Sunterra Springs Riverview
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 3550 West Americana Terrace, Boise, Idaho 83706
- CMS Provider Number
- 135139
- Inspections on file
- 19
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Sunterra Springs Riverview during CMS and state inspections, most recent first.
A resident with impaired vision and multiple diagnoses was found to be self-administering antacids and Tylenol from a bedside bottle, despite documentation that she did not wish to self-administer medications and without interdisciplinary team approval, as required by facility policy.
The facility did not notify the physician of significant changes in condition for three residents, including substantial weight loss and abnormal vital signs. Two residents experienced notable weight loss without physician notification, despite care plans indicating risk for nutritional deficits. Another resident had abnormal vital signs prior to death, with no evidence that the physician or DON were informed or that appropriate monitoring was documented.
An LPN diverted multiple doses of controlled medications, including oxycodone, that were prescribed for three residents with serious medical conditions such as fractures, dementia, and post-surgical care. The LPN removed the medications, failed to administer them as ordered, provided inconsistent explanations about their whereabouts, and refused a search of personal belongings. The facility's investigation confirmed the misappropriation and exploitation of resident property.
A resident with multiple diagnoses was transferred to a hospital after experiencing severe pain and diaphoresis during a clinic visit, but the facility failed to provide discharge paperwork or document the reason for hospitalization in the medical record. The DON confirmed that documentation of the transfer and hospitalization reason was not completed as required.
A resident with a history of falls and left-sided weakness had their bed moved against the wall by staff after a fall, but this intervention was not added to the care plan. The DON and RNC confirmed the omission when reviewing the care plan and observing the resident's room.
Three residents experienced deficiencies in care, including unclarified medication orders for Parkinson's and antifungal treatment, and missed or undocumented physical and occupational therapy sessions. The facility did not ensure medication orders were clarified with providers or that therapy was delivered and documented as scheduled.
An LPN was found to have worked with residents without completing the required onboarding training, having finished only a small portion of the assigned modules. The Administrator confirmed the incomplete training, and the DON was unaware of the deficiency and had not addressed it.
A pharmacist recommended that an antipsychotic medication be administered with food for a resident, but the physician did not indicate acceptance or rejection of this recommendation on the review form. The medication was scheduled without instructions to give it with food, and nursing leadership confirmed the lack of physician acknowledgment.
A resident with multiple medical conditions was given lorazepam, an anti-anxiety medication, on two occasions without any documented symptoms or behaviors of anxiety. The DON confirmed that the medication was administered without the necessary documentation to support its use as required.
Two residents experienced significant medication errors when one received divided doses of lurasidone against physician orders, and another was given Lyrica and auvelity intended for a different resident. The DON confirmed both incidents after reviewing records and staff reports.
A resident with hypertensive heart disease and heart failure was prescribed Prazosin HCl 1 mg, 2 capsules twice daily, but the pharmacy label instructed administration of only 1 capsule twice daily. An LPN administered the medication according to the incorrect label, and the DON confirmed that the label should have matched the physician's order.
Three residents experienced discomfort due to improper temperature control in their rooms. One resident's room was consistently cold, another's bathroom was particularly cold, and a third faced fluctuating temperatures. Despite thermostat settings indicating compliance, ambient temperature readings showed discrepancies, leading to discomfort and potential health risks. The Maintenance Director acknowledged issues with thermostat accuracy, and the Administrator noted that while regulatory temperature ranges were met, the facility's policy required resident comfort.
The facility did not ensure pharmacy recommendations were addressed by the attending physician for two residents, potentially leading to harm. One resident was prescribed alprazolam without a stop date, and another was prescribed vancomycin without a specified duration. The DON received the recommendations but could not show they were reviewed by the physician due to a rescheduled QAPI meeting.
A resident with a documented allergy to opioid analgesics was administered oxycodone due to an error in transcribing allergy information from hospital documents. The allergy was not listed in the transferring hospital's records, leading to the administration of the medication without complication. The error was confirmed by the DON and went unnoticed during order verification and medication administration.
Failure to Ensure Interdisciplinary Team Approval for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined it was safe for a resident to self-administer medications, as required by facility policy. The policy stated that residents may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely. In this case, a resident with multiple diagnoses, including hypertension and GERD, and who was legally blind, had a care plan and a self-administration evaluation indicating she did not want to self-administer medications while in the facility. Despite this, surveyors observed a bottle labeled antacids on the resident's bedside table containing both antacids and Tylenol. The resident stated she took the antacids and Tylenol whenever she needed them. The DON confirmed the medications at the bedside and acknowledged that the resident should not be self-administering medications, as documented in the assessment.
