Royal Plaza Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Idaho.
- Location
- 2870 Juniper Drive, Lewiston, Idaho 83501
- CMS Provider Number
- 135116
- Inspections on file
- 20
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Royal Plaza Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that kitchen equipment and food-contact surfaces were not properly cleaned or maintained, with visible accumulations of food debris and encrusted residue on ovens, grills, and dishwashing equipment. Food items served to residents were not held at safe temperatures, with several items below the required hot holding standard. Staff confirmed that cleaning routines were not followed due to short staffing, and the RDN acknowledged that food temperatures did not meet safety standards.
A resident with multiple chronic conditions and poor decision-making abilities did not receive prescribed bowel care medications for nine days despite clear physician orders. The medication administration record showed no administration of laxatives or other interventions during this period, and the DON confirmed that the protocol was not followed.
A resident with diabetes and hypertension was administered insulin Aspart on several occasions when her blood glucose was below the physician-ordered threshold, contrary to the prescribed instructions. The DON confirmed that insulin was given when it should have been held, resulting in a significant medication error.
The facility failed to address resident concerns as documented in Resident Council Meeting minutes and confirmed through interviews. Residents raised issues about staffing and call light response times, which were ongoing problems. The Activities Director did not document resolutions to these concerns, and the Administrator confirmed the absence of call light audits, indicating a failure to ensure issues were addressed.
A resident with multiple diagnoses, including quadriplegia, filed a grievance after a staff member turned off his call light and left without assisting him. The facility did not document any investigation or actions taken to address this grievance, as confirmed by the Administrator.
The facility failed to consistently calibrate glucometers in Oak Hall, Maple Hall, and the TCU, as required by the EvenCare Blood Glucose Monitoring System guidelines. The absence of a facility policy for glucometer calibration and missing logbooks contributed to this deficiency, as confirmed by staff interviews.
The facility failed to provide necessary medical information to the receiving hospital during the transfer of three residents, as required by regulations. The records lacked documentation of essential details such as the basis for transfer, practitioner contact information, and care plans. The CNO confirmed the absence of a hospital transfer policy and acknowledged the lack of documentation, which could potentially delay timely treatment.
The facility failed to notify the ombudsman of hospital transfers for three residents, including one with Alzheimer's and another with respiratory failure. The CNO and CEO confirmed the omission, which violated residents' rights to informed and safe transitions of care.
The facility failed to provide bed-hold notices to residents or their representatives during hospital transfers. This deficiency was identified for three residents, including one with Alzheimer's and another with respiratory failure, who were transferred without receiving the required notices. The CNO confirmed the lack of documentation for these notices, indicating a failure to comply with regulations.
A resident with multiple mental health diagnoses, including bipolar disorder and depression, was not referred for a required PASARR level II evaluation upon admission. The facility's initial PASARR level I screening failed to identify these conditions, and subsequent documentation was not forwarded to the appropriate authority. The Social Services Manager admitted the paperwork was incorrectly completed.
A resident's care plan for renal failure was not updated to reflect accurate monitoring, despite directives for staff to monitor for signs of hypo/hypervolemia. The MDS Coordinator acknowledged the error, as there were no physician's orders for kidney function monitoring, and the care plan was not revised after assessments.
Two residents in an LTC facility experienced medication administration errors. One resident received hydrocodone after the order was discontinued due to a failure to check the EMAR, while another was given Amoxicillin instead of Augmentin due to a transcription error in the facility's computer system. The CNO confirmed these errors and noted the need for proper medication management.
A resident with diabetes was administered 10 units of insulin Lispro on multiple occasions when their blood sugar was below the prescribed threshold of 360 mg/dl. The facility's MAR documented these errors, which were confirmed by the CNO, indicating a failure to follow the physician's order and potentially risking hypoglycemia.
Deficient Kitchen Sanitation and Food Temperature Control
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to cleanliness, maintenance, and food safety. The floor in the walk-in freezer had not been swept, with visible accumulations of onion peelings and other food debris. The convection oven doors and interior, two ovens, the flat top grill, and cooking skillets all had thick layers of dark or black encrusted residue. The dishwashing machine had a thick accumulation of dust and food particles on top, and a significant buildup of white lime or hard water deposits inside. Staff interviews confirmed that daily cleaning and sanitation routines had not been followed, reportedly due to short staffing. Additionally, food was not maintained at safe temperatures during service. When a test tray was plated and delivered, the milk was at 43°F, chicken cordon blue bites at 120°F, and green beans at 114°F, all below the required hot holding temperature of 135°F or above, except for the mashed potatoes and gravy at 145°F. The dining room steam table temperature log for the same meal showed much higher temperatures, indicating a discrepancy between recorded and actual food temperatures at the time of service. The RDN confirmed that the observed food temperatures did not meet food safety standards.
