were either not completed or not transmitted on time. The Director of Nursing (DON) confirmed that the facility was behind in reporting assessments to CMS and offered no explanation for the delays. Specific examples included residents with diagnoses such as malnutrition, seizures, dementia, bipolar disorder, and diabetes mellitus, whose MDS assessments were overdue by periods ranging from 11 to 52 days. The failure to complete and transmit these assessments as required resulted in the potential for harm and inaccuracy in identifying and addressing residents' needs, as timely assessments are necessary for proper care planning and regulatory compliance.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed all identified needs for several residents. For multiple residents with complex medical and behavioral histories, care plans did not reflect current physician orders, observed behaviors, or required monitoring. For example, one resident with dementia and behavioral issues was being monitored for paranoia, hallucinations, delusions, and verbal aggression, but these behaviors were not included in her care plan. Another resident with depression and chronic pain was monitored for increased sadness, excessive sleeping, and overeating, yet these behaviors and specific side effects to monitor for her antidepressant were not documented in her care plan. Additional deficiencies were noted for residents with psychiatric and neurological conditions. One resident with aphasia and on psychotropic medication was monitored for behaviors such as being snappy, short-tempered, and experiencing air hunger, but these were not included in her care plan, nor was there documentation to monitor for adverse side effects of her medication. Another resident with bipolar disorder, anxiety, and depression did not have these diagnoses or related interventions and triggers documented in her care plan, despite being a trauma survivor. The facility also failed to address physical safety and equipment use in care plans. A resident with a history of falls and a recent fall incident did not have fall prevention interventions documented or updated in the care plan following the event. Another resident who used bed rails daily did not have this use reflected in her care plan. Staff interviews confirmed that these omissions were recognized and acknowledged as deficiencies in the care planning process.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified dietary manager with the required certification and competencies to oversee the food and nutrition service. The current dietary manager had been working in the role for about five weeks but had not yet obtained certification, although she was enrolled in classes to become a certified dietary manager. The dietary manager reported being supervised by a Registered Dietitian, who was not employed full-time at the facility but visited at least once a week. This deficiency had the potential to affect all 20 residents who received food from the facility's kitchen.
Improper Hair Restraint Use and Storage of Expired Food Items in Kitchen
Penalty
Summary
Kitchen staff failed to wear hair restraints appropriately, as observed when a dietary aide was seen in the kitchen with her hair not completely restrained, leaving her bangs and hair around her face exposed. The dietary manager confirmed that the aide should have worn her hair restraint to fully cover her hair, in accordance with FDA Food Code requirements for food safety. Additionally, multiple outdated and undated food items were found during two separate kitchen inspections. These included expired Hershey syrup, taco mix, flour and corn tortillas, and undated soup base and seasoning. The dietary manager acknowledged that these items should not have been present in the kitchen and should have been discarded.
Failure of QAA Committee to Identify and Resolve Systemic Problems
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee effectively identified and resolved systemic problems, impacting all 20 residents in the facility. Document review and staff interviews revealed that while the QAPI plan required comprehensive monitoring, evaluation, and cross-departmental involvement, the committee did not have a method to measure or track improvements in performance improvement plans (PIPs). The Director of Nursing (DON) was unable to provide evidence of improved outcomes or measurements for the PIPs, instead relying on incident counts from the prior month without a system to track progress. This deficiency resulted in failures to report resident assessments and comprehensive care planning, as required, with the potential for adverse outcomes when residents' needs were not identified.
Inaccurate Resident Assessments Related to Bedrail Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status regarding the use of bedrails. For four residents, the Minimum Data Set (MDS) assessments were coded to indicate daily use of bedrails as restraints, despite documentation in care plans and side rail assessments that the bedrails were used for mobility, independence, or at the resident's discretion. In several cases, care plans and assessments noted that the bedrails were not used as restraints, and residents or their representatives were informed of the risks and had provided consent for their use. However, the MDS continued to be coded as if the bedrails were restraints. Staff interviews, including statements from the Director of Nursing (DON) and Licensed Social Worker (LSW), confirmed that the MDS coding did not accurately reflect the actual use of bedrails for these residents. The DON stated that the coding was based on daily use of the side rails, not on whether they functioned as restraints, and expressed concern about falsifying records. This inconsistency between the MDS coding and the documented purpose and use of bedrails resulted in inaccurate assessments for the affected residents.
