Temple View Transitional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rexburg, Idaho.
- Location
- 660 South Second Street West, Rexburg, Idaho 83440
- CMS Provider Number
- 135105
- Inspections on file
- 18
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Temple View Transitional Care Center during CMS and state inspections, most recent first.
Surveyors found multiple environmental and safety deficiencies, including fly strips covered with bugs left hanging in a resident room since the prior summer, a metal bracket protruding at eye level in a bathroom used by a visually impaired resident, and vents in resident and common areas coated with gray and black substances. Walls near a nurse’s station had large gouges and missing paint, and vents in that area had visible buildup, with no evidence on the housekeeping schedule that vents were routinely cleaned. Leadership acknowledged vents had not been cleaned for about a year and that the fly strips and metal bracket should not have been present. In addition, a sharps container in a medication prep room was overfilled past the full line, and its wall enclosure was left unlocked and ajar, contrary to what an RN and the DON stated should occur when sharps containers are full.
Staff failed to provide dignified assistance during mealtime when an RNA was observed standing while spoon-feeding a resident seated at a dining table. The RNA reported that she routinely stands so she can move around the room to assist others, despite the DON and Regional Nurse stating that staff should not stand while feeding residents. This practice, identified through observation and staff interviews, had the potential to negatively affect residents’ self-esteem, enjoyment of meals, and food and fluid intake.
Surveyors found that the facility did not follow its own policy requiring that residents receive information and assistance with advance directives at admission and that this be documented in the medical record. For two residents with serious conditions, including acute posthemorrhagic anemia, COPD, acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib, records lacked any advance directive and lacked documentation that information or assistance to formulate one was offered to the residents or their representatives. A social services assessment incorrectly indicated that one resident had an advance directive when only a financial DPOA was on file, and both the LSW and DON confirmed that neither resident had been offered help to create an advance directive.
Surveyors found that the facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by its own care planning policy. One resident with COPD and other conditions had a physician order for continuous oxygen at 2 LPM via NC every shift, but this oxygen therapy was not included in the care plan, which the DON acknowledged should have been care planned. Another resident with acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib was observed with bilateral upper side rails in use, yet the care plan did not document side rail use, which the DON also confirmed should have been included. These omissions were identified through observation, policy and record review, and staff interview.
Two residents did not receive care according to physician orders and professional standards. One resident with bilateral lower extremity amputations had a wound vac ordered for a left BKA site, but observations showed the device applied to the right residual limb, and the DON’s transcription of the order remained inconsistent with the resident’s actual anatomy. The same resident had Biotene ordered for dry mouth and a care plan for self-administration after nurse preparation, with the Biotene kept at the bedside despite no specific order authorizing bedside availability. Another resident with COPD and diabetes had a detailed PRN bowel regimen ordered, but over a prolonged period without a documented BM, there was no documentation that any of the ordered laxatives, suppositories, or enemas were administered, which the DON acknowledged should have occurred.
The facility failed to follow its safe resident handling policy by using improper transfer techniques and not ensuring adequate staff assistance during transfers. One resident with anemia and COPD was lifted from a wheelchair to bed by two CNAs who grabbed under the arms and legs instead of using a gait belt as described in the facility’s approved “bear hug” method. Another resident with pneumonia, UTI, and CHF, care planned for two-person assistance and documented as dependent for transfers, was moved using a bear hug by a single CNA while another CNA only stood by; a gait belt was either not used or was too loose, and the resident ended up positioned perpendicular on the bed.
Surveyors found that two residents did not receive oxygen therapy as ordered. One resident with COPD and depression had a provider order for continuous O2 at 1.5 L/min via nasal cannula, but was repeatedly observed receiving 2 L/min from both bedside and portable concentrators, which were labeled and set at 2 L/min. Another resident with orthopedic aftercare, Sjogren's disease, and diabetes had orders for weekly O2 tubing changes and a humidifier bottle change every Sunday night shift, yet the humidifier bottle remained in use beyond the ordered interval, as shown by its dated label and confirmed by the DON.
A resident with acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib was observed with bilateral upper side rails in use, but the facility failed to follow its bed rail policy requiring attempts and evaluation of alternatives before rail installation. The medical record did not contain documentation of alternatives attempted, how they failed to meet the resident’s needs, or the purpose of the side rails. The DON acknowledged that a required side rail assessment had not been completed.
Surveyors found that controlled medications were not consistently tracked according to facility practice on two of three medication carts. During audits of two hall carts, narcotic accountability sheets covering several days were missing one of the two required licensed nurse signatures. A CMA and an LPN each stated that two nurses should sign the narcotic sheets when accepting or releasing the carts, and the DON confirmed this requirement. The missing signatures showed that dual-nurse verification of controlled medications was not reliably completed, affecting all residents receiving controlled drugs.
A resident with a right above-knee amputation and diabetes had PRN orders for acetaminophen for pain rated 1–5 and Percocet for pain rated 6–10, with a maximum of four doses per day. MAR review showed Percocet was administered multiple times for documented pain levels of 4–5, which did not match the ordered indication. The DON acknowledged that the pain medication should have been administered according to the specified pain levels but was not, resulting in opioid use without adequate indication as required by the facility’s unnecessary drugs policy.