Failure to Administer Bowel Care Medications as Ordered
Penalty
Summary
The facility failed to follow professional standards of practice for bowel and bladder care for one resident with multiple diagnoses, including congestive heart failure, diabetes, and constipation. The resident had poor decision-making abilities and required cues and supervision. Physician orders specified a bowel care protocol involving Milk of Magnesia (MOM) after two days without a bowel movement, followed by a Dulcolax suppository if MOM was ineffective, and then a Fleets enema if needed, with physician notification if there was still no result. Despite these orders, the resident did not have a bowel movement for nine consecutive days, as documented in the bowel movement records. During this period, the medication administration record showed that no bowel care medications were administered. The Director of Nursing confirmed that the resident should have received MOM after two days without a bowel movement and that the physician should have been notified prior to a recent visit.
Failure to Hold Insulin per Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Record review showed that a resident with diabetes and hypertension was prescribed seven units of insulin Aspart subcutaneously before meals, with instructions to hold the dose if blood glucose was less than 140 mg/dl. Despite this order, documentation revealed that the resident was administered the insulin on multiple occasions when her blood glucose was below the specified threshold. The Director of Nursing confirmed that, according to the documentation, insulin was given when it should have been held.
Failure to Address Resident Concerns
Penalty
Summary
The facility failed to address resident concerns as documented in Resident Council Meeting minutes and confirmed through interviews with residents and staff. During a Resident Group interview attended by eight residents, concerns were raised about staffing issues and long call light response times, which were described as ongoing problems. The Resident Council minutes from May to October 2024 consistently documented various issues, including staffing continuity, inadequate training, inappropriate staff behavior, and unmet care needs such as unmade beds and unanswered call lights. However, there was no documentation of actions taken to resolve these concerns. The Activities Director, who has been in her role since August 2024, stated that residents' concerns were discussed during staff meetings and communicated to department heads, but she did not document the resolutions. The Administrator confirmed the absence of call light audits for the period in question. This lack of documentation and follow-up on resident concerns indicates a failure to ensure that issues raised by residents were addressed, potentially leading to ongoing frustration and unmet care needs.
Failure to Address Resident Grievance on Call Light Response
Penalty
Summary
The facility failed to ensure resident grievances were investigated and resolutions were documented, which placed all residents at risk of having unmet needs and poor quality of life. A review of the facility's grievances from May 2024 to October 2024 revealed an unresolved grievance involving a resident with multiple diagnoses, including sepsis, urinary tract infection, and quadriplegia. The grievance report, dated July 10, 2024, documented that the resident activated his call light, but a staff member entered the room, turned off the call light, and left without providing assistance. The report lacked documentation of any investigation or actions taken by the facility to address the resident's concerns. On November 8, 2024, the Administrator confirmed that the grievance related to the call light response was not addressed.
Glucometer Calibration Deficiency
Penalty
Summary
The facility failed to ensure the proper calibration of glucometers, which is essential for maintaining the accuracy of blood glucose readings. This deficiency was identified across three halls: Oak Hall, Maple Hall, and the Transitional Care Unit (TCU). The EvenCare Blood Glucose Monitoring System guidelines require control solution testing under specific conditions, including using the meter for the first time, using a new package of test strips, and at least once per week. However, the review of the facility's glucometer calibration logbooks revealed that calibration was not consistently performed for Oak Hall and Maple Hall from October to November 7, 2024. Additionally, the logbook for the TCU glucometer calibration was missing. Interviews with staff, including an RN and the CNO, confirmed the lack of consistent calibration and the absence of a facility policy for glucometer calibration.
Failure to Provide Necessary Medical Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary medical information was provided to the receiving hospital during the transfer of three residents, which is a requirement as per the State Operations Manual, Appendix PP. This deficiency was identified through record reviews and staff interviews. The records for three residents, who were transferred to the hospital on various dates, did not include documentation that medical information was provided to the hospital to ensure a safe and effective transition of care. Specifically, the records lacked documentation of the basis for the transfer, contact information of the responsible practitioner, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plans, and other necessary information. The Chief Nursing Officer (CNO) confirmed that the facility did not have a hospital transfer policy and acknowledged that the necessary documentation was not provided during the transfers of the residents. The CNO also confirmed that the facility had not been providing hospital paperwork when residents were transferred. This lack of documentation and communication had the potential to cause harm if residents were not treated in a timely manner due to the absence of critical information.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide transfer notices to the ombudsman for three residents who were transferred to the hospital. This deficiency was identified during a review of records and staff interviews. Resident #3, who had Alzheimer's disease and dementia, was transferred to the hospital on two occasions, but the facility did not notify the ombudsman of these transfers. Similarly, Resident #45, with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and stroke, was transferred twice to the hospital without ombudsman notification. Additionally, Resident #51, who had right hemiplegia and hemiparesis following a stroke, was transferred to the emergency room due to critical lab results, but the ombudsman was not informed of this transfer. The Chief Nursing Officer (CNO) and Chief Executive Officer (CEO) confirmed that the facility had not been providing the required notifications to the ombudsman for hospital transfers, which is a violation of the residents' rights to be informed and to have a safe and effective transition of care.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide bed-hold notices to residents or their representatives upon transfer to the hospital, as required. This deficiency was identified for three residents during a review of records and staff interviews. Resident #3, who was admitted with Alzheimer's disease and dementia, was transferred to the hospital on two occasions, but there was no documentation of a bed-hold notice being provided. Similarly, Resident #45, with diagnoses including respiratory failure, COPD, and stroke, was transferred twice without receiving a bed-hold notice. The Chief Nursing Officer (CNO) confirmed that the facility had not been providing the necessary bed-hold paperwork to residents or their representatives during hospital transfers. Resident #51, admitted with right hemiplegia and hemiparesis following a stroke, was transferred to the emergency room due to critical lab results indicating elevated blood sugar and low blood pressure. Despite the urgency of the situation, there was no documentation of a bed-hold notice being provided to her or her representative. The CNO was unable to find any record of a bed-hold notice for Resident #51, further confirming the facility's failure to comply with the requirement to inform residents or their representatives of their right to return to their former bed or room within a specified time frame.
