Syringa Chalet Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Blackfoot, Idaho.
- Location
- 700 East Alice Street, Blackfoot, Idaho 83221
- CMS Provider Number
- 135111
- Inspections on file
- 15
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Syringa Chalet Nursing Facility during CMS and state inspections, most recent first.
Surveyors observed that a sharps container in a resident room was filled past the designated full line on multiple occasions, and the flip-top lid was not freely movable. During a joint observation, the DON confirmed the container remained overfilled and acknowledged it should have been changed when full but was not. This failure had the potential for injury and infections.
Surveyors found that the facility did not provide a required bed-hold notice to a resident or the resident’s representative at the time of a hospital transfer. The resident, who had multiple behavioral health diagnoses including paranoid schizophrenia and anxiety, was transferred to the hospital and later returned, but the facility’s bed-hold documentation was not completed for this episode. During interview, the Administrator confirmed that the bed-hold notice was not provided at the time of transfer, despite the requirement to do so.
A resident admitted with major depressive disorder, anxiety disorder, and status post right hip revision had a baseline care plan that did not include key person-centered care information. The facility’s policy required baseline care plans within 48 hours of admission to include physician orders, social services, and PASRR recommendations. However, the resident’s PASRR evaluation, which recommended psychotherapy, community-based rehabilitative services, mental health case management, psychiatric follow-up, and a safety plan for suicidal ideation, was not reflected in the baseline care plan. A physician order for a knee immobilizer to be worn in bed or while sitting was also omitted, and the DON later confirmed these omissions.
A resident with constipation and serious mental illness did not receive bowel management medications as ordered by the physician or as outlined in the facility’s bowel and bladder protocol. The protocol required escalating interventions, including Milk of Magnesia and Bisacodyl, based on the number of hours since the last bowel movement, but documentation showed prolonged periods without bowel movements and no corresponding administration of ordered constipation medications, except for isolated Bisacodyl doses. The Administrator acknowledged that the resident should have received the ordered bowel management medications and did not.
Surveyors found that staff failed to follow and document physician-ordered respiratory services for multiple residents with conditions such as schizophrenia, dementia, COPD, obesity, and bipolar schizoaffective disorder. Several residents had orders for oxygen via nasal cannula with specific SpO2 targets, yet records showed repeated low SpO2 readings, some in the low 80s, without corresponding nursing interventions. One resident was observed with the O2 regulator on but the cannula off, and another reported using oxygen only at night despite an order to maintain certain SpO2 levels. The DON attributed the lack of documented responses to poor and incomplete nursing documentation.
Surveyors found that controlled medications on one medication cart were not properly tracked or secured when narcotic accountability sheets were missing required nurse signatures on multiple days. An RN and the DON both stated that two nurses were expected to sign the narcotic accountability records when accepting or releasing the cart, but this did not occur as required, creating the potential for undetected misuse or diversion of controlled medications affecting all residents receiving these drugs.
Surveyors observed that medication carts for two halls were left unattended outside a dining room during mealtime, with one cart’s drawer containing medications left ajar. Facility policy required all medication areas and cabinets to remain locked when the medication nurse was not present. When an RN returned to the cart and stated it was locked, the surveyor pointed out the open drawer, and the RN was able to open and then properly close and relock it, acknowledging the drawer should have been locked but was not, resulting in unsecured medications accessible to unauthorized individuals.
Surveyors found that in two resident rooms, the bathroom shower call light strings were curled up and did not extend to the floor, making them inaccessible to a resident who might be on the shower floor. The Administrator confirmed that the shower call light strings were expected to extend to the floor area but did not in these bathrooms, creating a situation where a resident could be unable to summon staff for assistance.
Two residents experienced a decline in their ability to perform ADLs due to the facility's failure to provide necessary restorative nursing services. One resident, with schizophrenia and diabetes, did not receive restorative care despite documented needs. Another resident, with schizoaffective disorder and polyneuropathy, experienced increased dependency after physical therapy was discontinued, and restorative services were not consistently provided as ordered.
