Shaw Mountain Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 909 Reserve Street, Boise, Idaho 83712
- CMS Provider Number
- 135090
- Inspections on file
- 23
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Shaw Mountain Of Cascadia during CMS and state inspections, most recent first.
Three residents did not receive care in accordance with physician orders and professional standards. One resident with CHF and hypertension had multiple episodes of severely elevated BP and increased edema without documented reassessment or provider notification. Another resident with muscle weakness and cognitive deficits had a distended abdomen and absent bowel sounds, but the provider was not notified until the next day. A third resident with abdominal drains had conflicting orders, delays in order implementation, and missing documentation of drain output.
The facility did not maintain adequate nursing staff to meet resident needs, resulting in multiple instances where residents experienced prolonged call light wait times, were left soiled for extended periods, and did not receive timely assistance with daily care. The DON acknowledged ongoing problems with call light response and staffing levels.
A resident admitted for post-sepsis care with multiple liver abscesses had inconsistencies in medical record documentation regarding the number of abdominal drain tubes present. Despite Interventional Radiology notes indicating drain removals, nursing progress notes continued to reflect incorrect drain counts, likely due to staff copying and pasting previous entries. The DON confirmed the records were not accurate.
The facility failed to maintain infection control and sanitation standards, with a CNA using the same gloves to feed two residents, an RN handling medication with bare hands, and an LPN placing feeding supplies on a resident's bed. The laundry room was also found in unsanitary conditions, with water and substances on the floor and surfaces. These deficiencies risked cross-contamination and infection.
The facility did not maintain residents' dignity during dining as a CNA was observed standing while feeding two residents, contrary to the facility's policy requiring staff to sit while assisting with meals. Both an LPN and the DON confirmed this practice was incorrect.
The facility failed to assist two residents in formulating Advance Directives, as their medical records lacked these documents. Both residents, with serious medical conditions, had unsigned admission agreements and incorrect documentation in their care conferences, indicating the facility had copies of their Advance Directives when it did not.
A facility failed to provide the NOMNC form CMS-10123 at least two days prior to discharge for a resident with PTSD and cirrhosis. The resident was discharged from Medicare Part A, and the NOMNC was signed on the same day instead of the required two days prior. The administrator confirmed the oversight.
A resident with dementia and weakness fell out of bed, but their care plan was not updated with new fall prevention interventions. The DON confirmed that the care plan should have included the intervention of keeping the bed in the lowest position, as noted in the Fall Investigation report.
A resident with Spastic Diplegic Cerebral Palsy and anxiety did not receive proper care for their feeding tube. An LPN used an incorrect method to check tube placement, and the feeding formula bottle was not labeled as required. The DON confirmed these lapses, indicating non-compliance with the facility's enteral nutrition policy.
The facility failed to ensure staff completed necessary training and did not adequately monitor a resident's oxygen levels. An RN did not complete required dementia and communication training, and a resident with COPD had multiple instances of low oxygen saturation levels that were not addressed by nursing staff, despite physician orders for continuous oxygen therapy.
The facility failed to ensure controlled medications were properly tracked and secured, leading to potential theft or diversion. An audit revealed missing signatures on the narcotic accountability record for multiple shifts. An RN confirmed that nurses should sign the accountability sheet when handling the medication cart, but this was not consistently done, affecting all residents receiving controlled medications.
A resident with multiple diagnoses, including kidney disease and a right leg amputation, experienced medication administration errors during a medication pass. The nurse failed to prime the insulin pen before administering Glargine insulin and did not wait the required 3-5 minutes between administering two types of eye drops. These actions resulted in a medication error rate of 8.82%, exceeding the acceptable rate of less than 5%.
The facility failed to properly label, date, and store medications, as observed in various medication carts and storage rooms. Issues included expired medications, loose pills, and undated vials, creating potential risks for residents.