Failure to Complete PASARR Level II Evaluation for Resident with Major Mental Illness
Penalty
Summary
The facility failed to refer a resident for further evaluation when diagnosed with a major mental illness, which is a requirement under the Pre-Admission Screening and Resident Review (PASARR) program. This deficiency was identified for a resident who was admitted with multiple diagnoses, including Parkinson's disease, bipolar disorder, major depressive disorder, anxiety disorder, and unspecified psychosis. Despite these diagnoses, the resident's pre-admission PASARR level I screening did not identify the major mental illnesses, and a PASARR level II evaluation was not completed as required. The resident's care plan indicated the use of various medications for mental health conditions, yet the necessary PASARR level II evaluation was overlooked. A subsequent facility PASARR level I screening later identified the resident's mental health conditions, but the documentation was not forwarded to the Bureau of Long Term Care. The Social Services Manager acknowledged that the resident should have had a PASARR level II completed, indicating that the preadmission screening and follow-up paperwork were filled out incorrectly.
Failure to Update Resident Care Plan for Kidney Monitoring
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated, which was identified during a review of care plans for 18 residents. Specifically, the care plan for a resident with multiple diagnoses, including Parkinson's disease, kidney disease, and bipolar disorder, was not updated to reflect accurate monitoring for renal failure. The care plan, initiated in March 2024, included directives for staff to monitor for signs and symptoms of hypo/hypervolemia and other kidney-related issues. However, a review of the resident's treatment administrative record from 2023 through 2024 did not show evidence of such monitoring as ordered in the care plan. Further investigation revealed that there were no physician's orders on file directing staff to monitor kidney function, which the MDS Coordinator acknowledged might have been an error. The care plan interventions for kidney monitoring were selected before a doctor's order was placed, based on the admitting diagnoses. The Director of Nursing confirmed that the resident's record did not include the necessary monitoring related to the kidney interventions as directed by the care plan, and the care plan had not been updated after MDS quarterly or annual assessments.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medication according to professional standards of practice for two residents, leading to medication errors. Resident #57, who had chronic kidney disease and a history of falling, received hydrocodone after the order for the medication had been discontinued. The error occurred because the nurse did not check the electronic medication administration record (EMAR) before administering the drug. The nurse realized the mistake only after attempting to document the administration in the EMAR, which showed the order had been discontinued. The Chief Nursing Officer (CNO) confirmed the error and noted that discontinued medications should be removed from the medication cart. Resident #55, with a diagnosis of a non-pressure chronic ulcer, was supposed to receive Augmentin for a venous stasis ulcer but was instead given Amoxicillin. The error was due to a transcription mistake when the nurse entered the medication order into the facility's computer system. The system did not recognize Augmentin, which appeared as Amoxicillin-Potassium Clavulanate, leading the nurse to select Amoxicillin. The CNO stated that the nurse should have sought clarification from another nurse or the Resident Care Manager (RCM) when the order was unclear.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The resident, who was admitted with multiple diagnoses including diabetes, was prescribed 10 units of insulin Lispro to be administered as needed between meals when their blood sugar level exceeded 360 mg/dl. However, the Medication Administration Record (MAR) for October and November 2024 documented that the resident received 10 units of insulin Lispro on several occasions when their blood sugar was below the prescribed threshold of 360 mg/dl. These instances occurred on specific dates and times, with blood sugar levels recorded as low as 237 mg/dl. The Chief Nursing Officer (CNO) confirmed upon review that the insulin was administered incorrectly according to the physician's order, which could potentially lead to hypoglycemia for the resident.
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Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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