Silverton Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Silverton, Idaho.
- Location
- 405 West Seventh Street, Silverton, Idaho 83867
- CMS Provider Number
- 135058
- Inspections on file
- 18
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Silverton Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
The facility failed to ensure meals were palatable and maintained at appropriate hot and cold temperatures. A resident reported that salads were served warm after being placed on hot plates under plate covers, and another resident refused a meal when a cold salad was observed on a hot plate. Resident council minutes documented ongoing complaints that hot foods were not consistently hot, cold foods were not consistently cold, and some items such as mashed potatoes were watery. Surveyors observed items on the serving line that required reheating and a test tray in which both hot and cold foods and beverages were outside acceptable temperature ranges. The RD and dietary manager acknowledged that salads should be kept on the cold side, that test tray temperatures were out of parameters, and that cold items should not be placed on hot plates or under plate covers.
The facility failed to ensure proper use of beard restraints by dietary staff during food preparation and plating. A staff member with facial hair was observed plating food with a beard guard worn around the neck and then pulling it over the face with gloved hands, without performing hand hygiene, and was later observed plating food without any beard guard. The Dietary Manager confirmed that staff with facial hair are required to wear beard guards and that this staff member had not complied on multiple occasions.
Surveyors found that the facility did not notify the State LTC Ombudsman when four residents were discharged or transferred, despite documenting coordinated discharges and hospital transfers. One resident with dementia and a history of falls was sent to the ED after a fall, another was discharged home after post-surgical recovery, a third with dementia and diabetes was transferred for cellulitis treatment, and a fourth with heart failure and COPD was transferred twice for COPD exacerbations. In each case, records showed coordination with receiving providers but no Ombudsman notification, which the Administrator confirmed had not occurred.
Surveyors found that Schedule II controlled substances were not properly secured during a storage and labeling audit with an LPN. When the LPN unlocked the medication refrigerator, the internal Schedule II compartment was observed to have a black lock that detached from the drawer, leaving the controlled medications accessible instead of stored in a permanently affixed, locked compartment. The LPN acknowledged that the compartment was not appropriately secured and that it should remain locked at all times to ensure the safety of Schedule II medications.
A resident with chronic respiratory failure, diabetes, dementia, and muscle weakness experienced ongoing dizziness, upper body weakness, dysuria, and altered mental status over a period of 1–2 weeks, but nursing did not document timely assessments, vital signs, or completion of a pending UA during this change in condition. Nursing notes later described increased weakness, transfer difficulty, and abnormal movements, with a UA and culture eventually collected and found positive for infection. Vital signs were only recorded on two dates, and there was no documentation of nursing assessment or UA collection during the earlier phase of the resident’s decline. The DON stated that non-STAT medical orders are usually completed within 24 hours and that vitals are typically taken every 30–60 days unless otherwise ordered, and did not explain why the UA was not completed earlier.
A resident with a right humerus fracture and other conditions had an acceptable pain goal of 4/10 and was ordered scheduled acetaminophen and PRN oxycodone, yet documented pain scores repeatedly ranged from 6/10 to 10/10. Therapy notes described persistent shoulder pain that limited participation and episodes of severe pain, and observations showed the resident guarding the affected arm and reporting constant pain without relief since admission. Although the DON believed pain was well managed based on PRN use, there was no documentation that the pain management plan was reassessed or its effectiveness evaluated despite ongoing pain above the resident’s stated goal.
A resident with iron deficiency anemia and a right humerus fracture had a physician order for daily Ferrous Gluconate for supplementation, but the medication was not administered as ordered. During a med pass, a MAC reported the iron supplement was not available, and further review showed the order had been in place for an extended period without doses given. The DON later stated the medication had been obtained but was not moved to the resident’s new med cart after a room change, resulting in ongoing failure to provide the ordered iron therapy.
Two residents’ records were not maintained accurately and completely. For one resident with dementia and a history of falls, an INTERACT hospital transfer form listed vital signs from nearly a week before the actual transfer, which the ADON confirmed did not reflect the resident’s condition at the time of transfer. For another resident with dementia and visual hallucinations, a physician order required per-shift documentation of target behaviors and specific interventions, but behavior monitoring records showed multiple behavior episodes without corresponding documentation of the ordered interventions, and the DON acknowledged that the record did not accurately reflect the interventions used.