Resident Privacy Not Maintained During Wound Care
Penalty
Summary
A deficiency occurred when a resident with Huntington's disease, who was admitted with multiple diagnoses, received wound care from an LPN while her privacy was not maintained. During the care, the resident was in bed with her shorts pulled down to her knees, exposing her periarea as she moved from her back to her side. The window blind in the room was left open throughout the procedure, allowing potential exposure. The LPN acknowledged that the blinds should have been closed before performing the wound care. This incident was observed directly by surveyors and confirmed through staff interview, demonstrating a failure to ensure the resident's right to privacy during personal care, as required by regulatory guidelines.
Failure to Update Care Plan After Fall and Implementation of Tab Alarm
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated as needed following significant events. A resident with Alzheimer's disease and apraxia experienced two unwitnessed falls, one of which resulted in a recommendation to implement a tab alarm for safety. Documentation showed that the tab alarm was in use after the second fall. However, review of the resident's care plan revealed that it did not include the use of a tab alarm, only instructions to leave the call button within reach. The Director of Nursing confirmed that the care plan should have been updated to reflect the addition of the tab alarm after it was implemented.
Failure to Adhere to Fluid Restriction Orders for Resident with SIADH
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH), which requires careful fluid management, was not provided care in accordance with physician orders. The resident had a physician's order for a fluid restriction of 1,500 ml per day, and the care plan specified that the kitchen would provide 1,200 ml, leaving 300 ml for other fluids. Despite these orders, the resident's fluid intake records showed that on multiple days within the review period, the resident consumed more than the prescribed 1,500 ml limit, with intake ranging from 1,510 ml to 2,220 ml on several days. Staff interviews revealed that the resident was aware of being on a fluid restriction but could not specify the allowed amount. The Director of Nursing (DON) acknowledged that the resident's fluid intake was not adequately controlled or monitored, and that closer monitoring should have been implemented to ensure compliance with the fluid restriction order. This failure to follow professional standards of care and physician orders resulted in the resident receiving more fluids than prescribed.
Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess residents for bed rail use, as required by its own policy and regulatory standards. Specifically, three residents with multiple diagnoses, including malnutrition, cancer, history of falls, bipolar disorder, major depressive disorder, muscle weakness, dementia, and hypertension, were observed with bed rails in use. For one resident, no documentation of a bed rail assessment or risk versus benefit review was provided upon request. Another resident's care plan allowed for bed rail use at their discretion, but the corresponding assessment was incomplete, with several required questions left unanswered or marked incorrectly, and no evidence that the resident or family had been informed of the risks. The third resident's assessment form was also improperly completed, with most questions marked 'No' or 'NA', and there was no documentation of quarterly reassessment as required by policy. Staff interviews confirmed that previous assessments were not documented correctly, and the facility was unable to provide evidence that the required risk assessments, informed consent, and ongoing evaluations were conducted for these residents. The lack of proper documentation and assessment created a situation where residents were not adequately evaluated for entrapment or other risks associated with bed rail use, contrary to facility policy and best practices.
Physician Failed to Address Pharmacist Medication Recommendation
Penalty
Summary
The facility failed to ensure that a physician addressed a pharmacist's recommendation regarding a resident's medication regimen. Specifically, for a resident with multiple diagnoses including dementia, urinary tract infection, and chronic pain, the pharmacist documented a recommendation to clarify the dose of citalopram on the Physician Action Report/Pharmacist Report form. Although the physician signed the form, they did not provide the requested information about the citalopram dosage. This omission was not identified by staff during a psychotropic medication meeting, resulting in the pharmacist's recommendation not being addressed as required by facility policy.
Failure to Monitor for Adverse Effects of Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not properly assessing for adverse effects related to anticoagulant therapy. A resident with multiple diagnoses, including a non-surgical wound, history of falls, and a right artificial hip joint, was prescribed Apixaban and Aspirin for DVT prevention. Despite these medications, the resident's record did not include any monitoring for bruising or bleeding, which are known potential adverse effects of anticoagulants. The Director of Nursing confirmed that there was no documentation of monitoring for adverse outcomes, and that while the physician assessed the resident every 60 days, licensed nurses did not perform daily assessments for bleeding.