The facility failed to treat residents with dignity by administering medications and checking blood sugar in common areas without documented consent. Observations showed residents receiving care in public spaces, and interviews revealed a lack of audits and documentation of resident preferences, leading to a deficiency in maintaining resident dignity.
A facility failed to provide a bed hold notice to a resident or their representative at the time of hospital transfer. The resident, with schizophrenia and traumatic brain injury, was transferred to the hospital, but the bed hold document was completed three days after their return. The DON confirmed the notice should have been completed at the time of transfer.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documented medical conditions. A resident's MDS incorrectly noted a feeding tube, while another's inaccurately documented an enteral feeding tube. Additionally, a third resident's MDS omitted a psychosis diagnosis despite being on antipsychotic medication. These errors were confirmed by the DON and staff.
A facility failed to update a resident's care plan to reflect current physician orders. The resident, with schizoaffective disorder and a rotator cuff tear, had a care plan listing spironolactone, which was not in their active or discontinued medication orders. The DON confirmed the resident was not receiving the medication and the care plan should have been updated.
A resident with schizoaffective disorder and COPD had a care plan requiring oxygen saturation levels to be maintained at 90% and physician notification for decreases. Despite multiple documented instances of levels below 90%, CNAs did not inform licensed nursing staff, and the physician was not notified, potentially affecting the resident's health. The DON acknowledged the failure in communication.
The facility's kitchen staff failed to follow proper food handling and storage protocols, including not washing hands before donning gloves and keeping expired food items in storage. A senior cook was observed not washing hands before putting on new gloves, and expired food items were found in both the walk-in and resident refrigerators, contrary to the facility's policy.
The facility failed to ensure garbage cans in the kitchen and food serving area were properly closed with lids, as required by Idaho Administrative Rules and the FDA Food Code. Five uncovered garbage cans were observed, and the Dietary Manager was unaware of the requirement for closing lids. This oversight could attract pests and rodents, potentially affecting all residents and staff.
Failure to Replace Overfilled Sharps Container in Resident Room
Penalty
Summary
The facility failed to provide a safe and functional environment by not properly managing sharps containers in one of four resident rooms. On two separate observations, the sharps container in room 411 was noted to be filled past the indicated full line, and the flip-top lid was not freely movable. During a subsequent joint observation with the DON, the sharps container in the same room was again observed to be filled past the full line. The DON stated that the sharps container should have been changed when it was full and acknowledged that it had not been. This failure had the potential for injury and infections. No additional information was provided about the specific resident(s) occupying the room, their medical history, or their condition at the time of the deficiency.
Failure to Provide Bed-Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a required bed-hold notice to a resident or the resident’s representative at the time of transfer to the hospital, as identified through record review and staff interview. One resident, admitted with multiple diagnoses including paranoid schizophrenia and anxiety, was transferred to the hospital on 7/19/25 and returned on 8/4/25. Review of this resident’s medical record showed that the facility’s bed-hold document had not been completed for this hospitalization. In an interview on 1/22/26 at 4:03 PM, the Administrator confirmed that the bed-hold notice had not been completed at the time of transfer and acknowledged that it should have been done. This deficiency involved the facility’s failure to ensure residents were informed of their rights related to bed-hold and return to their former bed or room at the time of transfer, as required by policy and regulation, for 1 of 4 residents reviewed for transfers.
Failure to Include PASRR Recommendations and Safety Device in Baseline Care Plan
Penalty
Summary
Surveyors identified that the facility failed to include required person-centered care information on the baseline care plan for one resident. The facility’s Baseline Care Plan policy dated 7/11/24 required that a baseline care plan be developed within 48 hours of admission and include minimum healthcare information necessary to properly care for the resident, such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASRR recommendations when applicable. For the resident in question, who was admitted with multiple diagnoses including major depressive disorder, anxiety disorder, and status post right hip revision, the baseline care plan was created but not dated and did not reflect all required elements. The resident’s PASRR Mental Illness Evaluation dated 1/8/26 documented recommendations for individual psychotherapy, community-based rehabilitative services, mental health case management, weekly or quarterly psychiatrist appointments for psychiatric prescription medication management, and development of a safety plan to address suicidal ideation. Additionally, a physician order dated 1/12/26 directed that the resident wear a knee immobilizer while lying in bed or sitting in a chair. Despite these documented recommendations and orders, the baseline care plan did not include the PASRR recommendations or the physician-ordered knee immobilizer. On 1/21/26 at 5:00 PM, the DON confirmed that these items were not included on the baseline care plan and acknowledged they should have been.