Failure to Notify Physician of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure timely physician notification of significant changes in condition for three residents. For one resident with multiple diagnoses including a femur fracture, diabetes, and Crohn's Disease, a 14.9% weight loss occurred over 27 days, but there was no documentation that the physician was informed of this significant change. Another resident with a femur fracture, B-12 deficiency anemia, and hyperlipidemia experienced an 11.66% weight loss over 84 days, again without evidence of physician notification. Both residents were identified as being at risk for nutritional deficits and had care plans indicating that untreated weight variances should not occur. A third resident with mild cognitive impairment, sepsis, and Parkinson's disease exhibited a notable decrease in blood pressure and increases in temperature and heart rate, but there was no documentation that the physician or DON were notified of these changes. The resident was later found pulseless and passed away, with conflicting documentation regarding the frequency and nature of monitoring prior to death. Interviews with facility staff confirmed the lack of physician notification and absence of required documentation regarding these significant changes in condition.
Diversion of Controlled Substances by LPN Resulting in Misappropriation and Exploitation
Penalty
Summary
The facility failed to protect residents from misappropriation of property and exploitation, as evidenced by the diversion of controlled medications intended for three residents. The incident involved an LPN who was observed by the DON to mishandle and ultimately divert multiple pills, including oxycodone, which were prescribed for residents with significant medical needs such as fractures, dementia, post-surgical care, and congestive heart failure. The LPN removed several controlled substances into a single medicine cup, signed them out in the controlled medication logbook, and then failed to administer them to the residents as ordered. When questioned, the LPN provided inconsistent explanations regarding the disposal of the medications and refused to allow a search of her personal belongings before leaving the facility. A review of the controlled drug logbook, medication administration records, and resident interviews confirmed that five doses of oxycodone, belonging to three residents, were signed out but not administered. The facility's investigation substantiated that the LPN diverted these medications, constituting misappropriation of resident property and exploitation. The incident was documented in a Facility Reported Incident and confirmed by the Administrator, with evidence showing that the medications were not located and the LPN was responsible for their diversion.
Failure to Provide Resident-Specific Discharge Documentation During Hospital Transfer
Penalty
Summary
The facility failed to provide resident-specific discharge paperwork to the hospital during the transfer of a resident. Record review showed that the resident, who had multiple diagnoses including aftercare following a surgical procedure, was transported to an infectious disease clinic but refused to get out of the vehicle due to severe pain and diaphoresis. The clinic's physician assistant assessed the resident and sent him to the emergency room. However, the nursing notes did not document the reason for the resident's hospitalization, and there was no documentation in the record explaining why the resident was at the hospital. The Director of Nursing confirmed that the best practice would have been to document the resident's transfer and the reason for hospitalization, but this was not done.
Failure to Update Care Plan After Fall Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated as needed following a significant change in the resident's condition. The resident, who had a history of repeated falls, major depressive disorder, and anxiety, was admitted with left-sided weakness and was identified as being at risk for falls. The initial care plan directed staff to encourage the use of the call light and to keep the resident's room free of clutter and tripping hazards. However, after the resident fell out of bed and staff moved the bed against the wall as a fall intervention, this change was not documented or incorporated into the resident's care plan. The Director of Nursing and Registered Nurse Coordinator confirmed that the intervention of placing the bed against the wall was not included in the care plan, despite being implemented after the fall.
Failure to Clarify Medication Orders and Provide Scheduled Therapy
Penalty
Summary
The facility failed to ensure professional standards of care were followed for three residents reviewed for quality of care. For one resident with mild cognitive impairment, dysphagia, sepsis, and Parkinson's disease, there was a lack of clarification regarding the frequency of Carbidopa/Levodopa ODT dosing after the resident's spouse brought in medication and requested a change due to swallowing difficulties. Documentation showed conflicting orders and a possible transcription error, but there was no evidence that the provider clarified the correct dosing frequency. For another resident with chronic lymphocytic leukemia, the medication order for Voriconazole was unclear and inconsistent with the hospital discharge summary, and the DON acknowledged the order should have been clarified with the physician. A third resident, admitted for aftercare following digestive surgery and heart failure, did not receive scheduled physical and occupational therapy sessions as ordered. Progress notes lacked documentation on the number of therapy attempts, whether the resident refused therapy, or reasons for missed sessions. There was also no evidence that missed therapy sessions were made up on the weekend, and a progress note explaining a missed session was entered 14 days after the fact. These deficiencies demonstrate failures in medication order clarification and therapy service delivery according to professional standards and resident care plans.
LPN Provided Care Without Completing Required Training
Penalty
Summary
The facility failed to ensure that a licensed nurse had completed the required onboarding training and demonstrated the necessary competencies before providing care to residents. Personnel record review showed that one LPN, hired on 9/26/25, had only completed 3 out of 24 assigned training modules, with no documentation of full onboarding training in her file. The Administrator confirmed that the LPN had not completed the required training and acknowledged that she should not have been working with residents. The DON stated that all newly hired staff are required to complete assigned training before working with residents but was unaware that this LPN had not fulfilled the requirement and had not addressed the issue.
Physician Failed to Address Pharmacist Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding medication administration were addressed by the physician for one resident. Specifically, a pharmacist reviewed a resident's medication regimen and recommended that lurasidone, an antipsychotic medication, be administered with food as per the manufacturer's instructions for proper absorption. This recommendation was documented on the Interim Medication Regimen Review form, which included a section for the physician to indicate acceptance or rejection of the pharmacist's recommendation. Despite the pharmacist's documented recommendation, the physician signed the form without indicating whether the recommendation was accepted or declined. Further review of the resident's Medication Administration Record (MAR) showed that the medication was scheduled for administration in the afternoon, but there was no indication that it should be given with food. Facility nursing leadership confirmed that the physician should have acknowledged the pharmacist's recommendation, but this was not done.
