Terraces Of Boise, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 5301 E Warm Springs Ave, Boise, Idaho 83716
- CMS Provider Number
- 135141
- Inspections on file
- 18
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Terraces Of Boise, The during CMS and state inspections, most recent first.
A resident with cognitive impairment experienced emotional and financial harm when a staff member used the resident's credit card for personal expenses. The facility did not initiate an internal investigation when the family first reported unauthorized charges, only acting after law enforcement confirmed the theft.
Surveyors found that food items were improperly stored, uncovered, undated, and unlabeled, with cooked food stored below raw food and raw fish above raw beef. Cutting boards were discolored and pitted, making them difficult to sanitize, and equipment such as condenser fan covers and dish drying racks had accumulated dust. During meal preparation, a staff member failed to clean or sanitize cutting boards and knives between uses, increasing the risk of cross-contamination.
Surveyors found that staff left wet laundry in washing machines for extended periods, failed to keep clean and dirty laundry separated, and brought dirty linen into clean areas. Staff also did not consistently perform hand hygiene during medication administration, and medications were left unsecured on top of a medication cart. These actions reflect lapses in infection control and medication handling.
Staff failed to treat residents with dignity by referring to those needing eating assistance as "feeders" and by not serving meals at the same time to residents seated together. One resident with Alzheimer's and other conditions waited for her meal while another at the same table was already eating, due to a delay in preparing a special diet meal. The facility's policy requires respectful communication and simultaneous meal service, which was not followed.
Two residents with Alzheimer's disease and muscle weakness were placed on position change alarms without prior assessment of less restrictive interventions, documentation of the alarms as potential restraints, or obtaining required consents and physician orders. The DON confirmed that only fall risk assessments were completed and that no consent was obtained before alarm use.
A resident with multiple medical conditions reported a missing heirloom ring, which was not formally investigated or documented as potential misappropriation. Although staff searched and posted notices, there was no written record of the investigation or staff interviews, resulting in a failure to appropriately address the alleged violation.
A resident with multiple medical conditions had conflicting MDS assessments regarding mobility, with the admission assessment showing no impairment and the quarterly assessment incorrectly documenting impairments. Observations confirmed the resident could move both arms, and the MDS nurse later acknowledged the quarterly assessment was coded in error.
A resident with chronic lung conditions was observed multiple times without the prescribed oxygen nasal cannula, despite orders and a care plan requiring continuous oxygen. Staff later confirmed the resident had been weaned off oxygen and was on room air with monitoring, but the care plan and physician's order were not updated to reflect this change.
A nurse administered the incorrect dose of gabapentin to a resident with multiple medical conditions, giving 400 mg in the morning instead of the prescribed 300 mg. This error was discovered after the medication was given, when the LPN reviewed the physician's order and realized the mistake, indicating a failure to follow medication administration protocols.
A resident with sleep apnea and COPD did not receive physician-ordered oxygen therapy at 2 LPM via nasal cannula at all times. The resident was observed on multiple occasions without oxygen, and facility staff confirmed the order was not being followed.
A resident's medications were left unattended on the medication cart by an LPN, who also failed to ensure that the pharmacy label for Oxycodone matched the physician's order. Both the LPN and DON confirmed that medications should not be left unattended and that pharmacy labels must reflect current orders, but discrepancies and improper practices were observed.
The facility failed to ensure kitchen equipment cleanliness and proper food storage, potentially affecting 36 residents. Observations showed dust on air conditioner fan covers in the walk-in refrigerator and pink slime mold in the ice machine. The Maintenance Technician confirmed quarterly cleaning schedules but was unsure why the air conditioning cover was not cleaned. The Dietitian was unaware of the last service date for the ice machine.
The facility failed to properly dispose of garbage, leading to debris accumulation around the garbage compactor, which could attract pests. The area was cleaned every two weeks, but the Dietitian was unsure of the last cleaning date. The Maintenance Technician and Administrator confirmed the cleaning schedule, noting the area was cleaned the previous week and was due for cleaning the next day.
