Teton Healthcare Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Idaho Falls, Idaho.
- Location
- 3111 Channing Way, Idaho Falls, Idaho 83404
- CMS Provider Number
- 135138
- Inspections on file
- 20
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Teton Healthcare Of Cascadia during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy and acute respiratory failure with hypoxia was found keeping OTC Refresh eye drops at the bedside and self-using them as needed, despite no documented assessment by the IDT for safe self-administration. Facility policy required the IDT to determine safety, assign responsibility for storage and documentation, and record these decisions in the medical record and care plan before allowing self-administration. Record review showed no such assessment or care plan authorization, and an RN Clinical Resource Nurse confirmed the resident had not been assessed and should not have had the eye drops in the room.
The facility did not follow its call light policy requiring call systems to be within residents' reach. One resident with psychosis and muscle weakness was observed eating at a side table while the call light was tied to a nightstand drawer behind her, out of reach, which a CNA acknowledged was improper. Another resident with hemiplegia and diabetes was found reclining in bed with the call light placed on a bedside table he could not reach after staff provided care, and a CNA confirmed it should have been positioned within his reach. The CNO also stated that call lights are expected to be within residents' reach and were not in these cases.
A resident admitted for post-surgical care following a left femur fracture and muscle weakness did not receive a Notice of Medicare Non-Coverage (NOMNC) within the required timeframe before Medicare Part A skilled services ended. Documentation showed the NOMNC listed the last covered day but was signed by the resident and representative only one day before coverage ended, rather than 48 hours in advance. Social Services noted a phone discussion with the resident’s daughter about the last covered day, and facility leadership acknowledged that the NOMNC was not issued within the required 48-hour window, creating potential financial harm or distress related to unnotified liability for non-covered services.
The facility did not ensure a safe and clean environment in the dining area when surveyors observed two large dining room ceiling vents with brown, hairy-like debris covering part of the inside of each vent and a strip of red, confetti-like paper in one vent, along with brown/black discoloration on the ceiling around other dining room vents. The CEO acknowledged that the vents should have been cleaned and had not been, confirming the lack of appropriate environmental maintenance.
A resident with multiple chronic conditions, including diabetes, heart failure, and cirrhosis, was transferred twice to the ER without documented provision of the required written Notice of Transfer and bed-hold policy. Facility policies required written notice of transfer, with specified exceptions for urgent medical needs, and written information on bed-hold policies prior to and upon transfer for hospitalizations or therapeutic leave. Record review and an RN interview confirmed that no such documentation could be found for these transfers, resulting in a deficiency related to resident rights and notification.
The facility failed to complete baseline care plans within 48 hours of admission for two residents, contrary to its policy requiring a baseline plan of care to be developed within 48 hours to address immediate needs. One resident with ESRD and acute respiratory failure had a baseline care plan initiated but not locked or completed until more than 48 hours after admission, and facility staff confirmed that a plan is not considered complete until it is locked. Another resident with necrotizing fasciitis and diabetes with diabetic polyneuropathy had a baseline care plan completed 5 days after admission. The RN Clinical Resource Nurse acknowledged in both cases that the baseline care plans were not created within the required timeframe.
A resident with acute and chronic respiratory failure and other breathing abnormalities had physician orders for a compression glove and Tubi grip sleeve to be applied to the left upper extremity each day and night for edema, but these interventions were not included in the resident’s care plan. On multiple observations, the resident was noted without the ordered compression glove and sleeve in place. Record review confirmed the active physician order, and the RN Clinical Resource Nurse acknowledged the care plan had not been revised when the new orders were received.
The facility did not accurately post daily nurse staffing information for multiple months. Review of daily staffing sheets covering several months showed that the facility name and LPN hours were missing from all sheets. The CEO later confirmed that both the LPN hours and the facility name should have been included on the daily staffing sheets during this period but were not, affecting the completeness of staffing information available for review.