Surveyors found that the facility failed to ensure medications were properly stored and not expired. During an audit of a medication cart on one hall, an RN was present when a bottle of Gas Relief with an expiration date of 7/25 was found on the cart. The RN acknowledged the medication should have been discarded but had not been removed, and the DON confirmed that expired medications should have been removed from the cart but were not.
Surveyors identified that the facility did not employ a qualified Director of Food and Nutrition Services, as both the Dietary Supervisor and Assistant Dietary Supervisor reported they were not Certified Dietary Managers or otherwise qualified for the director role. The Dietary Supervisor stated he was only enrolled in a Certified Dietary Manager course, and the Assistant Dietary Supervisor stated she had taken the course previously but did not complete the required in-person training and needed to retake it. The Administrator confirmed that neither individual met the qualifications for Director of Food and Nutrition Services and that they were only in the process of pursuing certification, creating a situation in which all residents receiving meals were potentially affected by the absence of a qualified food and nutrition services director.
The facility failed to maintain accurate medical records for pain management for two residents. For one resident with a right above-knee amputation and diabetes, the MAR showed Percocet administrations documented under a staff member whose role was inconsistently recorded in the EMR, with the DON acknowledging the system reflected incorrect credentials. For another resident with an above-knee amputation, multiple sclerosis, and chronic pain syndrome, physician orders required a Fentanyl 75 mcg/hr patch every three days and Q-shift documentation of the patch site, but the December MAR contained discrepancies between recorded administration sites and Q-shift site observations. The DON stated that nurses had not been documenting the correct Fentanyl patch site on the MAR.
Surveyors identified multiple infection control failures, including an LPN serving meal trays to two residents without offering hand hygiene before eating and performing a wound vac dressing change for a resident while changing gloves several times without washing hands between glove changes. In addition, two CNAs entered the room of a resident on enhanced barrier precautions and transferred the resident without donning required PPE, and an RN removed a dirty food cover and meal tray from a food cart that still contained an undelivered meal tray, acknowledging that soiled items should not have been placed in the cart with undelivered meals.
A resident with multiple sclerosis and an overactive bladder was observed in a hallway with an uncovered urinary drainage bag. The DON confirmed the bag should have been covered, resulting in a failure to maintain the resident's dignity.
The facility did not accurately post daily nurse staffing information for 46 days between April and October 2024. Observations and staff interviews revealed missing data on the scheduled and actual hours worked by RNs, LPNs, and CNAs. The DON, Administrator, and ADON confirmed the incomplete status of the staffing sheets.
The facility failed to store and label food items properly, with observations of non-dated and improperly sealed food in refrigerators, and cold items left without proper chilling. The Food Service Manager confirmed these items should have been labeled and dated, indicating non-compliance with food safety policies.
The facility failed to maintain a clean and safe environment for its residents, as evidenced by unclean equipment and disrepair. Observations included a sit-to-stand device and feeding pump stand with visible dirt and substances, unsanitary conditions in resident rooms, and structural issues like missing flooring and cracked windows. The Housekeeping Supervisor and Maintenance Manager acknowledged these oversights, indicating a lapse in maintaining the facility's standards.
The facility failed to maintain infection control practices, as staff did not encourage hand hygiene before meals and improperly handled medications. A CNA and an NA did not offer hand hygiene to residents before eating, and an RN and an LPN were observed touching medications with bare hands. Both staff members acknowledged their errors.
The facility failed to ensure resident dignity by not knocking and waiting for acknowledgment before entering rooms during meal delivery. Staff entered two residents' rooms without following this protocol, with one CNA stating the door was open and another acknowledging the oversight. The ADON confirmed the requirement to knock before entering.
Two residents in the facility were found with medications in their rooms without proper assessments or physician's orders for self-administration. One resident with multiple sclerosis had a bottle of Equate Fiber Powder, and another with COPD had TUMS, both lacking necessary documentation. The facility's policy requires assessments and orders for self-administration, which were not followed, leading to potential inappropriate medication use.
The facility failed to accurately document the MDS assessments for residents with serious mental illnesses, such as schizophrenia and bipolar disorder. Despite PASRR Level II indicating these diagnoses, the MDS assessments were incorrectly marked, potentially leading to unmet mental health needs. The inaccuracies were confirmed by the MDS Resource Nurse and acknowledged by the Regional Nurse, ADON, and Administrator.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with chronic right heart failure and COPD. The facility's policy and state regulations require such a plan to ensure effective and person-centered care. The oversight was confirmed by the MDS clinical resource nurse and ADON, acknowledging the absence of a completed baseline assessment.
The facility failed to update care plans for two residents, one with multiple sclerosis and nicotine dependence, and another with cirrhosis of the liver. The first resident's care plan inaccurately reflected her smoking abilities, while the second resident's care plan lacked documentation of required quarterly assessments for self-administration of medications. The DON acknowledged these oversights.