The facility failed to maintain proper infection prevention and control practices, including sanitary PPE storage, wound care setup, and hand hygiene. A resident with a stage 4 pressure ulcer, paraplegia, a suprapubic catheter, and chronic wounds had an Enhanced Barrier Precaution gown stored unwrapped on personal linens instead of in protective packaging as required. In a separate case, the ADON prepared wound care supplies on an unsanitized cart and initially placed them on a toilet surface before moving them to a sanitized bedside table, later acknowledging a barrier should have been used under the supplies. Additionally, a medication aide performed hand hygiene before medication preparation but did not sanitize hands again immediately before donning gloves to administer oral medication and an inhaler to a resident.
A resident with dementia and psychotic disturbances repeatedly physically assaulted three other residents with similar vulnerabilities, while staff failed to consistently monitor, intervene, or document required actions as outlined in care plans and physician orders. This resulted in multiple incidents of abuse and a lack of protection for residents.
Five residents with orders for bowel management did not receive prescribed medications such as MOM, Dulcolax, or Fleet Enema after multiple days without a BM. Despite documented periods of constipation, staff did not administer interventions as ordered, and the DON confirmed that nursing staff should have tracked and provided bowel care medications according to physician instructions.
During kitchen inspections, spoiled onions with visible mold, a toaster with heavy black residue, and coffee cups with brown buildup were found, with staff confirming these items were not in sanitary condition.
A resident with bipolar disorder, dementia, and insomnia was prescribed multiple psychotropic medications, but staff failed to monitor and document side effects as ordered. The resident was repeatedly observed falling asleep during activities and meals, appearing unkempt, and showing signs of over-sedation, yet these observations were not recorded in the MAR. The DON confirmed that staff were not documenting the resident's condition, resulting in inadequate assessment for chemical restraint.
A resident with multiple mental health diagnoses had a PASRR Level II documented in the medical record, but the MDS assessment was incorrectly coded to indicate no PASRR Level II. The MDS Coordinator confirmed the error, which was identified through record review and staff interview.
A resident with dementia and major depressive disorder had a care plan that directed staff to identify triggers for aggressive behavior and use non-pharmacological interventions, but the plan did not specify what those triggers were. The DON confirmed that the resident becomes agitated by overstimulation, but this information was not included in the care plan, leaving staff without necessary guidance.
A resident with muscle weakness, difficulty walking, and a history of falls was assisted to a couch by a CNA. After the transfer, a nurse instructed the CNA to remove the resident's wheelchair from reach. The resident then attempted to self-transfer, lost balance, and fell, sustaining a head injury that required hospital evaluation. Staff statements indicated that removing the wheelchair contributed to the fall.
A resident with obstructive sleep apnea and muscle weakness did not receive prescribed CPAP therapy at bedtime because the machine was nonfunctional and not in use, with the mask found on the floor and the water chamber empty. The resident reported not using the CPAP for a month and instead used oxygen at night. The DON confirmed the CPAP had not worked for two weeks, and although the provider was notified and oxygen was used as an alternative, the order for the CPAP was not placed on hold and the care plan continued to reference its use.
Nursing staff were not adequately educated or competent in identifying and documenting residents' mood, behaviors, and side effects. Despite agendas indicating planned education sessions, there was no evidence that these trainings occurred or that specific content was covered. The DON acknowledged that staff were not consistently recognizing abnormal behaviors, and documentation lacked necessary details.
The facility did not have an RN on-site for 8 consecutive hours on three separate days, as confirmed by staffing records and the Administrator. This failure affected all residents during those days.
The facility failed to maintain accurate documentation in resident records, including inconsistent weight entries for a resident with dysphagia and vitamin D deficiency, and inaccurate recording of CPAP care for another resident with obstructive sleep apnea. Staff signed off on tasks that were not completed, and assessments reflected incorrect information, as confirmed by the DON and an LPN.
The QAPI committee did not take action to resolve systemic problems with inaccurate documentation of resident mood, behaviors, and side effects, despite being aware of the issue. This failure affected all residents in the facility.
During peri-care for a resident, two CNAs sanitized their hands and donned gloves before starting care. One CNA removed soiled gloves and donned new gloves without performing hand hygiene in between, contrary to CDC guidelines. Both CNAs performed hand hygiene only after completing care and removing gloves. Staff interviews confirmed the expectation for hand hygiene between glove changes.