Surveyors identified that controlled medications were not consistently tracked according to facility policy, as narcotic accountability sheets for two medication carts were missing required dual nurse signatures on multiple occasions. During audits, staff, including an RN and the CNO, acknowledged that two nurses were supposed to sign the narcotic sheets when accepting or releasing the med carts, but this did not always occur, affecting all residents receiving controlled meds.
A resident with lumbar spinal stenosis and neurogenic bladder had a physician order for Gentamicin Sulfate bladder irrigation that lacked a documented indication or diagnosis and specified an indefinite duration. Facility policies required all medication orders to include an indication or diagnosis and duration, and to ensure regimens were free from unnecessary medications. Review of the order and an interview with the ACNO confirmed that these required elements were missing, resulting in noncompliance with the facility’s own medication and unnecessary drug policies.
Surveyors identified expired medications and unsecured drug storage when they observed multiple expired vitamin, supplement, and shampoo products in the medication storage room despite a policy requiring prompt removal and disposal of expired items. They also found a 100 Hall medication cart left unlocked and unattended while several staff members walked by without securing it, until an RN acknowledged it should not have been left open. A later audit of the same cart revealed loose, unidentified pills in two drawers and an expired bottle of multivitamins, and both the RN and CNO confirmed that loose pills should not be present in the cart and should have been destroyed.
Surveyors found that kitchen staff failed to follow FDA Food Code and facility policy for food storage, labeling, and sanitation. Ready-to-eat salads remained in the walk-in refrigerator beyond their intended use date, and chocolate pieces in the walk-in freezer were stored on an uncovered, unlabeled, and undated cookie sheet. Supposedly clean muffin pans on the storage rack were encrusted with buildup on both sides, and the area around the food prep sink, including the drain grate and floor-wall junctions under counters and sinks, was heavily soiled with dirt, food, and grime. These issues affected all residents receiving meals prepared in the kitchen.
A nurse failed to follow infection prevention and control practices during medication administration when removing an unwanted medication from a medication cup with an ungloved finger. A resident with COPD and diabetes had fifteen morning medications prepared in a single cup, including a Colace capsule the resident declined. Instead of using a clean device or gloves, the RN used an ungloved finger to remove the capsule before giving the remaining medications to the resident, contrary to facility policy requiring medications be handled without direct contact.
Surveyors observed unclean conditions throughout the facility, including sticky and dried substances on over-bed tables and commodes, soiled briefs and dirty wipes left in trash cans, and resident care items such as wheelchairs and Hoyer lift pads that were visibly dirty. Staff interviews revealed inconsistent cleaning practices and a lack of documentation for required cleaning tasks, resulting in a failure to provide a safe, clean, and homelike environment for all residents.
A resident with multiple medical conditions experienced a fall while reaching for food and drink in a wheelchair. Although the IDT recommended ensuring food and drink were placed closer to the resident to prevent further falls, this intervention was not added to the care plan. The DON confirmed the care plan was not updated to reflect the new intervention.
A medication cup containing a purple substance was found on a resident's bedside table, despite the resident not having an order or care plan documentation to self-administer medications. Staff confirmed that medications should not have been left in the room, indicating improper medication storage.
Staff did not follow enhanced barrier precautions when assisting a resident with multiple medical conditions during transfers and showering, as required by posted instructions. A CNA provided care without donning a gown and gloves, misunderstanding the protocol, while other staff and the DON confirmed that protective equipment was required for these activities.
A resident with dementia and necrosis of the left femur was injured during a Hoyer lift transfer due to improper storage and use of the equipment. The lift tipped over, causing a head laceration and cheek bruising, requiring hospital treatment. The facility's policy required equipment to be stored out of egress areas, but a lift was found stored in a resident's room, creating a fall hazard. The CRN confirmed that CNAs should have been properly trained in safe lift transfers.
The facility failed to ensure CNAs were trained to operate Hoyer lifts, leading to an incident where a resident was injured during a transfer. Additionally, nurses lacked competencies for respiratory equipment, resulting in incorrect AVAP settings for a resident with respiratory failure. The facility had no documented competencies for these skills.