A resident with multiple diagnoses, including anxiety and depression, was identified as needing supervised smoking. Despite this, the resident was found smoking unsupervised, leading to a fall from a wheelchair and a skin tear. The facility's DON confirmed the resident was supposed to be supervised but was allowed to smoke independently, and no documentation of supervision was provided.
The facility failed to provide respiratory services as ordered for three residents. A resident with chronic respiratory failure was seen without her oxygen cannula, despite a continuous oxygen order. Another resident with COPD received unauthorized nebulizer treatment from a COTA, while a third resident with heart failure and COPD was found without his oxygen cannula, using it only at night against physician orders.
A resident with acute osteomyelitis and cerebral palsy was not appropriately monitored for Levetiracetam levels, prescribed for seizure disorder. The facility failed to conduct baseline and biannual therapeutic level checks, as confirmed by the ADON and Clinical Resource nurse.
The facility failed to properly label, date, and store medications, as observed in the medication storage room, resident rooms, and treatment carts. A Tubersol vial was undated, and two residents had unauthorized medications in their rooms. Additionally, an unlocked treatment cart with prescription wound care supplies was found, posing a risk for cross-contamination.
The facility failed to employ sufficient qualified staff in food and nutrition services, as the Food Service Manager lacked the Certified Dietary Manager certification and the dietitian was only part-time. This deficiency could impact residents needing medical nutrition therapy and dietary interventions.
Failure to Maintain Clean, Homelike Environment and Safe Sharps Handling
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Homelike Environment policy. Surveyors observed in one resident room a fly strip in the middle of the room covered with bugs and another fly strip by the window with several bugs; the resident in that room reported the fly strips had been there since the previous summer and had been placed by maintenance. In the same room’s restroom, a metal bracket was observed protruding from the wall at eye level; the resident stated she did not know what metal bracket was being referenced because she could not see very well. In another room’s restroom, the vent was observed to be covered with a gray, fuzzy substance. In common areas, a ceiling vent in the hallway outside the dining rooms was covered with a thick black substance, and vents in the front lobby had a black substance on both the vent and the surrounding ceiling. Additional environmental concerns were observed on Hall 100, where walls near the nurse’s station had large areas of gouges and missing paint, and the vent above the nurse’s station had a black substance on the vent and surrounding ceiling. Review of the Housekeeping Weekly Cleaning Schedule showed no documentation that vents were included in routine cleaning. The Maintenance Supervisor acknowledged the walls should have been repaired, the vents needed cleaning, and that the fly strips and metal bar should not have been in the resident room, while the DON stated she was unaware of the fly strips and that they should not have been present. The Administrator reported that vents, which should have been cleaned by maintenance, had not been cleaned for a year. In the medication prep room on Hall 100, a sharps container was observed filled past the full line, with the wall-mount enclosure unlocked and ajar; an RN and the DON both stated the sharps container should have been changed when full and the enclosure kept locked.
Failure to Provide Dignified Assistance During Mealtime
Penalty
Summary
The deficiency involves staff failing to treat a resident who required assistance with eating in a dignified and respectful manner, as required by resident rights to a dignified existence, self-determination, and communication. On 1/5/26 at 11:37 AM, a restorative nursing assistant (RNA #1) was observed standing next to a dining room table while spoon-feeding Resident #34 during lunch, rather than sitting at eye level or in a more respectful position. At 11:40 AM, the RNA stated she always stands while feeding so she can move around the room to help other residents if needed. At 11:50 AM, the DON and the Regional Nurse confirmed that staff should not be standing while feeding residents, indicating that the observed practice was inconsistent with facility expectations and contributed to the failure to provide dignified assistance with eating. This practice was identified through observation, review of the State Operations Manual, and staff interviews, and was determined to have the potential to negatively affect residents’ self-esteem, enjoyment of meals and mealtime, and food and fluid intake.
Failure to Provide and Document Assistance With Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advance directive, as required by facility policy. The Nursing Administration – Advance Directive Documentation policy (revised December 2019) required that, at admission, residents be provided written information regarding advance directives and that the medical record document whether the resident had executed such a document. For one resident with diagnoses including acute posthemorrhagic anemia and COPD, the social services assessment documented that the resident had an advance directive, but the medical record contained only a Durable Power of Attorney for financial matters, not for medical decisions. The record lacked any advance directive and lacked documentation that information about advance directives was provided or discussed with the resident or her representative. The LSW confirmed that this resident did not have an advance directive or documentation that she was offered assistance to formulate one and that she should have. Another resident, admitted with diagnoses including acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib, also had no documentation of an advance directive in the medical record. Review of this resident’s record showed no evidence that an advance directive existed or that the resident or his guardian had been offered assistance to formulate one. The DON confirmed there was no advance directive in the record and that neither the resident nor his guardian had been offered the opportunity to formulate an advance directive. The surveyors determined that, for 2 of 17 residents reviewed for advance directives, the facility did not follow its policy or regulatory requirements to provide information and assistance regarding advance directives and to document this in the medical record.