Failure to Maintain Proper Food Temperatures and Palatability
Penalty
Summary
The deficiency involves the facility’s failure to provide food that was palatable and maintained at residents’ preferred and appropriate temperatures for all residents receiving facility-prepared meals. One resident reported that cold salads were served warm because they were placed on the hot food plate under a plate cover, and stated she preferred her salads cold and did not know why they were not served with cold beverages. Another resident refused a lunch tray when the surveyor observed that the cold salad had been placed on the hot food plate under the plate cover, while a cold fruit bowl and juice were placed next to the hot plate. Resident council minutes over several months documented repeated concerns that some foods expected to be hot were not served hot, some foods expected to be cold were not served cold, and that certain items such as mashed potatoes were watery. On a later observation of the serving line, two items (pureed chili macaroni and regular-diet green peas) required reheating before plating, and dietary staff stated the food had been on the serving line for 30 minutes and should not have lost temperature so quickly. A test tray taken from a hall tray cart showed hot items (chili macaroni casserole, peas, toast) and cold items (cantaloupe, apple juice, milk, salad) all outside appropriate temperature parameters. The registered dietitian acknowledged that small cold salads should be kept on the cold side and not placed on the hot plate, and agreed that the test tray temperatures were out of range. The dietary manager stated he did not know why the steam table was not maintaining proper temperatures and acknowledged that cold food items should not be placed on hot plates or under plate covers.
Failure to Ensure Proper Use of Beard Restraints in Food Preparation Area
Penalty
Summary
The facility failed to maintain a clean and sanitary food preparation environment when dietary staff with facial hair did not consistently use beard restraints in accordance with the FDA Food Code. On 1/5/26 at 11:49 AM, one staff member was observed plating residents’ food while wearing a beard guard around his neck rather than over his facial hair; upon making eye contact with the surveyor, he pulled the beard guard up over his chin and mouth with his gloved hands and continued plating food, without performing hand hygiene. On 1/6/26 at 11:58 AM, the same staff member was again observed plating residents’ food without wearing any beard guard. On 1/8/26 at 11:54 AM, the Dietary Manager stated that all staff with facial hair were required to wear beard guards and confirmed that this staff member had not been wearing one on 1/5/26 and 1/6/26 and had shaved his facial hair before work on 1/7/26. This deficient practice was cited under the requirement to procure, store, prepare, distribute, and serve food in accordance with professional standards and the FDA Food Code, which requires food employees to wear effective hair and beard restraints to prevent hair from contacting exposed food, clean equipment, utensils, and linens.
Failure to Notify State LTC Ombudsman of Resident Discharges and Transfers
Penalty
Summary
The facility failed to ensure the discharge process included required notification to the Office of the State LTC Ombudsman for four residents whose discharges or transfers were reviewed. For a resident with muscle weakness, dementia, and a history of falls who was transferred to the emergency department after a fall, the record showed a coordinated discharge with the receiving facility but lacked documentation that the Ombudsman was notified. Another resident admitted for post-surgical care and treatment of multiple abscesses was discharged home after meeting goals and no longer requiring skilled nursing care; her record documented a coordinated discharge but did not include any indication that the Ombudsman was informed. A resident with dementia, diabetes, and neuropathy was transferred to the emergency department for cellulitis of the right lower leg, and the record reflected coordination with the receiving hospital but no documentation of Ombudsman notification. Another resident with heart failure and COPD required transfers to the emergency department on two separate occasions for COPD exacerbations; in both instances, the records documented coordination with the receiving hospital but did not show that the Ombudsman was notified of either transfer. During an interview, the Administrator confirmed that the facility did not inform the Office of the State LTC Ombudsman of these residents' discharges.
Improperly Secured Schedule II Medications in Medication Refrigerator
Penalty
Summary
Surveyors identified a deficiency in the storage of Schedule II controlled substances when conducting a storage and labeling audit with LPN #1. During the audit, LPN #1 unlocked the medication refrigerator in the medication room, revealing a Schedule II drug compartment inside the refrigerator that was secured with a black lock attached to a drawer. Upon further inspection, the black lock detached from the drawer, leaving all Schedule II medications inside the compartment accessible rather than securely stored in a permanently affixed, locked compartment. LPN #1 confirmed that the compartment was not appropriately secured and stated that, to ensure the safety of Schedule II medications, the compartment should remain locked at all times. The report notes that this failure to ensure Schedule II controlled substances were stored in a permanently affixed, secured compartment created the potential for drug diversion and misappropriation.