The facility was found to have deficiencies in maintaining a clean kitchen environment and safe food handling practices. Missing temperature and sanitizer log entries, calcified build-up on the ice machine, and a dirty floor were noted. Additionally, expired orange juice was served, and improper hand hygiene was observed during food preparation.
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by disrepair in residents' rooms and an overfilled sharps container. Observations included loose baseboards, damaged walls and doors, and protruding needles from a sharps container. Staff acknowledged these issues, indicating lapses in maintaining a safe environment.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential negative outcomes. A resident with mental health diagnoses had incorrect PASARR Level II documentation, while two residents were inaccurately documented as having active pneumonia despite resolution. The CRN confirmed these coding errors.
The facility failed to develop comprehensive care plans for four residents, leading to potential negative outcomes. A resident with a fractured pelvis did not have oral care documented, while another with dementia had no care plan addressing the condition. A third resident's care plan omitted TED hose use for edema, and a fourth resident's frequent diarrhea was not addressed. The Administrator and CRN acknowledged these omissions.
The facility failed to update care plans for three residents, leading to outdated interventions that did not reflect their current needs. One resident required a two-person assist after a fall, but the care plan was not updated. Another resident's care plan still included hospice services after they were no longer needed. A third resident's care plan was not individualized, remaining a template without specific goals or interventions.
The facility failed to ensure meals were palatable and at correct temperatures, affecting residents' nutritional status. Residents reported cold and unappetizing food, and a tray test showed gravy and scrambled eggs below the required temperature. The Dietary Manager acknowledged the non-compliance.
The facility failed to maintain infection control practices, including inadequate hand hygiene assistance, improper PPE use, and poor storage of medical equipment. Staff did not consistently change gloves or perform hand hygiene during care, and equipment was not cleaned after use. These deficiencies increased the risk of cross-contamination and infection among residents.
The facility failed to provide the required Advance Beneficiary Notice (ABN) to two residents after their Medicare A benefits ended, and a Notice of Medicare Non-Coverage (NOMNC) was signed late by another resident. This oversight could lead to financial harm or distress for the residents involved.
The facility failed to ensure resident privacy and confidentiality, as a computer with resident information was left open on an unlocked medication cart, and a resident did not receive privacy during medical procedures. Additionally, mail was not delivered to residents on Saturdays, despite being received by the facility.
A facility failed to review a resident's hospital discharge instructions upon readmission, resulting in the absence of physician orders for a foley catheter, its care, or removal. The resident, with osteomyelitis and diabetes, had hospital orders for bladder training and catheter discontinuation, but these were not documented in the facility's records. Staff acknowledged the oversight, confirming the resident had a catheter upon readmission.
A facility failed to provide appropriate restorative nursing services to a resident with a history of a tibia fracture and need for personal care assistance. The resident's ability to walk was documented as declining from 150 feet with touch assistance to not attempting 10 feet due to medical or safety concerns. A staff member confirmed the resident was not on a restorative program, which was necessary to maintain or improve his functional ability.
The facility failed to notify the physician of significant weight loss in three residents, each with multiple diagnoses including dementia and kidney failure. Despite care plans directing staff to inform the physician of weight changes, there was no documentation of such notifications. A CRN confirmed that the physician should have been notified, highlighting a lapse in following care plan directives.
The facility failed to provide the required 12 hours of in-service education for a CNA and did not conduct annual performance evaluations for two CNAs. One CNA had only 6 hours of training for 2022-2023 and none for 2023-2024, while both CNAs lacked documentation of annual evaluations. The HR/Payroll coordinator and Administrator acknowledged these oversights, which increased the risk for harm to residents.
The facility did not update the nurse staffing information daily as required. On a morning observation, the Daily Staffing form was found to be two days old, and the Administrator confirmed it should have been updated every morning.
A resident was prescribed Risperdal without a documented medical necessity, contrary to the facility's policy that psychoactive drugs should only be used for specific conditions. The resident's care plan noted the use of antipsychotic medications for dementia with agitation and distress, but behavioral episodes were resolved with reassurances. A CRN later indicated that dementia was not an appropriate diagnosis for Risperdal, suggesting the medication should have been discontinued or properly justified.