Failure to Include Oxygen Therapy and Side Rail Use in Resident Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans as required by its Comprehensive Person-Centered Care Planning policy, revised April 2025. The policy states that the IDT must develop and implement a comprehensive, person-centered, culturally competent, and trauma-informed care plan for each resident within seven days of completion of the MDS, including needs identified in the comprehensive assessment, specialized services from PASARR recommendations, and the resident’s goals, desired outcomes, and discharge preferences. Record review showed that a resident with multiple diagnoses, including acute posthemorrhagic anemia and COPD, had a physician’s order dated 12/19/25 for continuous oxygen at 2 LPM via nasal cannula every shift, but this oxygen use was not documented in the resident’s care plan. During an interview on 1/6/25 at 11:54 AM, the DON confirmed that the resident’s oxygen had not been care planned and acknowledged that it should have been. Another resident, admitted with multiple diagnoses including acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib, was observed on 1/5/26 at 10:21 AM with bilateral upper side rails in use on the bed. Review of this resident’s care plan showed that the use of side rails was not documented. In an interview on 1/6/26 at 1:38 PM, the DON stated that the resident’s care plan did not document the use of side rails and confirmed that it should have. Based on observation, policy review, record review, and staff interview, surveyors determined the facility failed to develop and implement comprehensive resident-centered care plans for 2 of 17 residents reviewed, placing residents at risk of negative outcomes if services were not provided or were provided incorrectly due to lack of information in their care plans.
Failure to Follow Physician Orders for Wound, Medication Access, and Bowel Management
Penalty
Summary
The facility failed to follow professional standards of practice in providing care according to physician orders and resident care plans for two residents. One resident with a left below-knee amputation and right above-knee amputation had a physician order dated 12/26/25 for a wound vac to the left below-knee residual limb with continuous suction at 125 mmHg every shift. Observation on 1/5/26 showed the wound vac attached instead to the right above-knee residual limb. The DON reported she had transcribed the order incorrectly and later revised the order, but the revision still documented the wound vac to the right BKA, which did not match the resident’s actual physical assessment. The same resident also had an order for Biotene mouthwash for dry mouth and a care plan indicating self-administration of medication after the nurse prepares it, with Biotene observed at the bedside. The DON later stated the medical record should have included an order allowing the Biotene to be kept at the bedside, but no such order was present. Another resident with COPD and diabetes had multiple physician orders for a bowel management regimen, including Milk of Magnesia, prune juice, Dulcolax suppositories, and Fleet enemas to be administered as needed on specified days without a bowel movement. The medical record documented a bowel movement on 12/28/25 and then not again until 1/4/26, indicating more than 168 hours without a documented bowel movement. During this period, there was no documentation that the ordered bowel management medications were administered. The DON stated that this resident should have received the ordered medications for bowel management but had not.
Unsafe Resident Transfer Techniques and Failure to Follow Safe Handling Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were handled safely during transfers in accordance with its Safe Resident Handling/Transfers policy, which requires safe transfer techniques and use of gait belts or lifts as needed. For one resident with acute posthemorrhagic anemia and COPD, surveyors observed two CNAs transferring her from wheelchair to bed by one CNA standing behind the wheelchair and sliding her arms under the resident’s armpits while the other CNA placed her arms under the resident’s legs, lifting her out of the wheelchair and placing her in bed. When questioned, one CNA stated the resident was care planned to be transferred in this manner. The Director of Rehabilitation later explained that the proper “bear hug” transfer is for a resident who can assist with a one-person transfer and requires a gait belt around the resident’s waist, and that grabbing a resident under the arms and legs is not appropriate. The DON also stated the CNAs should not have transferred the resident by grabbing her under the arms and legs. The deficiency also includes an incident involving another resident admitted with pneumonia, UTI, and CHF, whose care plan required two staff for transfers. A physical therapy evaluation documented the resident needed partial/moderate assist for chair/bed-to-chair transfers, and a subsequent MDS documented the resident was dependent for such transfers, requiring the assistance of two or more helpers. Despite this, an incident report and staff statements showed that one CNA performed a bear hug transfer from wheelchair to bed while another CNA stood behind and did not actively assist. The CNA performing the transfer reported not remembering using a gait belt, while the other CNA stated a gait belt was present but too loose, and the resident landed perpendicular on the bed after the transfer. The DON stated that the CNA used the bear hug technique, was hurrying, and should have slowed down and waited for the second CNA to assist.
Failure to Follow Oxygen Therapy Orders for Two Residents
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for two residents. One resident with COPD and depression had a physician order for continuous oxygen at 1.5 L/min via nasal cannula starting 11/6/25, but was observed on multiple occasions receiving oxygen at 2 L/min via nasal cannula in both the dining room and her room. Both the bedside oxygen concentrator and the portable concentrator on her walker were labeled and set to deliver 2 L/min, and an RN confirmed that the oxygen rate should have been 1.5 L/min as ordered and had not been. Another resident with diagnoses including orthopedic aftercare, Sjogren's disease, and diabetes had a physician order for weekly oxygen tubing changes and humidifier bottle changes every Sunday on the night shift, starting 12/21/25. Surveyors observed on three separate days that this resident’s oxygen humidifier bottle was still dated 12/28/25, indicating it had not been changed according to the order. The DON stated that the humidifier should have been changed on the most recent Sunday and had not been.
Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own bed rail policy requiring that appropriate alternatives be attempted and evaluated before installing bed rails, and that residents or their representatives be provided sufficient information to make an informed decision. The policy, revised in August 2017, states that alternatives must be tried prior to installing side or bed rails and that, if rails are used, the facility must ensure correct installation, use, and maintenance. The policy also requires documentation of the assessed medical needs addressed by bed rails, the expected benefits and likelihood of those benefits, the risks and how they will be mitigated, and the alternatives attempted that failed or were considered inappropriate. For one resident reviewed for bed rails, the facility did not document that these requirements were met. The resident was admitted with multiple diagnoses, including acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib. During observation, the resident was noted to have bilateral upper side rails in use. However, the medical record lacked documentation of any evaluation of alternatives attempted, any explanation of how those alternatives failed to meet the resident’s needs, and any documentation of the purpose or intended use of the side rails. In an interview, the DON confirmed that the resident did not have a side rail assessment completed and acknowledged that such an assessment should have been done.
Failure to Maintain Proper Narcotic Accountability on Medication Carts
Penalty
Summary
Surveyors determined the facility failed to ensure controlled medications were properly tracked and secured from potential theft or diversion on two of three medication carts reviewed. During an audit of the 200 Hall medication cart on 1/7/26 at 4:40 PM, the narcotic accountability sheet for 1/1/26 to 1/7/26 was observed with one required licensed nurse signature missing. Shortly thereafter, a CMA stated that two nurses should have signed the narcotic accountability sheet and acknowledged she had not signed it when she accepted the medication cart that day. During an audit of the 100 Hall medication cart at 4:45 PM, the narcotic accountability sheet for the same date range was also found with one licensed nurse signature not documented. An LPN stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart. The DON likewise stated that two nurses should have signed the narcotic accountability record when they accepted or released the medication cart. These observations and staff interviews showed that required dual signatures for narcotic accountability were not consistently obtained or documented for controlled medications on two medication carts, creating the potential for undetected misuse or diversion of controlled medications for all residents receiving such medications in the facility.
Opioid PRN Order Not Followed for Pain-Level Parameters
Penalty
Summary
The facility failed to ensure a resident’s opioid pain medication was used only with adequate indications, as required by its Unnecessary Drugs policy, which states that a resident’s medication regimen must be free from unnecessary drugs, including those given without adequate indications for use. A resident with multiple diagnoses, including a right above-knee amputation and diabetes, had PRN orders for acetaminophen 325 mg every 4 hours as needed for pain rated 1–5, and Percocet 10-325 mg every 4 hours as needed, with a maximum of 4 doses per day, for pain rated 6–10. Medication administration records showed that Percocet was repeatedly administered for pain levels documented as 4 or 5, which did not meet the ordered indication of pain rated 6–10. On interview, the DON confirmed that the pain medication should have been administered according to the ordered pain levels and that it had not been, demonstrating that the resident’s opioid regimen was not managed in accordance with the facility’s policy and the physician’s orders. This failure was identified for one of seventeen residents reviewed for unnecessary medications and created the potential for residents to experience adverse consequences or increased risk of death.
Expired Medication Found on Medication Cart During Audit
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices when auditing a medication cart. During an audit of the 200 Hall medication cart conducted with an RN present, surveyors observed one bottle of Gas Relief on the cart with an expiration date of 7/25 printed on the bottle. The RN acknowledged that the bottle of Gas Relief should have been discarded and had not been removed from the cart. Later, the DON also stated that expired medications should have been removed from the medication cart and confirmed that this had not occurred. The report states that, based on observations, record review, and staff interviews, the facility failed to ensure medications were properly stored and not expired, and that this failure was true for the entire facility. The presence of the expired Gas Relief on the medication cart demonstrated noncompliance with requirements that drugs and biologicals be labeled in accordance with accepted professional principles and properly stored.
Lack of Qualified Director of Food and Nutrition Services
Penalty
Summary
The deficiency involves the facility’s failure to employ a qualified Director of Food and Nutrition Services as required. During an initial kitchen tour, the Dietary Supervisor reported that he was not a Certified Dietary Manager or a qualified Director of Food and Nutrition Services, although he was enrolled in a Certified Dietary Manager course. At the same time, the Assistant Dietary Supervisor stated she was also not a Certified Dietary Manager or qualified Director of Food and Nutrition Services; she had previously taken a Certified Dietary Manager course in 2023 but did not attend the required three-day in-person training needed to complete the course and therefore had to retake it. Later, the Administrator confirmed that both the Dietary Supervisor and Assistant Dietary Supervisor were not qualified Directors of Food and Nutrition Services and were only enrolled in an online Certified Dietary Manager course, with anticipated certification at a later date. This lack of a qualified Director of Food and Nutrition Services had the potential to affect all residents receiving meals prepared in the facility’s kitchen. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was identified through staff interviews and review of qualifications against regulatory requirements for food and nutrition services leadership.