Failure to Assess and Timely Complete UA for Resident With Ongoing Weakness and Mental Status Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the resident’s goals and preferences when a resident experienced a change in condition. The resident was admitted with multiple diagnoses including chronic respiratory failure, diabetes, dementia, depression, and muscle weakness. On 12/26, a doctor/nursing communication note documented ongoing dizziness and upper body weakness, with a provider indicating a follow-up would be scheduled. On 12/30, a physician’s history and physical note indicated a pending urinalysis related to dysuria and altered mental status. On 1/4, nursing documented increased weakness and difficulty with transfers and notified physical therapy for an evaluation. On 1/6, nursing documented the resident had a “tick,” dropping arms and head, and staff were directed to collect a urine specimen after the resident was found soiled, although she was usually continent. On 1/7, nursing documented that a UA and culture were collected and sent to a local laboratory, and later that day the lab faxed positive UA results indicating infection. The resident’s record did not include documentation of nursing assessment, vital signs, or UA collection related to her change in mental status and weakness between 12/30 and 1/6, despite these ongoing symptoms. Vital signs were only documented on 1/6 and 1/8. On 1/8, the resident’s POA called the facility expressing concern that the resident “isn’t right” and requested transfer to the ER, and the resident was transferred via non-emergent services. Hospital records from that day documented the resident was seen for weakness and dizziness lasting 1–2 weeks and was admitted with findings including weakness, expressive aphasia, stroke-like symptoms, acute kidney injury on chronic kidney insufficiency, hyperkalemia, and UTI. The DON stated that staff usually complete medical orders within 24 hours if a STAT order is not placed and did not provide a response when asked why the UA had not been completed around 12/30, and also stated that vitals are typically taken only every 30–60 days unless ordered otherwise.
Failure to Reassess and Effectively Manage Ongoing Pain
Penalty
Summary
The facility failed to provide effective pain management for a resident admitted with a right humerus fracture, head injury, and iron deficiency anemia. At admission, the care conference established goals to get the resident’s pain under control and to work with therapy, and a pain evaluation set the resident’s acceptable pain level at 4/10. Medication orders included scheduled Tylenol Extra Strength 500 mg, two tablets three times daily, and PRN oxycodone 5 mg every eight hours for severe pain. The MAR showed 17 administrations of oxycodone over the review period, with documented pain scores ranging from 6/10 to 10/10, all above the resident’s stated acceptable pain level. Physical therapy notes during the same period documented ongoing shoulder pain that created barriers to participation, with one entry describing the resident as very upset with 10/10 pain and emotional about wanting to improve mobility to return home. Another therapy note recorded increased pain while the resident was lying in bed and a request to nursing to administer pain medication. Observations found the resident guarding her right shoulder and reporting she was always in pain and could not recall a time since admission when her pain had been under control, and later stating she was in pain all the time during a medication pass. The DON stated she believed the resident’s pain was well managed based on PRN effectiveness, but upon review of the record did not identify documentation of reassessment or evaluation of the overall pain management plan despite repeated reports of pain levels above the resident’s acceptable goal.
Failure to Provide Ordered Iron Supplement Due to Medication Unavailability and Cart Transfer Error
Penalty
Summary
The facility failed to ensure a resident received a routinely ordered medication when a prescribed iron supplement was not available or administered as ordered. A resident admitted with multiple diagnoses, including a right humerus fracture and iron deficiency anemia, had a physician order for Ferrous Gluconate 324 mg by mouth once daily for supplementation. During a medication pass observation on 1/7/26 at 9:08 AM, the medication aide (MAC #1) preparing the resident’s medications reported that the Ferrous Gluconate was not available in the facility. At 9:10 AM, MAC #1 stated that the physician’s order had been in place since 12/24/25, but the medication had not been administered because it had not been available. On 1/8/26 at 12:38 PM, the DON reported that the facility had obtained the Ferrous Gluconate on 1/1/26, but after the resident was moved to a different room, the medication was not transferred to the new medication cart for nursing staff to administer, resulting in continued missed doses despite the medication being on site.