The facility did not adhere to infection prevention measures as reusable medical equipment was not disinfected between residents. An LPN used a mobile vital signs machine on two residents without cleaning it between uses, contrary to the facility's policy and CDC recommendations. The LPN and a CNA indicated that the equipment was cleaned only once daily, while the Administrator stated it should be cleaned after each use.
Failure to Prevent Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect a resident's rights by not preventing the misappropriation of the resident's funds. A resident, admitted with multiple diagnoses including dementia and depression, was found to have had $1,900 stolen from their personal finances by a facility staff member. The theft was discovered after the resident's family noticed unauthorized activity on the resident's credit card statement following a short-stay rehabilitation. The family reported their concerns to the facility, but due to uncertainty about the source of the charges, the Executive Director directed the family to contact law enforcement rather than initiating an internal investigation at that time. Subsequently, law enforcement confirmed that a staff member had used the resident's credit card for personal expenses. The facility only began its internal investigation, staff training, and resident reviews after being notified by the police of the confirmed theft. The failure to act promptly when first notified by the family resulted in emotional and financial harm to the resident, as the facility did not take immediate steps to investigate or prevent further misappropriation.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and sanitation practices. In the walk-in meat refrigerator and freezer, food items such as salmon, cooked beef, chicken wings, chicken tenders, and scones were found open, uncovered, undated, and unlabeled. Cooked food was stored below raw food, and raw fish was stored above raw beef, contrary to FDA Food Code requirements. The Kitchen Manager confirmed that these items should have been covered, labeled, dated, and stored according to proper food safety protocols. Cutting boards in the main kitchen and storage areas for multiple houses were found to be discolored, pitted, and stained, making them difficult to clean and sanitize. The Kitchen Manager acknowledged that these cutting boards should have been replaced due to their condition. Additionally, condenser fan covers in the walk-in produce refrigerator and dish drying racks were observed with layers of dust, and the Kitchen Manager admitted these had not been cleaned or sanitized as required. During dinner tray line observation, a staff member repeatedly placed food containers and utensils on a cutting board and knife used for preparing mechanical chopped diets without cleaning or sanitizing the surfaces between uses. The staff member also placed a drinkable straw on the same cutting board before serving it to a resident. The staff member stated that containers were cleaned prior to use but did not believe cross-contamination was occurring. The Kitchen Manager later confirmed that the cutting board and knife should have been cleaned and sanitized after contact with containers and between uses.
Deficient Infection Control in Laundry, Hand Hygiene, and Medication Storage
Penalty
Summary
Surveyors identified multiple deficiencies related to infection prevention and control within the facility. Observations revealed that residents' wet laundry was left sitting in washing machines for extended periods, with no tracking system in place to monitor when loads were started or moved to the dryer. Clean and dirty laundry were not consistently separated, as clothes were found hanging on both sides of the laundry room, and staff entered the clean side of the laundry area with bags of dirty linen. Staff interviews confirmed inconsistent practices and a lack of clear procedures for handling laundry, with some staff unaware of proper protocols for maintaining separation between clean and dirty items. Additionally, staff failed to consistently perform hand hygiene during medication administration. One RN did not perform hand hygiene before entering a resident's room to administer medications, acknowledging the lapse when questioned. Medication storage practices were also deficient, as capsules were observed left directly on top of a medication cart without a barrier, and an LPN admitted the capsules should have been placed in a medication cup. These actions and inactions demonstrate lapses in basic infection control and medication handling procedures.