Failure to Follow Bowel Management Orders and Protocol
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own bowel and bladder protocol for a resident with constipation and multiple diagnoses, including bipolar schizoaffective disorder. The facility’s protocol dated 7/8/20 directed staff to offer prune juice or Milk of Magnesia 24–48 hours after the last bowel movement, Bisacodyl 5 mg PO/PR at 48–72 hours, and to review the resident’s condition with a medical provider at 72 hours if no bowel movement occurred. Physician orders for this resident included Milk of Magnesia 30 ml by mouth, with one repeat dose allowed in 24 hours as needed for constipation, and one-time Bisacodyl 5 mg EC tablet orders on several dates. Record review showed that after a documented bowel movement on 12/14/25, the resident did not have another recorded bowel movement until 12/23/25, a gap of over 192 hours, with no documentation that any ordered constipation medications were administered between 12/15/25 and 12/23/25. After a bowel movement on 12/30/25, the next was not documented until 1/6/26, during which time only one dose of Bisacodyl 5 mg EC tablet was given on 1/5/26, with no other constipation medications documented from 12/31/25 to 1/4/26. Following a bowel movement on 1/6/26, the next was not documented until 1/12/26, with only one Bisacodyl 5 mg EC tablet administered on 1/12/26 and no documentation of constipation medications from 1/7/26 to 1/11/26. The Administrator confirmed that the resident should have received the ordered bowel management medications and had not.
Failure to Provide and Document Ordered Respiratory Services for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services as ordered by physicians and to document nursing interventions in response to low oxygen saturation (SpO2) readings for seven residents. For one resident with disorganized schizophrenia and anorexia, the physician ordered oxygen at 1–2 LPM by nasal cannula as needed to keep SpO2 greater than 90%. The resident’s record showed multiple SpO2 readings of 90% on various dates with no documented nursing interventions. Another resident with anxiety disorder and dementia had an order for PRN oxygen by nasal cannula, titrated 2–5 LPM to keep SpO2 at 90% as allowed. This resident was observed in bed with the O2 regulator set at 2 LPM while the nasal cannula lay on the overbed table, and the record showed several SpO2 readings between 83% and 89% with no timely or documented interventions, except for one instance where an intervention was documented two hours late. Additional residents with dementia, upper respiratory infection, bipolar schizoaffective disorder, hypertension, paranoid schizophrenia, and obesity had physician orders for oxygen titrated by nasal cannula to maintain SpO2 above 90% as tolerated. Their medical records contained multiple low SpO2 readings, ranging from 85% to 90%, without corresponding documentation of nursing interventions. One resident with bipolar schizoaffective disorder and diabetes had an oxygen order of 2–5 LPM to keep SpO2 at 87–90% as allowed, yet was observed at the nurse’s station without supplemental oxygen and later reported using oxygen only at night or when sitting in his room. This resident’s record also showed several low SpO2 readings, including one as low as 80%, with no documented interventions. A resident with COPD and dementia had a physician order for oxygen via nasal cannula at 0.5–5 LPM, titrated to keep SpO2 between 88–92% as allowed. The record showed SpO2 readings of 82%, 84%, and 87%, with one nursing intervention documented five hours late and no other interventions recorded for the other low readings. Across all seven residents reviewed for respiratory services, surveyors identified repeated instances where low SpO2 values were recorded without corresponding nursing actions or documentation, despite existing physician orders specifying oxygen parameters. The DON stated that the low SpO2 documentation without documented nursing intervention was due to poor and lacking nursing intervention documentation.