The facility failed to ensure proper storage and labeling of medications, affecting three residents and a medication cart. Medications were found in residents' rooms without proper orders or assessments, and the medication cart contained improperly labeled and loose tablets. These issues indicate non-compliance with the facility's Medication Management policy.
A resident with lactose intolerance and gluten sensitivity was not provided with appropriate meals, leading her family to bring food from outside. The facility served meals containing gluten and lactose, and when the resident complained, she was given a grilled cheese sandwich, which was unsuitable. The culinary manager admitted that dietary notes were not properly monitored.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was initially assessed by the interdisciplinary team to determine if it was safe for the resident to self-administer medications before doing so, as required by the facility’s Self-Administration of Medications policy dated 11/28/17. That policy specified that the interdisciplinary team must determine safety for self-administration, decide who is responsible for storage and documentation of drug administration and the location of administration, and document these determinations in the medical record and care plan. Surveyors found that these required assessments and documentation steps were not completed. The resident involved had been admitted with multiple diagnoses, including metabolic encephalopathy and acute respiratory failure with hypoxia. During observation, the resident was noted to have OTC Refresh eye drops on the overbed table and stated that the drops were kept in the room for use when needed. Review of the medical record and care plan showed no assessment for self-administration of medications and no documentation authorizing self-administration. In an interview, the RN Clinical Resource Nurse confirmed that the resident should not have Refresh eye drops in the room and had not been assessed for self-administration of that medication.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure residents' call lights were within reach as required by its "Call Light Response Time" policy, revised 10/15/22, which states that call light systems are expected to be available and within reach at the bedside and in toileting and bathing areas. For one resident with multiple diagnoses including unspecified psychosis and muscle weakness, surveyors observed her sitting at her side table in the middle of her room eating breakfast while her call light was tied around the nightstand drawer handle behind her next to the bed, out of her independent reach. A CNA confirmed that this resident's call light should have been within reach and was not. Another resident, admitted with multiple diagnoses including hemiplegia and diabetes, was observed reclining in bed with his call light placed on the bedside table to the left side of the bed, which he stated he could not reach after staff had assisted him with cares. A CNA confirmed that this resident's call light also should have been within reach and was not. The CNO further stated that resident call lights should be within residents' reach and acknowledged that in these instances they had not been.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a timely Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) to a resident receiving Medicare Part A skilled services. Record review showed the NOMNC for Resident #81 stated that coverage for current SNF services would end on 11/18/25, but the form was signed by both the resident and the resident’s representative on 11/17/25, not 48 hours prior to the end of covered services as required. Social Services documentation on 11/17/25 indicated that the resident’s daughter was informed via telephone about the NOMNC and the last covered day of 11/18/25. The CEO confirmed that the NOMNC should have been signed 48 hours before the end of skilled nursing coverage and acknowledged that this did not occur. Resident #81 had been admitted with multiple diagnoses, including post-surgical repair of a left femur fracture and muscle weakness, and was receiving skilled nursing facility services under Medicare Part A at the time the deficient notification occurred. The surveyors determined that this failure to provide timely NOMNC had the potential to cause financial harm or distress to residents by not informing them of their potential liability for payment when Medicare Part A benefits ended.
Failure to Maintain Clean and Safe Dining Room Ceiling Vents
Penalty
Summary
The facility failed to honor residents' right to a safe, clean, comfortable, and homelike environment by not maintaining clean dining room ceiling vents. On 3/2/26 at 12:22 PM, surveyors observed two large dining room ceiling vents with brown, hairy-like debris covering approximately one-third of the inside of each vent, and a small strip of red, confetti-like paper in one of the vents. On 3/2/26 at 12:23 PM, surveyors also observed brown/black discoloration on the ceiling around other dining room ceiling vents. At 12:34 PM on the same day, the CEO acknowledged that the vents should have been cleaned and confirmed that they had not been cleaned, supporting the finding that the facility did not ensure a safe and clean environment in the dining area.
Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to a resident or the resident's representative when the resident was transferred to the hospital. Policy review showed the facility's "Discharge or Transfer" policy, revised 8/30/25, required that the resident, the resident's representative (if any), and the State Long-Term Care Ombudsman receive written notice at least 30 days before a transfer or discharge, except when urgent medical needs require an immediate transfer. The facility's "Bed-Hold" policy, revised 9/9/25, required that written information about bed-hold policies be provided to residents prior to and upon transfer for absences such as hospitalization or therapeutic leave. Record review and staff interview revealed that a resident admitted with multiple diagnoses including diabetes, heart failure, and cirrhosis was transferred to the ER on 9/22/25 and again on 2/8/26, and on both occasions the medical record lacked documentation that a written Notice of Transfer or bed-hold policy was provided. The RN Clinical Resource Nurse confirmed on 3/3/26 at 4:00 PM that they could not locate the Notice of Transfer or bed-hold documentation for either ER transfer. The deficient practice was identified for 1 of 2 residents reviewed for transfers and was determined to have the potential to create psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure baseline care plans were developed and completed within 48 hours of admission, as required by facility policy. The facility’s Baseline Care Plans policy, revised 10/15/22, states that a baseline plan of care is to be developed within 48 hours of admission to address the immediate needs of residents and used/updated until a comprehensive care plan is implemented. For one resident with end stage renal disease and acute respiratory failure with hypoxia, the baseline care plan was initiated on 2/2/26 but was not locked or completed until 2/3/26, which exceeded the 48-hour requirement. The RN Clinical Resource Nurse and the CNO both stated that a baseline care plan is not considered completed until it is locked, and the RN Clinical Resource Nurse acknowledged that this resident’s baseline care plan had not been completed within 48 hours and should have been. A second resident, who had diagnoses including necrotizing fasciitis and diabetes with diabetic polyneuropathy, was also found to have a baseline care plan completed outside the required timeframe. A closed record review showed that this resident’s baseline care plan was not completed until 12/29/25, which was 5 days after admission. The RN Clinical Resource Nurse stated that the baseline care plan for this resident should have been created within 48 hours of admission and had not been. These findings demonstrate that for 2 of 3 residents reviewed for baseline care plans, the facility did not complete the baseline care plans within the 48-hour timeframe specified in its own policy, resulting in care plans that did not provide timely direction for care.
Care Plan Not Updated to Reflect Physician-Ordered Edema Interventions
Penalty
Summary
The facility failed to ensure an existing care plan was revised to reflect current physician-ordered interventions for a resident with acute and chronic respiratory failure and other breathing abnormalities. The resident, who reported that his left arm had been swollen "for a while," had a physician order dated 9/16/25 for a compression glove to the left hand and a Tubi grip sleeve to the left arm from wrist to shoulder to be applied every day and night shift for edema. On multiple observations, the resident was seen sitting in his room without the ordered compression glove and Tubi grip sleeve in place. Review of the resident’s care plan showed no documentation regarding the compression glove or Tubi grip sleeve, despite the active physician order. The RN Clinical Resource Nurse acknowledged that the care plan should have been updated when the physician orders for these edema interventions were received and that it had not been updated.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurate and posted daily for each shift. During an observation on 3/3/26 at 1:50 PM, the surveyor reviewed the Daily Staffing sheets for the period from February 2025 through July 2025 and noted that the name of the facility and the LPN hours were not listed on any of these sheets. On 3/4/26 at 10:35 AM, the CEO confirmed that the LPN hours and the facility name should have been included on the daily staffing sheets for that entire period but were not. This deficiency affected the accuracy and completeness of the posted staffing information available for review by residents, their representatives, visitors, and others.