Psychoactive Medication Administered Without Documented Indication
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs when a psychoactive medication was administered without adequate indication for its use. A resident with multiple diagnoses, including depressive disorder, hypertension, and osteoporosis, had a physician's order for lorazepam to be given as needed for anxiety. The medication administration record showed that lorazepam was administered on two occasions, but there was no documentation of anxiety symptoms or behaviors at those times. The Director of Nursing confirmed that the medication was given without documentation of the required symptoms or behaviors, contrary to facility expectations.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by two documented incidents involving medication administration. For one resident with multiple diagnoses, including aftercare for a right femur fracture and psychiatric conditions, the physician's order specified lurasidone 100 mg daily, to be given as 20 mg and 80 mg together. However, the Medication Administration Record (MAR) showed the doses were administered separately at different times over a ten-day period, contrary to the order. The Director of Nursing (DON) reviewed the records and could not explain why the doses were divided during that period. In another case, an LPN administered Lyrica 75 mg and auvelity 45-105 mg, both controlled and antipsychotic medications, to the wrong resident. The medication was intended for a different resident in another room. The error was documented in a medication error report, and both the affected resident and her husband were upset, though no physical harm was noted. The DON confirmed the LPN reported the error and accepted responsibility.
Medication Labeling Discrepancy for Antihypertensive Drug
Penalty
Summary
The facility failed to ensure that the pharmacy label for a resident's medication matched the physician's order. Specifically, a resident with hypertensive heart disease and heart failure had a physician's order for Prazosin HCl 1 mg capsules, instructing administration of 2 capsules by mouth twice daily. However, the pharmacy label on the medication card directed staff to give only 1 capsule by mouth twice daily. During medication administration, an LPN prepared and administered the medication according to the label, not the updated physician's order. Upon review, the LPN confirmed the discrepancy between the label and the order, and the Director of Nursing acknowledged that the pharmacy label should match the physician's order.
Temperature Control Issues in Resident Rooms
Penalty
Summary
The facility failed to maintain comfortable bedroom temperatures for three residents, leading to discomfort and potential health risks. Resident #10 reported his room was consistently too cold, despite the thermostat being set to 78 degrees Fahrenheit. Observations confirmed the room felt drafty and cold, with the ambient temperature measured at 71 degrees Fahrenheit, indicating a discrepancy with the thermostat reading. The Maintenance Director acknowledged the issue, suggesting the thermostat might need repair. Resident #127 also experienced discomfort due to cold temperatures, particularly in her bathroom, which she described as feeling like the North Pole. Despite the thermostat being set to 76 degrees Fahrenheit, the ambient temperature in her bedroom was 70 degrees Fahrenheit, and the bathroom was even colder at 68 degrees Fahrenheit. The Maintenance Director was unaware of her complaints, and the discrepancy between the thermostat and ambient temperature readings was noted. Resident #144 faced fluctuating temperatures, with her room being too cold in the mornings and too hot in the evenings. The thermostat settings and readings varied, with the ambient temperature measured at 71 degrees Fahrenheit, despite the thermostat reading 77 degrees Fahrenheit. The Maintenance Director attributed the temperature fluctuations to the large windows in her room. The Administrator noted that the Maintenance Director's computer showed all rooms within the regulatory temperature range, but the facility's policy required temperatures to be comfortable for residents.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed or addressed by the attending physician for two residents, which could potentially lead to harm if medications were administered without a clinical rationale. The facility's policy required the pharmacist to send monthly medication reviews to the Director of Nursing (DON) or designee, who would then print the recommendations and provide them to the medical provider for review and signature. However, this process was not completed for two residents, as the physician did not sign off on the pharmacy consultation reports. One resident was prescribed alprazolam for depression without a stop date, and the pharmacy recommended re-evaluation after 14 days, as per regulations for PRN psychotropic medications. Another resident was prescribed vancomycin for osteomyelitis, but the order lacked a specified duration of therapy, with the pharmacy recommending a duration of at least six weeks. The DON acknowledged receiving the pharmacy recommendations but could not provide evidence that the physician had addressed them, as the review was delayed due to a rescheduled Quality Assurance and Performance Improvement (QAPI) meeting.
Medication Error Due to Inaccurate Allergy Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, which led to the administration of a medication listed on the resident's allergy list. The resident, admitted for care following a lumbar fracture, had an allergy to opioid analgesics documented in his medical record. Despite this, the resident was prescribed and received oxycodone, an opioid analgesic, since mid-December. The Director of Nursing (DON) confirmed that the allergy was incorrectly transcribed from the transferring hospital's documents, which did not list an opioid allergy. This error went unnoticed during the verification of physician orders and each administration of the opioid medication.
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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