Failure to Follow Physician Orders and Document Care According to Standards
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for three residents. For one resident with congestive heart failure and hypertension, staff did not document reassessment or provider notification after multiple instances of severely elevated blood pressure and increased edema, despite care plan directives to monitor and report such changes. The Director of Nursing (DON) confirmed that while verbal notifications may have occurred, there was no documentation in the medical record to support this. Another resident with muscle weakness and cognitive communication deficit experienced a distended abdomen with absent bowel sounds, a condition associated with serious complications. Nursing notes showed that the resident had not had a bowel movement in over 72 hours and continued to have abdominal distention. The provider was not notified of the absent bowel sounds until the following day, despite the DON acknowledging that absent bowel sounds are considered an emergency. A third resident, admitted for care following sepsis and multiple liver abscesses, had three abdominal drain tubes. There were conflicting physician orders regarding the amount of sterile saline to flush the drains, and new orders were not implemented on the treatment administration record (TAR) until the day after they were received. Additionally, the record did not document the amount of fluid drained from the collection bags on several dates, and nurses did not follow the physician order to record output as directed.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to ensure sufficient nursing staff were on-site to provide necessary nursing services to residents. Multiple entries in the facility's Grievance Log from July to December 2025 documented repeated incidents where residents experienced long call light wait times, were left soiled for extended periods, or did not receive timely assistance with activities of daily living. Specific incidents included residents waiting up to two and a half hours for restroom assistance, being left in soiled clothing for hours, and not having their call lights answered promptly. In one case, a resident was left in the same clothes all weekend, and another was found soiled with urine and stool in their recliner. Staff interviews confirmed ongoing issues with call light response times. The Director of Nursing acknowledged that call lights were a constant problem and that administrative staff were encouraged to assist when possible. Despite audits and education efforts, the administration continued to struggle with finding a solution to the persistent issue of inadequate staffing and delayed response to resident needs.
Inaccurate Documentation of Resident Drain Tubes
Penalty
Summary
The facility failed to ensure that resident medical records were accurately documented in accordance with professional standards of practice. For one resident admitted for care following sepsis and multiple liver abscesses, there were inconsistencies in the documentation of the number of abdominal drain tubes present. Interventional Radiology notes indicated the removal of specific drains on certain dates, but progress notes from nursing staff continued to document an incorrect number of drains for several days following these procedures. For example, after the removal of drain #1 and later drain #2, progress notes still reflected the presence of three drains, and only later adjusted to two and then one drain as per the actual clinical situation. The Director of Nursing confirmed that multiple progress notes contained inaccurate information regarding the number of drains, attributing the errors to nurses potentially copying and pasting previous notes rather than updating them to reflect the current clinical status. This resulted in inaccurate clinical documentation for the resident, as the medical record did not consistently match the resident's actual condition and the interventions performed.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices in several areas, including meal assistance, medication administration, and laundry room sanitation. During meal service, a CNA was observed assisting two residents with feeding using the same gloved hand without changing gloves or performing hand hygiene between residents. Additionally, the CNA touched a chair without changing gloves or sanitizing hands before continuing to feed the residents. In medication administration, an RN was seen handling a Buprenorphine HCl tablet with bare hands before placing it in a resident's medication cup. Furthermore, an LPN was observed placing feeding tube supplies directly on a resident's bed, which is against proper sanitary procedures. The laundry room was found in unsanitary conditions, with water and a dark green substance on the floor, and a thick layer of gray, fuzzy substance on various surfaces, including pipes and vents. The laundry manager admitted there was no check-off sheet to guide staff on cleaning tasks. These deficiencies in infection control practices and unsanitary conditions in the laundry room posed a risk of cross-contamination and infection to all residents in the facility.
Failure to Maintain Dignity During Dining
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect during dining operations. Observations revealed that a Certified Nursing Assistant (CNA) was standing while spoon-feeding two of the five residents at a dining table during breakfast. This practice is contrary to the facility's Dining Standards policy, which requires staff to sit next to residents while assisting with feeding. Both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that staff should not stand over residents when assisting them with meals.
Failure to Assist Residents in Formulating Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an Advance Directive. This deficiency was identified for two residents whose records were reviewed. Resident #18, who was admitted with diagnoses including Parkinson's disease with dyskinesia and dementia, did not have a copy of his Advance Directives in his medical record. Additionally, the admission agreement, which should have been signed to acknowledge the offering of information regarding Advance Directives, was not signed by the resident or their representatives. Despite documentation in the Multidisciplinary Care Conference indicating that the facility had a copy of the resident's Advance Directives, the Administrator later confirmed that this was incorrect. Similarly, Resident #30, admitted with conditions such as pulmonary embolism and acute respiratory failure with hypoxia, also did not have a copy of his Advance Directives in his medical record. The admission agreement was unsigned, and the Multidisciplinary Care Conference documentation inaccurately stated that the facility had a copy of the resident's Advance Directives. The Administrator acknowledged that the Social Services Director had incorrectly marked the documentation, and the facility had not obtained the necessary documents. This oversight created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 at least two days prior to discharge for one resident reviewed for beneficiary protection notification. This deficiency was identified during a record review and staff interview. The resident in question was initially admitted to the facility with multiple diagnoses, including post-traumatic stress disorder and cirrhosis. The resident was discharged from Medicare Part A on December 16, 2024, and the NOMNC was signed on the same day, rather than the required two days prior. The facility administrator confirmed that the NOMNC had not been completed in accordance with the required timeline.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current needs and interventions, as required by their policy. This deficiency was identified for one resident who had been admitted with multiple diagnoses, including dementia and weakness. The resident experienced a fall from bed, which was documented in their medical record. Despite the fall, the resident's care plan was not updated with new fall prevention interventions. The Director of Nursing confirmed that the care plan should have been updated to include the intervention of keeping the resident's bed in the lowest position, as documented in the Fall Investigation report.