Inaccurate Pain Management Documentation and Staff Credential Recording
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records for residents, specifically related to pain management documentation. For one resident with a right above-knee amputation and diabetes, the November 2025 MAR showed that Percocet 10-325 mg was administered on three occasions and documented as given by CNA #4. Review of the active employee list showed that this staff member was listed as a registered nurse with specific hire, termination, and rehire dates. The DON stated that CNA #4 was currently working as a registered nurse and that the facility had been unable to change her credentials in the electronic medical record system, resulting in inaccurate staff credential information on the MAR. For another resident with an above-knee amputation, multiple sclerosis, and chronic pain syndrome, physician orders dated 10/8/25 directed application of a Fentanyl 75 mcg/hr patch every three days, and an order dated 10/3/25 required documentation of the patch site every shift. The December 2025 MAR documented the dates, times, and shoulder locations where the Fentanyl patch was applied, as well as Q-shift documentation of the patch site. On review, a discrepancy was identified between the documented administration/site entries and the Q-shift site observations for the Fentanyl patch. The DON stated that nurses should have been documenting the correct site of the Fentanyl patch on the MAR and had not, resulting in inconsistent and inaccurate documentation for this resident’s pain management treatment.
Failure to Follow Hand Hygiene, Enhanced Barrier Precautions, and Meal Tray Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow its Infection Prevention and Control Program – Hand Hygiene Policy and enhanced barrier precaution practices, as well as improper handling of meal trays. The hand hygiene policy required handwashing with soap and water before eating and after using the restroom, when hands are visibly soiled, and after contact with residents with infectious diarrhea. Surveyors observed an LPN serving meal trays to two residents in their rooms without offering or encouraging hand hygiene before eating. During a wound vac dressing change for another resident, the same LPN washed her hands and donned a gown and gloves, removed the resident’s socks, Ace bandage, Kerlix, and old dressing, then removed and reapplied gloves multiple times without washing her hands between glove changes after cleaning the wound. The LPN later stated she should have washed her hands between glove changes and thought she had. Surveyors also observed failures to follow enhanced barrier precautions and proper food cart practices. Enhanced Barrier Precaution signage was posted on a resident’s door, but two CNAs entered the room and transferred the resident from wheelchair to bed without donning the required PPE; one CNA later acknowledged PPE should have been used before the transfer. In a separate observation, an RN identified that there was one undelivered tray remaining in the food cart, then removed a dirty food cover and meal tray from the same cart containing undelivered meals. The RN later stated that the dirty food cover and meal tray should not have been placed in the meal cart when undelivered lunch trays were still inside.
Failure to Maintain Resident Dignity by Not Covering Urinary Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis and an overactive bladder was observed in a wheelchair in the hallway with her urinary drainage bag exposed and without a privacy cover. This observation occurred during a survey, and the Director of Nursing confirmed in an interview that the urinary drainage bag should have been covered but was not. The lack of a privacy cover for the urinary drainage bag failed to uphold the resident's right to dignity and respect, as required by facility policy.
Inaccurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted daily for each shift, as required by the State Operation Manual, Appendix PP. This deficiency was identified through observation and staff interviews, revealing that the Daily Staffing sheets from April 2024 through October 2024 were incomplete for 46 days. Specifically, the sheets lacked the scheduled total hours and actual hours worked by registered nurses (RNs), licensed practical nurses (LPNs), and certified nurse aides (CNAs). The missing data was noted on specific dates in April, May, and June 2024. The Director of Nursing (DON) acknowledged that the staffing information for these dates was either incomplete or not posted at all. The Administrator and Assistant Director of Nursing (ADON) confirmed the incomplete status of the Daily Staffing sheets for the listed dates.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner, as observed during an inspection. Single-serve milk and yogurt containers were left on the counter without ice trays to keep them cold, violating the facility's policy for handling cold foods. In the reach-in refrigerator, a bag of shredded cheese was improperly sealed, a tray of poured juice cups was undated, and a 5-pound sour cream container lacked an opened date. Additionally, the walk-in refrigerator contained a whipped cream container and two containers of pesto that were past their use-by dates. Further inspection revealed multiple non-dated and improperly labeled food items in the snack refrigerators on different halls. These included containers of cottage cheese, milkshake bottles, shredded cheese, cheese spread, sandwiches, pizza, brownies, rice bowls, potato salad, and macaroni salad. The Food Service Manager acknowledged that all food items should have been labeled with a resident's name and dated when opened, indicating a failure to adhere to the facility's food safety policies and procedures.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment for all 65 residents, as evidenced by multiple observations of unclean equipment and disrepair in the facility. Observations included a sit-to-stand device with a white dried substance and visible dirt, and a feeding pump stand with a dry, cream-colored substance. The Housekeeping Supervisor admitted that the equipment should have been cleaned more frequently, and the Director of Nursing (DON) was unaware of the cleaning frequency. Additionally, the Maintenance Manager acknowledged that the sit-to-stand device should have been cleaned before storage. Further observations revealed unsanitary conditions in resident rooms, such as food particles and stains on carpets, large scrapes and scratches on walls, and a privacy curtain with a dry, brown substance. Structural issues were also noted, including a missing piece of flooring in a bathroom, a cracked window, and loose plastic door protectors, which the Administrator and Maintenance Supervisor recognized as potential hazards. These deficiencies indicate a failure to maintain a clean and safe environment, as required by the facility's housekeeping policy.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as observed during meal times and medication handling. On October 21, 2024, staff members did not encourage or offer hand hygiene to residents before meals. Specifically, a CNA and an NA were observed delivering food trays to residents without prompting them to clean their hands. Both staff members later acknowledged that they should have provided or encouraged hand hygiene before the residents began eating. The Infection Preventionist confirmed that hand hygiene should have been offered before meals. Additionally, on October 22 and 23, 2024, improper handling of medications was observed. An RN dispensed medication into a bottle cap, accidentally poured out an extra tablet, and touched it with her ungloved finger before returning it to the bottle. She admitted that she should not have touched the tablet with her bare hand. Similarly, an LPN was seen popping a tablet directly into her bare hand before placing it into a medication cup for a resident. The LPN later stated she did not realize she had done so and acknowledged that she should not have touched the pill with her bare hand.