Inaccurate Transfer Documentation and Incomplete Behavior Intervention Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with muscle weakness, dementia, and a history of falls, the record documented an unwitnessed fall on 12/9/25 at 5:50 PM and included an INTERACT Hospital Transfer Form dated the same day. However, the vital signs recorded on that transfer form were dated 12/3/25, six days prior to the transfer, and therefore did not reflect the resident’s condition at the time of transfer. On 1/7/26, the ADON confirmed that the INTERACT Hospital Transfer Form contained inaccurate information because the vital signs were not current at the time of transfer. For another resident with muscle weakness, visual hallucinations, and dementia, a physician order dated 12/1/25 directed staff to document the number of episodes per shift of specific target behaviors, including exit seeking, hallucinations, delusional statements, and sexually inappropriate comments, and to implement and document specified interventions such as 1:1 conversation, providing activities of choice, assisting the resident to a quiet and calm location with a snack and alternate activities, and reapproaching at a different time. Review of this resident’s behavior monitoring records from 10/1/25 to 12/31/25 showed multiple documented behavior episodes on listed dates without corresponding documentation of the ordered interventions. When the surveyor requested documentation of interventions for those episodes, no additional documentation was provided. On 1/8/26, the DON stated that while the record accurately reflected the behaviors, it did not accurately reflect the interventions used at the time the behaviors occurred.
Infection Control Lapses in PPE Storage, Wound Care Setup, and Hand Hygiene
Penalty
Summary
The deficiency involves failures in infection prevention and control practices related to PPE storage, wound care supply handling, and hand hygiene. One resident with a stage 4 pressure ulcer, paraplegia, a suprapubic catheter, and chronic wounds had an Enhanced Barrier Precaution (EBP) gown stored unwrapped on top of personal linens in the closet, contrary to the care plan that required EBP, including gown and gloves, to reduce MDRO transmission during high-contact care. The Infection Preventionist later stated gowns are to be stored in their original plastic wrapping in the upper area of the resident’s closet and that this resident’s EBP gown should have been stored in a plastic bag. In a separate observation, the ADON prepared wound care supplies on top of a wound cart without sanitizing the cart surface and then placed the supplies on the back of a toilet in a resident’s room before moving them to a sanitized bedside table, later acknowledging a barrier should have been used between the wound care items and the surfaces. In another incident, a medication aide sanitized her hands before preparing medications, then carried the medications and water to a resident’s room, placed them on the bedside table, and applied gloves without performing hand hygiene immediately prior to glove application. The medication aide confirmed she should have performed hand hygiene before donning gloves.
Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents where one resident with dementia and psychotic disturbances physically assaulted three other residents. The facility's abuse policy requires that residents remain free from abuse, neglect, and corporal punishment, but records show that this was not upheld. In each case, the aggressor resident initiated physical altercations, including kicking and slapping, against other residents who had diagnoses such as dementia, muscle weakness, and major depressive disorder. These incidents were reported and investigated, with the aggressor consistently identified as the source of abuse. Despite care plans and physician orders directing staff to monitor the aggressive resident closely, document behaviors, and intervene as necessary, there were repeated failures to implement or document appropriate interventions. Behavior monitoring records indicated multiple episodes of physical aggression without corresponding interventions, and in some cases, incidents of aggression were not documented in the resident's record at all. Staff interviews confirmed that interventions were either not carried out or not documented, and that staff missed opportunities to intervene when the resident became agitated. The lack of consistent monitoring, failure to implement or document required interventions, and inadequate response to escalating behaviors directly contributed to the ongoing risk and occurrence of resident-to-resident abuse. The facility's inaction and insufficient documentation allowed the aggressive behaviors to persist, resulting in repeated physical altercations and a failure to ensure a safe environment for all residents involved.
Failure to Administer Bowel Care Medications per Physician Orders
Penalty
Summary
The facility failed to follow professional standards of practice for bowel and bladder care for five residents with physician orders for bowel management. Each resident had specific orders for the administration of medications such as Milk of Magnesia, Dulcolax suppositories, and Fleet Enemas to be given if a bowel movement did not occur within a specified timeframe. Despite documented periods of three or more days without a bowel movement, the medication administration records showed that these residents did not receive the prescribed interventions. For example, one resident with dementia and poor decision-making ability did not have a bowel movement for four days and was not given any bowel care medications as ordered. Another resident, who was cognitively intact, experienced constipation for up to six days and reported having to request bowel medications from nursing staff, rather than being proactively offered them according to the physician's orders. The Director of Nursing (DON) confirmed upon review that nursing staff should have tracked bowel movements and administered medications as ordered when residents had not had a bowel movement within the specified period. Similar deficiencies were observed for the other residents reviewed, including those with impaired decision-making and those requiring cues or supervision. In each case, the residents' bowel movement records indicated extended periods without a bowel movement, and the corresponding medication administration records showed that the prescribed bowel care interventions were not provided. Staff interviews and record reviews confirmed that the facility did not adhere to the physician's orders for bowel management for these residents.