Failure to Properly Track and Secure Controlled Medications on Medication Cart
Penalty
Summary
The facility failed to ensure controlled medications were properly tracked and secured from potential theft or diversion for one of two medication carts reviewed. During a medication cart audit conducted on 1/21/26 at 12:46 PM, surveyors observed narcotic accountability sheets dated 1/1/26 to 1/21/26 that were missing three licensed nurse signatures on 1/8/26 and 1/13/26. At 12:48 PM, a registered nurse stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart. At 1:07 PM, the DON confirmed that two nurses were expected to sign the narcotic accountability record when accepting or releasing the medication cart. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medications in the facility. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to the facility’s process for documenting and securing controlled medications on the medication cart.
Unsecured Medication Cart Left Unattended During Mealtime
Penalty
Summary
The deficiency involves the facility’s failure to keep medications secure and inaccessible to unauthorized staff and residents, as required by its own policy and professional standards. The facility’s “Control and Administration of Medications” policy dated 11/13/24 states that all medication areas and cabinets must be kept locked at all times when the medication nurse is not present. During a mealtime observation on 1/20/26 at 12:30 PM, surveyors observed the Sawtooth Hall and Targhee Hall medication carts unattended outside the dining room, and the Sawtooth Hall cart had one drawer containing medications ajar. At 12:33 PM, an RN approached the Sawtooth Hall cart and, when asked, stated the cart was locked; however, the surveyor pointed out the open drawer, and the RN was able to pull the drawer out, push it back in, and then relock the cart. The RN acknowledged that the drawer should have been locked but was not, confirming that medications on that cart were left unattended and unsecured.
Inaccessible Shower Call Light Strings in Resident Bathrooms
Penalty
Summary
Surveyors identified a deficiency in the availability and accessibility of the resident call system in bathroom shower areas. During observations on 1/21/26 at 9:35 AM, the bathroom shower call light strings in resident rooms #303 and #307 were found curled up so they were not accessible to a resident who might be on the floor of the shower. In a subsequent interview on 1/21/26 at 12:50 PM, the Administrator acknowledged that the bathroom shower call light strings should not be curled up and confirmed they should extend to the floor area of the shower but were not. The report states this failure had the potential for harm if residents were not able to summon staff for assistance. No additional resident-specific medical histories or conditions at the time of the deficiency are provided in the report.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain or improve the ability of residents to perform activities of daily living (ADLs), as evidenced by the cases of two residents. Resident #8, with diagnoses including schizophrenia and diabetes, experienced a decline in ADLs without receiving restorative nursing services. Despite documentation showing no initial impairment, later assessments indicated a need for assistance with bed mobility, transfers, and toileting. The Director of Nursing (DON) confirmed the absence of a restorative program and lack of documentation to prevent the decline in Resident #8's ADLs. Resident #18, diagnosed with schizoaffective disorder bipolar type and polyneuropathy, also experienced a decline in ADLs. Initially, there was no impairment, but subsequent assessments showed increased dependency on assistance for mobility. Although a physician ordered restorative nursing for muscle strengthening and range of motion, the resident did not receive these services consistently. The DON acknowledged that Resident #18 had not received the ordered restorative services, contributing to her decline in strength and abilities.
Failure to Ensure Resident Dignity in Medication Administration
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by observations of residents receiving medical care in common areas without documented consent. Specifically, four residents were observed having their blood sugar checked or receiving medications in open areas such as the dining room, hallway, and activity room, where other residents could witness these procedures. The medical records for these residents did not document their preference or consent to receive such care in public spaces, which is a violation of their right to privacy and dignity. Interviews with staff revealed inconsistencies in the facility's practices regarding obtaining and documenting resident consent for receiving medical care in common areas. RN #1 mentioned that audits were conducted to determine residents' preferences, but the Director of Nursing (DON) later confirmed that no such audits were performed, and there were no orders or care plans documenting the residents' consent for public administration of medications or blood sugar checks. This lack of documentation and adherence to the facility's dignity policy resulted in a deficiency that compromised the residents' right to a dignified existence.