Failure to Ensure Resident Dignity During Room Entry
Penalty
Summary
The facility failed to ensure the dignity of residents by not adhering to the protocol of knocking and waiting for acknowledgment before entering residents' rooms. This deficiency was observed during the morning meal tray delivery, where staff entered two resident rooms without following this procedure. Specifically, on the morning of October 21, 2024, CNA #2 entered a resident's room without knocking or waiting for acknowledgment, justifying the action by stating that the door was open. Similarly, NA #2 also entered another resident's room without knocking or waiting for acknowledgment, later acknowledging the oversight. The Assistant Director of Nursing (ADON) confirmed that staff are required to knock before entering a resident's room, regardless of whether the door is open or if the resident is visible in their bed.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the ability to self-administer medications, as evidenced by the cases of two residents. Resident #3, who has multiple sclerosis and moderate cognitive impairment, was found with a bottle of Equate Fiber Powder in their room without a documented physician's order for self-administration. The facility's policy requires an assessment and a physician's order for self-administration, which was not followed in this case. The Director of Nursing (DON) acknowledged the oversight and mentioned difficulties in preventing the resident from acquiring unnecessary items. Similarly, Resident #36, who has acute respiratory failure and COPD, was found with a bottle of TUMS in their room without a current physician's order or a self-administration assessment. Although the resident was previously assessed for partial self-administration of a nebulizer, no assessment was documented for the TUMS. An LPN confirmed the absence of a current order and assessment for the TUMS, noting that a previous PRN order had expired. These lapses in following the facility's policy for self-administration assessments and orders created the potential for inappropriate medication use.
Inaccurate MDS Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for four residents, which could potentially lead to unmet mental health needs. Specifically, the MDS assessments for residents with serious mental illnesses, such as schizophrenia and bipolar disorder, were inaccurately documented. For Resident #3, who was diagnosed with schizophrenia, the MDS did not reflect this diagnosis, despite the PASRR Level II indicating the presence of a serious mental illness. Similarly, Resident #4, with a history of bipolar disorder, had multiple annual MDS assessments where section A1500 was incorrectly marked as 'no' for serious mental illness. Additionally, Residents #15 and #38, both diagnosed with schizophrenia, had their MDS assessments inaccurately marked as not having a serious mental illness. The MDS Resource Nurse confirmed that these inaccuracies were present and acknowledged that the MDS should have been marked 'yes' for mental illness in section A1500. The Regional Nurse, along with the ADON and Administrator, also confirmed the discrepancies in the MDS assessments for these residents, acknowledging that the PASRR Level II diagnoses were not accurately reflected in the MDS documentation.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one of the residents reviewed, specifically Resident #52. This deficiency was identified during a review of records, policies, and interviews. The facility's policy, revised in December 2023, mandates that a baseline care plan be developed and implemented within 48 hours of a resident's admission to ensure effective and person-centered care. This requirement is also supported by the State Operation Manual, which specifies that the baseline care plan must include essential healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. Resident #52, who was admitted with multiple diagnoses including chronic right heart failure and COPD, did not have a completed baseline care plan following their admission on September 26, 2024. This oversight was confirmed during an interview on October 24, 2024, with the MDS clinical resource nurse and the Assistant Director of Nursing (ADON), who acknowledged that the baseline assessment had not been completed. The absence of a timely care plan created the potential for harm as it failed to provide necessary direction for the resident's care.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents' care plans were revised to reflect their current needs and interventions, as evidenced by the cases of two residents. Resident #3, who has multiple sclerosis and nicotine dependence, had a care plan that was not updated to reflect her current smoking abilities. Despite a smoking evaluation indicating cognitive loss and dexterity problems, her care plan inaccurately stated she could smoke independently and keep smoking materials in her room. The Director of Nursing acknowledged that the care plan should have been updated to reflect her current status. Resident #21, diagnosed with cirrhosis of the liver and nicotine dependence, had a care plan that required quarterly assessments for self-administration of medications. However, the medical record lacked documentation of these assessments, despite a quarterly MDS assessment indicating the resident was cognitively intact. The Director of Nursing confirmed that the self-administration assessment should have been conducted periodically, and the care plan should have been updated accordingly.