Failure to Maintain Dual Nurse Signatures on Narcotic Accountability Sheets
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications by not completing required dual nurse signatures on narcotic accountability sheets for two medication carts. On the 400 Hall medication cart audit conducted on 3/3/26 at 8:52 AM, the narcotic accountability sheet dated 3/2/26 to 3/3/26 was missing one licensed nurse signature for 3/3/26, and the RN interviewed confirmed that two nurses should have signed the sheet. On 3/4/26 at 8:44 AM, during the 100 Hall medication cart audit, narcotic accountability sheets dated 2/6/26 to 2/12/26, 2/13/26 to 2/20/26, and 3/1/26 to 3/3/26 were found to be missing one licensed nurse signature on multiple dates (2/11/26, 2/12/26, 2/13/26, 2/19/26, and 3/3/26). An RN and the CNO both stated that two nurses were required to sign the narcotic accountability sheets when accepting or releasing the medication cart, but this had not occurred as required, creating the potential for undetected misuse and/or diversion of controlled medications for all residents receiving these medications. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency pertained to the facility’s medication accountability process for controlled substances affecting all residents who received controlled medications.
Lack of Indication and Duration for Antibiotic Bladder Irrigation Order
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when reviewing facility policies, medical records, and staff interviews. The facility’s Physician/Providers Orders Policy required each medication order to include the resident’s name, drug name and strength, indication or diagnosis, dosage, frequency, route, duration, and any required monitoring parameters. The Unnecessary Medications Policy required that each resident’s medication regimen be free from unnecessary medications, including those prescribed without adequate indications for use or without appropriate monitoring. For one resident admitted with multiple diagnoses including lumbar spinal stenosis and neurogenic bladder, a physician order dated 9/22/25 prescribed Gentamicin Sulfate irrigation, 400 mg every day and night shift, with instructions to inject 60 cc of solution into the bladder via Foley catheter, clamp for 30 minutes, then unclamp. This order did not document an adequate indication or diagnosis for the Gentamicin use and listed the duration as indefinite. During an interview on 3/3/26 at 1:37 PM, the ACNO acknowledged that the Gentamicin order should have included an indication for use and a duration but did not, confirming noncompliance with the facility’s own policies. The report stated this failure had the potential to cause significant harm if the resident were to develop antimicrobial resistance or toxicity.
Expired and Unsecured Medications Found in Storage Room and Medication Cart
Penalty
Summary
The deficiency involves failure to ensure medications were not expired and were stored securely and inaccessible to unauthorized staff and residents. Surveyors reviewed the facility’s Medication Storage & Labeling policy, which required medications to be stored in locked compartments, maintained in clean and sanitary conditions, and for expired or discontinued medications to be promptly removed and disposed of per facility policy and DEA guidelines. During an observation in the medication storage room with an LPN present, surveyors found multiple expired items, including three bottles of Rena Vite 100 tablets, two bottles of Melatonin 1 mg, one bottle of Multi Vitamin 1000 tablets, one bottle of Pro Stat Liquid Protein 30 ounces, and two bottles of anti-dandruff shampoo with Selenium Sulfide 1%, all with manufacturer expiration dates that had passed. The CNO acknowledged that these expired medications should have been removed from the medication storage room and had not been. Additional observations showed that a medication cart on the 100 Hall was left unlocked and unattended, with multiple staff members walking by without addressing the unsecured cart. An RN later approached the cart and stated it should not have been left unlocked when unattended, and the CNO confirmed the cart should not have been left unlocked when the nurse left it. A subsequent audit of the same medication cart with the RN present revealed loose, unidentified pills in the bottom of two drawers, including various capsules and tablets, as well as a bottle of Multi Vitamin with an expired manufacturer date. Both the RN and the CNO stated that pills should not have been loose in the medication cart, that the drawers should have been cleaned to remove loose pills, and that the loose pills should have been destroyed.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