Significant Medication Errors Due to Inadequate Verification and Competency
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by incidents involving two residents. One resident with diabetes and restless leg syndrome was administered the incorrect insulin by a Med-Tech who did not have documented competency in insulin administration. The error was discovered after the resident's blood sugar was closely monitored and various interventions were implemented to maintain safe glucose levels. The Med-Tech involved had not completed a skills check-off for insulin, and it was later acknowledged that oversight of the Med-Tech's competencies was lacking. Another resident with chronic pain, anxiety, and dementia did not receive a prescribed dose of Oxycodone-Acetaminophen as ordered for pain management. The omission was identified during a narcotic reconciliation, revealing that the resident had requested to take the medication at a later time but ultimately did not receive it. Both incidents were documented in the facility's incident and accident reports and involved failures in verifying the medication administration record (MAR) and adhering to the five rights of medication administration.
Expired Medication Administered from Medication Cart
Penalty
Summary
A medication cart inspection revealed that a Novolog insulin pen with an open date of 4/26/25 and an expiration date of 5/24/25 was still present in the cart after its expiration. During the inspection, it was confirmed by LPN #3 that the insulin pen was expired, and she acknowledged administering the expired insulin to Resident #11 earlier that morning. This indicates that the facility did not remove expired medications from availability for resident use as required.
Failure to Provide Timely Rehabilitative Services and Equipment
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident with multiple diagnoses, including age-related osteoporosis and pathological fractures. A physician's order was issued for the resident to be evaluated and treated for a wheelchair, but the evaluation and provision of an appropriate wheelchair were delayed. The resident reported waiting for physical therapy to obtain a properly fitting wheelchair, and observation confirmed that the current wheelchair was not suitable, with the hand rest positioned at chest level, making it difficult for the resident to use. The physical therapist acknowledged receiving the order three weeks prior but stated that a vendor visit was delayed until there were three residents in need, although the facility could purchase a wheelchair sooner if necessary. The DON indicated that the facility could not purchase equipment for everyone and noted that the delay was attributed to physical therapy. Additionally, the LSW confirmed there was no documentation of a wheelchair evaluation for the resident.
Failure to Use Required PPE During Medication Administration for MRSA-Positive Resident
Penalty
Summary
LPN #3 failed to follow appropriate infection control measures while administering medication to Resident #119, who was on enhanced barrier precautions due to a positive MRSA nasal swab. During a medication administration observation, LPN #3 performed hand hygiene and applied gloves before entering the resident's room and administering oral medication. However, when administering a nasal medication, LPN #3 did not put on a mask or gown as required for residents on enhanced barrier precautions. The Director of Nursing confirmed that a mask and gown should have been used during the nasal medication administration.
Failure to Offer and Document Pneumococcal Immunization per CDC Guidelines
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were offered and administered in accordance with current CDC recommendations. Record review and staff interviews revealed that one resident, who was admitted with multiple diagnoses including breast cancer, did not have documentation indicating she was offered or received the pneumococcal immunization upon admission. The resident's immunization history was unknown, and although staff stated that immunizations are offered upon admission, there was no evidence in the resident's record to support that the pneumococcal vaccine was offered at that time. Staff reported that the resident was eventually offered the pneumococcal immunization several months after admission, but only after attempts to obtain her immunization history from her primary physician were unsuccessful. The lack of documentation and delay in offering the vaccine did not align with CDC guidelines, which require routine vaccination for adults of the resident's age group, especially when previous vaccination history is unknown.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, as evidenced by the lack of notification to residents on how to file a grievance and the absence of a functional process for filing grievances anonymously. Additionally, the facility did not provide written responses to grievances, detailing the date received, investigation steps, and corrective actions. This was highlighted by the case of a resident with dementia and anxiety, who reported missing laundry but was unaware of any grievance form being filled out. The facility's grievance log did not document this issue, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the concern, indicating that grievances were only documented if issues could not be resolved.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of food and nutrition services. This deficiency was identified during staff interviews and had the potential to affect 20 residents requiring medical nutrition therapy, initial nutritional assessments, and appropriate dietary interventions. On July 10, 2024, it was noted that the documentation for the Dietary Manager (DM) certification was requested but not provided. Both the Registered Dietitian (RD) and DM admitted to sharing responsibilities for resident nutritional assessments, interventions, progress notes, and care plan development for about 18 months. It was revealed that the Food Services Manager held an engineering degree and lacked a degree in food and nutrition. Furthermore, the DM, who had worked as a kitchen aide for one year before being hired, confirmed she did not possess a DM certification or an associate degree or higher in food or nutrition services, although she planned to take the certification exam later in the year.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper hand hygiene practices in the kitchen, as observed during a tray-line inspection. Staff members, including the Dietary Manager (DM) and kitchen assistants, did not wash their hands between glove use, when changing tasks, or when entering the kitchen. Despite acknowledging the requirement for handwashing between these activities, the facility could not produce a specific policy on handwashing practices within the kitchen environment. Additionally, the annual handwashing safety training conducted by the facility was not specific to food services. The facility also did not adhere to proper food storage standards. During a kitchen inspection, it was observed that shelves in the dry pantry area were directly on the floor, contrary to the requirement that they be at least six inches above the floor. Items such as cherry pie filling, plastic cups, and tray liners were stored on these lower shelves. Furthermore, personal food items for a staff potluck and a personal container of food were improperly stored in the resident's nourishment refrigerator, despite the availability of a designated employee refrigerator. Cleaning and date marking practices were also found to be deficient. There was significant ice buildup in the deep freezer, and dust accumulation on the cooling fan in the refrigerator, with unboxed yogurt containers stored directly underneath. The cleaning schedule did not include the refrigerator fan. Additionally, multiple food items in the kitchen refrigerators and freezers were open and undated, including ice cream, bread, vegetables, frosting, and pies. Spice containers were also open and undated, with some dated as far back as early 2023. The DM acknowledged these issues and mentioned plans to address them, but the deficiencies remained uncorrected at the time of the inspection.