Failure to Supervise Resident During Smoking Leads to Accident
Penalty
Summary
The facility failed to ensure that a resident was free from accidents, specifically in relation to smoking supervision. The facility's Smoking Policy required that residents who were assessed as needing assistance with smoking be supervised during designated times. Resident #9, who had multiple diagnoses including anxiety disorder, depression, and malnutrition, was identified as requiring supervised smoking according to his care plan dated 7/22/24. However, on 8/6/24, Resident #9 was found smoking unsupervised outside, which led to an accident where he fell out of his wheelchair while attempting to dispose of a cigarette butt, resulting in a skin tear to his left forearm. The Director of Nursing (DON) confirmed that Resident #9 was supposed to be a supervised smoker from 7/21/24 until 10/2/24, following a previous incident in the smoking area. Despite this, the DON stated that Resident #9 had been allowed to smoke independently again, which was contrary to the care plan requirements. The facility was unable to provide documentation that Resident #9 was supervised during the incident on 8/6/24, indicating a lapse in following the established smoking supervision policy and care plan for the resident.
Failure to Provide Ordered Respiratory Services
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for three residents. Resident #14, who had chronic respiratory failure with hypercapnia and acute respiratory failure with hypoxia, was observed outside her room without her oxygen cannula on, despite a physician's order for continuous oxygen at 3 liters per minute. Staff were present but did not remind her to use her oxygen, as stated by the Director of Nursing (DON). Resident #28, diagnosed with emphysema and COPD, was observed receiving nebulizer treatment from a Certified Occupational Therapy Assistant (COTA), who was not authorized to administer such treatment according to the facility's job description. The resident's medical record indicated that they could self-administer nebulizer medications. Resident #52, with chronic right heart failure and COPD, was found without his oxygen cannula and his concentrator turned off, despite a physician's order for continuous oxygen at 2 liters per minute. The resident stated he only used oxygen at night, contrary to the physician's order.
Failure to Monitor Medication Levels
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident's medication regimen, specifically for therapeutic range and toxicity levels. This deficiency was identified for a resident who was admitted with multiple diagnoses, including acute osteomyelitis and cerebral palsy. The resident had a physician's order for Levetiracetam, a medication prescribed for seizure disorder, at a dosage of 1000 mg three times a day. However, it was discovered that the resident did not receive a baseline level for Levetiracetam, nor were they monitored for therapeutic levels every six months as required. This oversight was confirmed during an interview with the ADON and Clinical Resource nurse, who acknowledged the need for clarification on the drug dosage and blood monitoring with the physician and pharmacist.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of medications, as observed in the medication storage room, resident rooms, and treatment carts. During an inspection of the medication storage room, a Tubersol solution vial was found without an opened date, which is against CDC guidelines that require multi-dose vials to be dated upon opening. The Director of Nursing (DON) acknowledged that the Tubersol solution should have been dated. In the resident rooms, two residents were found with medications that were not properly documented or authorized. One resident, with moderate cognitive impairment, had a bottle of Equate Fiber Powder in their room without a corresponding medication order. The DON noted that the medication should not have been in the resident's room. Another resident, who was cognitively intact, had a bottle of TUMS without a documented physician's order or self-administration assessment. The LPN confirmed that the resident's PRN order for TUMS had expired, and the DON stated that the resident should not have had the TUMS in their room. Additionally, a treatment cart was observed unlocked outside resident rooms, containing prescription wound care supplies for various residents. RN #2 admitted that the cart should have been locked, and the Assistant Director of Nursing (ADON) confirmed that the treatment cart should not have been left unlocked. This oversight presented a risk for cross-contamination of wound care products stored in the treatment cart.
Insufficient Qualified Staff in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services. This deficiency was identified through observations and staff interviews, revealing that the facility did not have a full-time qualified dietitian or a designated director of food and nutrition services meeting the required qualifications. The Food Service Manager, who was responsible for these duties, had completed an online training program but had not obtained the Certified Dietary Manager (CDM) certification, as she did not complete the necessary exam. The deficiency was further highlighted by the fact that the dietitian was only part-time, visiting the facility once or twice a month for chart audits and being available by phone as needed. The Administrator was under the impression that the Food Service Manager was considered a CDM upon completing her training, unaware that certification required passing an exam. This lack of appropriate staffing and certification had the potential to affect all residents requiring medical nutrition therapy, nutritional assessments, and dietary interventions.
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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