Failure to Provide Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives at the time of transfer to a hospital, as required. This deficiency was identified during a review of records and staff interviews, specifically affecting one resident who was transferred to the hospital. The resident, who had multiple diagnoses including schizophrenia and traumatic brain injury, was admitted to the facility and later transferred to the hospital. The bed hold document, which should have been completed at the time of transfer, was not completed until three days after the resident returned to the facility. The Director of Nursing acknowledged that the bed hold should have been completed at the time of the hospital transfer.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could lead to negative outcomes due to inaccurate assessments. Resident #2 was admitted with multiple diagnoses, including bipolar disorder and hypertension. Her Quarterly MDS inaccurately documented the presence of a feeding tube, which was confirmed as an error by the Director of Nursing (DON) and a registered nurse (RN). Similarly, Resident #14's MDS incorrectly noted an enteral feeding tube, which the resident and the DON confirmed was never in place. Resident #33, diagnosed with dementia and major depressive disorder, was on Risperidone for psychosis, as documented in her pharmacy Drug Regimen Review report and care plan. However, her Quarterly MDS failed to document her psychiatric disorder, including dementia with behavioral disturbances and psychosis. The DON acknowledged that the physician had not updated the medication list, resulting in the omission of the psychosis diagnosis on the MDS.
Care Plan Not Updated to Reflect Current Orders
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current physician orders. This deficiency was identified for one resident who was admitted with multiple diagnoses, including schizoaffective disorder depressive type and a rotator cuff tear. The resident's care plan, initiated in September, incorrectly documented that the resident was to receive spironolactone, an anti-hypertensive medication, which was neither listed in the resident's active nor discontinued medication orders. This discrepancy was noted during a review in December, and the Director of Nursing confirmed that the resident was not receiving spironolactone and acknowledged that the care plan should have been updated to remove the medication.
Failure to Follow Care Plan for Oxygen Saturation Monitoring
Penalty
Summary
The facility failed to ensure that care plans were followed for a resident with schizoaffective disorder bipolar type and chronic obstructive pulmonary disease. The resident's care plan required CNAs and licensed nursing staff to maintain oxygen saturations at 90% and to notify the physician if levels decreased. However, multiple instances of oxygen saturation levels below 90% were documented by various CNAs over a period of time, with no evidence that the licensed nursing staff were informed or that the physician was notified. This oversight had the potential for adverse effects on the resident's medical and physical status. The Director of Nursing confirmed that the CNAs documented the low oxygen levels but failed to notify the licensed nursing staff as required.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The kitchen staff at the facility failed to adhere to proper food handling and storage protocols as outlined in the U.S. Food and Drug Administration 2022 Food Code. Specifically, a senior cook was observed not washing her hands before donning new gloves after removing the old ones, which is a violation of the food safety code that requires handwashing before putting on gloves. This lapse in hygiene practice was confirmed by the Dietary Manager, who acknowledged that the cook should have washed her hands before putting on new gloves. Additionally, the facility was found to have expired food items in both the walk-in refrigerator and the resident refrigerator. Observations revealed expired cut-up lettuce, ranch dressing, and pineapple juice in the walk-in refrigerator, as well as opened salsa, mayonnaise, French Onion Dip, and Watermelon Minute Maid in the resident refrigerator, all past their use-by dates. The Dietary Manager and the Director of Nursing confirmed that these items should have been discarded according to the facility's policy on refrigerated food storage.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that garbage cans in the kitchen and food serving area were properly closed with lids, as required by the Department of Health and Welfare - Idaho Administrative Rules and the U.S. Food and Drug Administration 2022 Food Code. This deficiency was observed on two separate occasions, with five uncovered garbage cans noted in the kitchen and food serving area. The Dietary Manager was interviewed and stated she was not aware that the garbage cans needed to have closing lids. This oversight had the potential to attract pests and rodents, affecting all residents and staff in the facility.
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Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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