Failure to Ensure Dignified Dining Experience and Simultaneous Meal Service
Penalty
Summary
Facility staff failed to ensure residents were treated with dignity during dining services, as evidenced by staff referring to residents requiring assistance with eating as "feeders" and identifying their table as a "special table" needing extra help. This was observed when a CNA oriented an agency CNA by pointing out the table with residents who needed assistance and repeatedly used the term "feeders" in reference to these individuals. The facility's Dignity Policy requires staff to promote residents' well-being and self-esteem and to always speak respectfully to residents, which was not followed in these instances. Additionally, the facility did not serve meals simultaneously to residents seated at the same table. One resident with Alzheimer's disease, osteoarthritis, and muscle weakness was observed waiting for her meal while another resident at the same table had already been served and was eating. The resident expressed concern about not having food and requested more to drink while waiting. Staff explained that the delay was due to the kitchen forgetting to prepare a special diet meal, resulting in the resident being served significantly later than her tablemate. The registered dietitian confirmed that residents at the same table should be served at the same time.
Failure to Assess and Document Use of Position Change Alarms as Potential Restraints
Penalty
Summary
The facility failed to ensure that position change alarms were properly assessed as potential restraints and that appropriate consents and physician orders were obtained prior to their use. Specifically, for two residents with Alzheimer's disease and muscle weakness, position change alarms were implemented as fall prevention devices without documentation that less restrictive interventions had been attempted first. There was also no assessment in the residents' records regarding the use of these alarms as potential restraints. Observations confirmed that both residents were using tab alarms attached to their wheelchairs and clipped to their shirts. Interviews with the DON revealed that while fall risk assessments were completed, no specific assessment was conducted before placing the alarms, and consents were not obtained from the residents' representatives. The facility's policy required monitoring and documentation of interventions, but these steps were not followed in these cases.
Failure to Investigate and Document Missing Resident Property
Penalty
Summary
The facility failed to investigate a resident's missing personal item as a potential misappropriation of property. A resident, who was cognitively intact and had diagnoses including Parkinson's disease, diabetes, and hypertension, reported that a ring given to her by her grandmother went missing. The resident stated she informed the facility, and staff told her they would look for the ring. The ring, described as having three stones (an emerald in the middle and two diamonds on the sides, set in gold), was brought into the facility by a family member and reported missing two weeks later. Staff actions included posting a picture of the ring in the facility and searching the resident's room and laundry, but the ring was not found. Despite these efforts, there was no documentation of the investigation, including interviews with staff or progress notes regarding the missing ring. The Executive Director confirmed that while staff were interviewed and searches were conducted, there was no written record of these actions. The lack of documentation and formal investigation into the missing item constituted a failure to respond appropriately to an alleged violation involving potential misappropriation of a resident's property.
Inaccurate MDS Assessment Coding for Resident Mobility
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessments accurately reflected their physical status. Specifically, a resident admitted and later readmitted with multiple diagnoses, including heart disease, anemia, and hypertension, had conflicting MDS documentation. The admission assessment indicated no impairment in upper and lower extremities, while the subsequent quarterly assessment documented impairments on both sides of the upper and lower extremities. Observations of the resident showed the ability to move both arms and support their chin, which contradicted the quarterly MDS assessment. Upon review, the MDS nurse confirmed that the quarterly assessment was mistakenly coded as showing impairments, when it should have indicated no impairment.
Failure to Update Care Plan Following Change in Oxygen Therapy
Penalty
Summary
The facility failed to ensure that care plans were revised as needed for a resident with multiple diagnoses, including sleep apnea and chronic obstructive pulmonary disease. A physician's order directed staff to provide continuous oxygen at 2 LPM via nasal cannula, and the resident's care plan reflected this order. However, on multiple occasions, the resident was observed without the oxygen nasal cannula and reported not having used it for some time. Staff confirmed that the resident had been weaned off oxygen and was now on room air with oxygen saturation monitored twice daily, but neither the care plan nor the physician's order had been updated to reflect this change in treatment.