Unsanitary Food Storage and Drinkware Maintenance
Penalty
Summary
The facility failed to store and maintain food and drinkware in a safe and sanitary manner, as observed during kitchen inspections. In the dry goods pantry, a large box of yellow onions was found with a green fuzzy substance on multiple onions, indicating spoilage. Additionally, a bread toaster on the kitchen counter was noted to have a thick layer of black encrusted particles, and several purple coffee cups stored in a clean cabinet were found with a layer of brown substance inside. These conditions were confirmed by staff interviews, with both the Dietitian and Kitchen Aid acknowledging the unsanitary state of the items.
Failure to Monitor and Document Effects of Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor and document the effects of psychotropic medications for a resident with multiple diagnoses, including bipolar disorder, dementia, and insomnia. Physician orders required staff to monitor for side effects such as over-sedation, lethargy, mental status changes, and changes in mobility. Despite these orders, there was no documentation in the resident's Medication Administration Record (MAR) regarding sedation or lethargy, even though the resident was observed multiple times falling asleep during activities, at meals, and while standing in her doorway. The resident also appeared unkempt and disheveled, with staff noting that her condition was not being documented. Observations included the resident falling asleep at a table during activities, at lunch after only a few bites, and while leaning on her doorway. The resident's care plan directed staff to monitor and report changes in cognitive function, but these changes were not documented. The Director of Nursing confirmed that staff were not documenting the resident's condition, making it unclear if medication adjustments were needed. This lack of monitoring and documentation resulted in the resident not being adequately assessed for potential chemical restraint or unnecessary medication use.
Inaccurate MDS Assessment Coding for PASRR Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for residents, as evidenced by the incorrect coding of a resident's PASRR (Preadmission Screening and Resident Review) status. Specifically, a resident with diagnoses including post-traumatic stress disorder, stimulant abuse, and panic disorder was found to have a PASRR Level II documented in the electronic medical record, but the annual MDS assessment incorrectly indicated that the resident did not have a PASRR Level II. This error was confirmed by the MDS Coordinator, who acknowledged that the assessment should have been coded to reflect the PASRR Level II status. This deficiency was identified through review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, and it was noted that such inaccuracies in assessment information could impact the monitoring and care of residents.
Care Plan Lacked Documentation of Behavioral Triggers
Penalty
Summary
The facility failed to ensure that care plans were revised according to residents' needs, as evidenced by the case of one resident with dementia and major depressive disorder. The resident's care plan, last revised on 11/14/24, instructed staff to investigate and identify potential triggers for aggressive behaviors and to use non-pharmacological interventions, as well as to keep the resident within line of sight due to aggressive tendencies. However, the care plan did not document specific triggers that led to the resident's aggression toward others. During an interview, the DON confirmed that the resident becomes agitated by overstimulation from loud sounds or excessive activity, and that the care plan did not include this information, leaving staff without guidance on identifying triggers for the resident's aggressive behaviors.
Failure to Provide Adequate Supervision Resulting in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with a history of muscle weakness, difficulty walking, and previous falls. The resident's care plan directed staff to keep personal items and assistive devices within reach. On the date of the incident, a CNA assisted the resident in transferring to a couch in the common area. After the transfer, the CNA placed the resident's wheelchair nearby, but a nurse instructed the CNA to remove the wheelchair and place it behind the couch to prevent the resident from attempting to self-transfer. Following the removal of the wheelchair, the resident attempted to self-transfer, lost balance, and fell, resulting in a head injury. The incident and accident report documented that the resident was 5-7 feet away from a transfer area at the time of the fall. Statements from two CNAs indicated that the removal of the wheelchair contributed to the fall. The resident sustained a goose egg on the right side of the head and was sent to the hospital for further evaluation.