QAPI Committee Member Requirement Not Met
Penalty
Summary
The facility failed to meet the minimum member requirement for its Quality Assurance and Performance Improvement (QAPI) committee, as the Medical Director did not attend the QAPI meetings. This was discovered during a review of the QAPI monthly meeting minutes for the prior six months. The Director of Nursing (DON) confirmed that the Medical Director had not been present at these meetings and was unaware of the requirement for his attendance.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to treat residents with respect and dignity, impacting their quality of life and dining experience. This deficiency was observed in two residents during meal times. One resident, with diagnoses including hypertensive heart disease, hypothyroidism, and type 1 diabetes, was seen with her meal tray untouched for 11 minutes before receiving assistance. Another resident, with hypertension and mild cognitive impairment, was left without her meal tray while others at her table were served, and her tray was only discovered in the food cart 5 minutes later. An LPN confirmed that meal trays are placed randomly in the cart, leading to delays in serving meals to residents at the same table.
Failure to Assess Resident for Self-Administration of Oxygen
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed for the ability to self-administer medications, specifically oxygen, as per their policy. The policy required a basic evaluation by the charge nurse, a review by the IDT, and a physician's order if self-administration was deemed safe. However, Resident #14, who had multiple diagnoses including dementia and COPD, was observed managing her oxygen supply independently without having been assessed or care planned for self-administration. This oversight was noted when the resident was seen without her nasal cannula and oxygen turned off, and later independently applied the nasal cannula and turned on the oxygen. The resident's care plan indicated a need for continuous oxygen at 2 Liters/minute due to COPD, yet there was no documented assessment for self-administration of oxygen. An evaluation from the previous year had determined that the resident was not a candidate for safe self-administration of medications. Despite this, the resident was managing her oxygen without staff assistance, which was not aligned with the facility's policy or the resident's care plan. The LPN and DON acknowledged the lack of assessment and care planning for the resident's self-administration of oxygen.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide a notice of transfer to the State Long Term Care Ombudsman when a resident was transferred to the hospital. This deficiency was identified during a review of the records for a resident who was admitted to the facility with multiple diagnoses, including hypertensive heart disease, hypothyroidism, and diabetes. The resident was discharged to a hospital with an anticipated return and was later readmitted to the facility. However, there was no documentation in the resident's record indicating that a Notification of Transfer was provided to the State Ombudsman regarding the hospitalization. During an interview, a social services employee stated that she was unaware of the requirement to notify the Ombudsman of such transfers.