Failure to Follow Enteral Nutrition Policy for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure adequate care and treatment for a resident with a feeding tube, leading to a potential risk of harm. The facility's Enteral Nutrition policy required staff to verify tube placement by gently tugging on the tube and noting the marking on the tube. However, an LPN was observed checking the resident's feeding tube placement by using a 60cc syringe, a stethoscope, and pushing 10cc of air into the resident's feeding tube while auscultating the abdomen, which was not in accordance with the policy. Additionally, the resident's feeding formula bottle was not labeled with the resident's name, start date, time, and rate of feeding, as required by the facility's policy. The resident involved had multiple diagnoses, including Spastic Diplegic Cerebral Palsy and anxiety, and was admitted to the facility with a physician's order for enteral feeding every shift. The physician's order specified checking the feeding tube placement by observing a change in the external length marked at the entry point before administering formula, medication, or flushing the tube. Despite these orders, the LPN did not follow the correct procedure for verifying tube placement, and the feeding formula bottle was not properly labeled. The Director of Nursing confirmed that the bottle should have been labeled and the feeding pole cleaned, indicating a lapse in adherence to the facility's policies and procedures for enteral nutrition care.
Failure to Ensure Staff Training and Resident Oxygen Management
Penalty
Summary
The facility failed to ensure that its staff completed the necessary annual trainings and competencies required to meet the needs of its residents. Specifically, one registered nurse (RN) hired on 5/29/21 did not complete dementia and communication training, as documented in his personnel file. Despite a Statement of Discussion dated 1/2/25 highlighting the need for this training, the Director of Nursing (DON) confirmed on 3/7/25 that the RN had not completed the required training. This lack of training could potentially impact the quality of care provided to all residents in the facility. Additionally, the facility did not adequately monitor and address the oxygen saturation levels of a resident with chronic obstructive pulmonary disease and depression. The resident's physician ordered continuous oxygen therapy to maintain oxygen saturation levels above 90%. However, multiple recorded instances showed the resident's oxygen saturation levels were below the prescribed threshold, both with and without oxygen. The medical records lacked nursing progress notes addressing these low oxygen levels or the resident's non-compliance with the oxygen order. The DON acknowledged that the oxygen desaturations should have been addressed by the nursing staff but were not.
Controlled Medication Tracking Deficiency
Penalty
Summary
The facility failed to ensure controlled medications were properly tracked and secured, which could lead to potential theft or diversion. During an audit of the medication cart on hall 300, it was observed that the narcotic accountability record had missing signatures from licensed nurses. Specifically, from 11/22/24 to 12/3/24, there were 16 instances where signatures were not documented for each shift, and from 2/9/25 to 3/5/25, there were 2 instances of missing signatures. RN #1 confirmed that nurses are required to sign the narcotic accountability sheet when they accept or release the medication cart. This oversight in documentation created the potential for undetected misuse or diversion of controlled medications, affecting all residents receiving such medications in the facility.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by an observed error rate of 8.82% during a medication pass. This deficiency was identified through the observation of medication administration for a resident with multiple diagnoses, including kidney disease and a right leg amputation. The resident's physician orders included Glargine insulin and two types of eye drops, Dorzolamide and Rednisol acetate. During the medication pass, the nurse did not prime the insulin pen before administering the Glargine insulin, which is a required step to ensure accurate dosing. Additionally, the nurse administered the resident's eye drops without waiting the required 3-5 minutes between applications, as stipulated in the facility's Eye Drop Administration policy. These actions were contrary to the facility's established medication administration policies, which require adherence to physician orders and specific procedures to ensure safe and effective medication delivery. The nurse acknowledged the errors, indicating a lack of awareness of the necessary procedures for insulin pen priming and the required waiting time between eye drop administrations.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled, dated, and stored appropriately, as observed during an inspection of the medication storage areas. In the Hall 100 medication cart, a dairy digestive tablet with an expiration date of July 2024 was found, which should not have been present. Additionally, in the medication storage room, a bottle containing 12 Calcium tablets with an expiration date of October 2023 was discovered, which should have been placed in the medication destruction tote. Furthermore, a loose Losartan tablet was found in the Hall 300 medication cart, which should have been disposed of in the drug buster. In the Friendship house medication cart, several issues were identified, including a loose Remeron tablet, three yellow pills, three white pills, and a multi-dose vial of Lidocaine without an open date. The loose pills should have been destroyed, and the Lidocaine vial should have been dated upon opening. These deficiencies in medication management created the potential for residents to miss doses or receive expired medications with decreased efficacy.
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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