Failure to Provide Prescribed Respiratory Care Due to Nonfunctional CPAP Machine
Penalty
Summary
The facility failed to provide necessary respiratory services for a resident with obstructive sleep apnea and muscle weakness. The resident had a physician's order for the use of a CPAP machine at bedtime, but the machine was observed to be nonfunctional and not in use, with the mask found on the floor and the water chamber empty. The resident reported not using the CPAP machine for a month due to it not working and instead used an oxygen cannula at night. The DON confirmed the CPAP machine had not worked for two weeks and that the provider was notified, resulting in the resident being placed on oxygen at night. However, the order for the CPAP machine was not placed on hold, and the care plan continued to reference its use, leading to a failure in following the prescribed respiratory care regimen.
Failure to Ensure Staff Competency in Identifying and Documenting Mood, Behaviors, and Side Effects
Penalty
Summary
The facility failed to ensure that nursing staff, including nurses and nurse aides, were properly educated and competent in identifying and documenting residents' mood, behaviors, and side effects. During a record review with the DON, it was revealed that concerns had been identified regarding incomplete or inaccurate documentation of these areas. Although agendas from several staff education sessions listed topics such as notifying nurses of behaviors and documenting behaviors and side effects, no proof of actual education or specific content covered was provided. The DON confirmed that staff were not consistently identifying abnormal behaviors, and the documentation reviewed did not reflect specific mood, behavior, or side effect information.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on-site for 8 consecutive hours each day, as required, for 3 out of 21 days reviewed. Specifically, on three identified dates, the facility did not provide the mandated RN coverage, as confirmed by a review of nursing staff hours and an interview with the Administrator. This deficiency was identified through record review and staff interview, and it affected all residents in the facility during the days in question. No specific residents or their medical conditions were mentioned in the report, and the deficiency was based on staffing records and administrative confirmation.
Inaccurate Documentation in Resident Medical Records and CPAP Care
Penalty
Summary
The facility failed to ensure that resident records contained accurate documentation for two residents. For one resident with multiple diagnoses including dysphagia and vitamin D deficiency, the medical record showed inconsistent and inaccurate weight entries over several months. A weight recorded on 5/13/25 was later crossed out as inaccurate, but this incorrect value was still used in both the Quarterly Nutritional Assessment and the Quarterly MDS assessment. The Director of Nursing confirmed that these assessments reflected the inaccurate weight. For another resident with obstructive sleep apnea, the care plan and physician orders required daily cleaning of the CPAP mask and weekly replacement of tubing. The Medication Administration Record (MAR) indicated that staff signed off on completing these tasks, but review showed that the order to assist with CPAP placement was not signed off as completed on multiple dates. An LPN stated she did not clean the CPAP machine, despite her credentials indicating otherwise, and the DON reported that the CPAP machine had not worked for two weeks, with no explanation for the inaccurate MAR documentation.
QAPI Committee Failed to Address Documentation Inaccuracies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) committee took effective action to identify and resolve systemic problems related to resident mood, behaviors, and side effects, as evidenced by inaccurate documentation of residents' current conditions. The QAPI plan required the committee to meet regularly, coordinate and evaluate QAPI activities, develop and implement corrective actions for identified deficiencies, and review and analyze data, including that from drug regimen reviews. Despite the Director of Nursing providing ongoing education to nursing staff on these topics, and the administrator acknowledging that the QAPI committee had identified documentation inaccuracies, the committee did not implement a Performance Improvement Plan (PIP) to address the issue. This deficiency affected all 49 residents in the facility.
Failure to Perform Hand Hygiene Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as observed during direct resident care. On one occasion, two CNAs entered a resident's room to provide peri-care. Both staff members sanitized their hands and donned gloves before beginning care. During the process, one CNA removed her soiled gloves, reached into her shirt pocket for a new pair, paused, and then obtained gloves from a box in the resident's bathroom. She donned the new gloves without performing hand hygiene between glove changes. The care was completed, and both CNAs performed hand hygiene only after removing their gloves and before leaving the room. Staff interview confirmed that hand hygiene should have been performed after removing dirty gloves and before donning new gloves, in accordance with CDC guidelines. The DON also stated that the expectation for direct care staff is to wash their hands between glove changes. The failure to follow these infection control protocols was observed and acknowledged by staff, indicating a lapse in adherence to established hand hygiene practices.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