Failure to Complete Annual MDS Assessment on Time
Penalty
Summary
The facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for a resident prior to the required completion date. This deficiency was identified through staff interviews, record reviews, and policy reviews. The facility's policy, revised in December 2018, mandates that a comprehensive assessment be completed for Medicare recipients at admission and annually. The resident in question was admitted with multiple diagnoses, including shortness of breath, gastroesophageal reflux disease, and diabetes. A review of the resident's MDS history revealed that a quarterly MDS was transmitted late, and there was no record of an annual comprehensive assessment being completed within the required timeframe. During an interview, the Director of Nursing (DON) confirmed that a quarterly assessment was submitted late and acknowledged the mistake of completing a quarterly MDS instead of an annual one.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for five residents, leading to potential risks of negative outcomes. Resident #14, diagnosed with dementia and COPD, was observed without her prescribed oxygen, and her care plan lacked an assessment for self-administration of oxygen. Resident #1's care plan did not include her dementia diagnosis, and the Director of Nursing (DON) was unaware of this condition. Resident #3's care plan did not document interventions for the use of side rails, despite an assessment indicating the resident's preference for them. Resident #6, diagnosed with Huntington's disease, was observed without a call light in the TV room, and her care plan did not address this need, despite multiple falls from the chair in that area. Resident #17, diagnosed with Alzheimer's disease, had a hospice order for oxygen use that was not reflected in the care plan, and the discontinuation of CPAP machine use was not documented. The DON acknowledged the care plans were not updated as required, contributing to these deficiencies.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions, as required by their Care Plans policy. This deficiency was identified for three residents whose care plans were reviewed. The policy, dated January 1, 2024, mandates that care plans be reviewed quarterly, annually, and with any change of status to ensure they are current. However, the care plans for Resident #6, Resident #15, and Resident #17 were not updated as scheduled, placing these residents at risk of adverse outcomes. Resident #6, diagnosed with Huntington's disease, had a care plan initiated on January 8, 2021, which was due for review on January 15, 2024, but was not updated. Similarly, Resident #17, with Alzheimer's disease, had a care plan that was supposed to be reviewed on February 23, 2024, but this was not done. Resident #15, who has multiple diagnoses including dementia and COPD, had a care plan that was overdue for review since January 18, 2024. The Director of Nursing (DON) acknowledged the oversight in updating these care plans, which were overdue for review.
Failure to Obtain Physician's Order for Discontinuing CPAP
Penalty
Summary
The facility failed to ensure the discontinuation of CPAP use for a resident was accompanied by a physician's order. This deficiency was identified for a resident who had a physician's order dated February 2, 2024, to use a CPAP machine nightly. The Medication Administration Record (MAR) indicated that CPAP equipment care was initiated on May 12, 2024, and discontinued on June 1, 2024. However, on July 8, 2024, a CPAP machine was not observed in the resident's room, and on July 9, 2024, the Director of Nursing (DON) confirmed that the resident no longer used a CPAP machine. The DON also stated that there was no order on file to discontinue CPAP use, although the cessation of CPAP was discussed in an Interdisciplinary Team (IDT) meeting.
Expired Medications Found in Storage Room and Cart
Penalty
Summary
The facility failed to ensure that medications available for residents had not expired, as observed during an audit of the medication storage room and a medication cart. In the medication storage room, four syringes of Tetanus Toxoid reduced Diphtheria Toxoid and Acellular Pertussis vaccine were found with an expiration date of March 2024, and three doses of Influenza vaccine were found with an expiration date of June 30, 2024. An LPN acknowledged that these vaccines were expired and should have been removed from the refrigerator, but she was unsure of the procedure for handling expired medications. The Director of Nursing (DON) stated that expired liquid medications are sent upstairs to be destroyed by the pharmacy, and other expired medications should have been removed from the medication room for destruction. Additionally, during a medication cart audit, a bottle of Antacid liquid was found with an expiration date of June 2024. The same LPN stated that she had opened the Antacid liquid bottle the previous day without noticing its expiration. She acknowledged that expired medications should have been removed from the medication cart. This oversight created the potential for residents to receive expired medications with decreased efficacy.
Infection Control and Prevention Failures
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as evidenced by several observations. A Hoyer lift and a Sit to Stand device were found with visible dirt and dust, and the cleaning log for these devices lacked documentation of regular cleaning. Additionally, a glucometer used by an LPN was not disinfected according to the recommended dry time, and the LPN was unaware of the proper procedure. This lack of adherence to cleaning protocols poses a risk of cross-contamination and infection among residents. Further deficiencies were noted in the handling and storage of oxygen and respiratory supplies. An oxygen concentrator in a common room had an undated water bottle and a nasal cannula on the floor, while a resident's nebulizer and tubing were undated and uncovered. The DON admitted there was no policy for storing respiratory supplies. Additionally, an LPN was observed not performing hand hygiene after blowing her nose and before dispensing medication. In the laundry room, inappropriate detergent was used for residents' personal laundry, as the machines were connected to a rinse aid meant for dishwashers.
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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