Medication Administration Error Due to Failure to Follow Physician's Orders
Penalty
Summary
A deficiency occurred when a nurse failed to administer medication according to professional standards and physician's orders for one resident. The facility's policy required staff to verify the correct medication, dose, time, and route before administration. Despite this, an LPN administered 400 mg of gabapentin in the morning instead of the prescribed 300 mg dose for that time. The error was identified when the LPN reviewed the physician's order after the medication had already been given. The resident involved had a history of inflammatory neuropathy, anemia, and hypertension, and was admitted with orders for both 300 mg and 400 mg gabapentin at different times of day. This incident was observed during a medication pass and confirmed through policy review and staff interview, demonstrating a failure to follow established medication administration protocols.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered for a resident with diagnoses including sleep apnea and chronic obstructive pulmonary disease. A physician's order directed staff to administer oxygen at 2 liters per minute via nasal cannula at all times for every shift. However, on two separate occasions, the resident was observed lying in bed without the prescribed oxygen. The resident reported not having used her oxygen for some time and was unsure when it had stopped. The Assistant Director of Nursing confirmed that the facility was not providing the ordered oxygen therapy at the time of review.
Failure to Secure Medications and Ensure Accurate Pharmacy Labeling
Penalty
Summary
The facility failed to ensure that medications were secured when unattended and that pharmacy labels matched physician orders for a resident with multiple diagnoses, including stage 4 pressure ulcers and hypertension. During medication administration, an LPN was observed leaving a cup containing a white powder (Miralax) unattended on top of the medication cart while attending to other tasks, including assisting a resident and checking the kitchen menu. Both the LPN and the Director of Nursing confirmed that medications should not be left unattended on the medication cart. Additionally, a discrepancy was found between the physician's order and the pharmacy label for the resident's Oxycodone prescription. The physician's order specified 0.5 tablet by mouth twice daily, both scheduled and as needed, while the pharmacy label indicated 0.5 tablet by mouth four times daily as needed. The LPN acknowledged the mismatch and stated that an order change sticker should be used, but none was present. The Director of Nursing confirmed that pharmacy labels should match physician orders and that a new card should be dispensed when orders change.
Deficiency in Kitchen Equipment Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain kitchen equipment cleanliness and proper food storage, which could potentially affect the 36 residents consuming food prepared by the facility. Observations revealed that the air conditioner fan covers in the main kitchen walk-in refrigerator were coated with dust, with strands waving in the air current. Additionally, the ice machine in the main kitchen had a layer of pink slime mold on the interior side. These conditions were confirmed by the Dietitian and the Maintenance Technician during the survey. The Maintenance Technician stated that the ice machine is serviced and cleaned quarterly by a third-party vendor, with the last cleaning occurring on 11/26/24. However, the presence of pink slime mold indicated a lapse in maintaining cleanliness. The Maintenance Technician also mentioned that the walk-in refrigerator air conditioning covers are supposed to be cleaned quarterly, but he was unsure why the specific cover in question was not cleaned. The Dietitian was also unaware of when the ice machine was last serviced, highlighting a lack of oversight in maintaining sanitary conditions.
Improper Garbage Disposal Attracts Pests
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which could attract insects and rodents, potentially affecting all residents, staff, and visitors. According to the FDA Food Code Section 5-501.15, outside receptacles and waste handling units should be installed to minimize debris accumulation and pest attraction. On December 19, 2024, it was observed that various items of edible and non-edible refuse were scattered around the ground near the garbage compactor. The Dietitian was unsure when the area was last cleaned, while the Maintenance Technician and Administrator confirmed that the area was cleaned every two weeks after the compactor was emptied. The area had been cleaned the previous week and was not scheduled for cleaning until the following day.
Failure to Disinfect Reusable Medical Equipment
Penalty
Summary
The facility failed to ensure proper infection prevention measures were taken when reusable medical equipment was not disinfected between residents. The facility's policy, revised in September 2022, required that resident care equipment, including reusable medical equipment, be cleaned and disinfected according to current CDC recommendations. However, on December 19, 2024, an LPN was observed using a mobile vital signs machine to obtain blood pressure, pulse, and temperature readings on two residents without cleaning or disinfecting the equipment between uses. The LPN stated that the machine was cleaned once at the end of her shift. Additionally, a CNA mentioned that the mobile vital signs machines were cleaned once a day by night shift staff. The Administrator confirmed that nursing staff were responsible for cleaning the machines after each resident use.
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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