Surveyors identified a deficiency in food storage, labeling, and equipment cleanliness in the facility’s kitchen based on the FDA Food Code, facility policy, observation, and interview. Ready-to-eat, time/temperature control for safety foods were required by the FDA Food Code and the facility’s Food Safety & Storage policy to be clearly labeled with preparation and use-by dates when held longer than 24 hours. During observation of the walk-in refrigerator, surveyors found 11 individual salads dated for the previous day that remained in storage beyond their intended use date. In the walk-in freezer, chocolate pieces were observed on a cookie sheet that was not covered, labeled, or dated, contrary to policy requirements that opened or repackaged food and food removed from original packaging be labeled with contents and use-by or expiration dates. Surveyors also found deficiencies related to equipment and environmental cleanliness. The clean pots and pans storage rack contained muffin pans with encrusted buildup on both the front and back surfaces, in violation of FDA Food Code requirements that food-contact surfaces of cooking equipment and pans be kept free of encrusted grease deposits and other soil accumulations. Additionally, the drain hole under the food prep sink had a split grate covered in black dirt and grime-like substance extending onto the surrounding floor tiles, and the floor areas underneath the counters, handwashing sink, and food prep sink where the floor and wall met had a thick layer of dirt, food, and grime. These conditions were confirmed by the Certified Food Manager (CFM) and Dietician during interviews.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control practices during medication administration, contrary to the facility’s Medication Administration policy that requires staff to remove medications from storage without directly touching them. Resident #60, admitted with diagnoses including COPD and diabetes, had physician orders for fifteen morning medications, including Colace 100 mg by mouth. During a medication pass observed on 3/4/26 at 8:30 AM, RN #3 placed all fifteen medications into a medication cup and brought them into the resident’s room. When Resident #60 stated she did not want the Colace, RN #3 removed the Colace capsule from the medication cup using her ungloved finger before handing the remaining medications to the resident. During an interview at 8:37 AM the same day, RN #3 acknowledged she should have used a spoon or donned gloves to remove the Colace from the medication cup and had not done so. Later that afternoon, the CNO confirmed that RN #3 should not have used her ungloved finger to remove the medication from the cup. These observations and interviews demonstrated that the facility failed to maintain infection control practices as required by its own policy during medication administration for Resident #60.
Failure to Maintain Clean and Homelike Environment and Properly Clean Shared Equipment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment for all residents, particularly those transferred with Hoyer lift equipment. Multiple observations revealed unclean conditions, including sticky substances on over-bed tables, dried black and brown substances on commodes, and trash cans containing soiled briefs and dirty wipes left in resident rooms. Additionally, resident care items such as wheelchairs were found with dried substances and odors, and supplies like briefs were stored on the floor. Staff interviews confirmed that cleaning protocols, such as removing trash after each brief change and cleaning wheelchairs twice weekly, were not consistently followed, and there was no documentation to verify that these tasks were completed. Further observations showed that shared equipment, specifically Hoyer lift crossbeam pads, were visibly dirty with whitish, brown, and black marks. Staff members, including CNAs and LPNs, were unsure about the cleaning schedules or procedures for these items. The Director of Nursing and other staff acknowledged that cleaning and storage practices were not in line with facility policy, which requires proper cleaning and disinfection of multiple-use resident care items between each use. These lapses in cleaning and maintenance created the potential for cross-contamination and did not meet the standards for a safe and homelike environment.
Care Plan Not Updated After Fall Incident
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current needs and interventions following a fall incident. Specifically, after a resident with multiple diagnoses, including acute osteomyelitis and adult failure to thrive, experienced a fall while leaning forward in a wheelchair to reach food and drink, the interdisciplinary team (IDT) assessed the situation and recommended that staff ensure the resident's food and drink be placed closer to him in the dining room. However, this recommendation was not incorporated into the resident's care plan fall prevention interventions. Record review, policy review, and staff interview confirmed that the care plan was not updated to include the IDT's recommendations after the fall. The facility's policy required that a person-centered plan of care be developed and revised by the interdisciplinary team to address falls and prevent future occurrences. The Director of Nursing acknowledged that the care plan had not been updated as required.
Medications Improperly Stored in Resident Room
Penalty
Summary
A deficiency occurred when a medication cup containing a purple substance with multi-colored specks and a spoon was observed on the bedside table of a resident who had been admitted with chronic obstructive pulmonary disease and hypertension. The resident did not have an order to self-administer medications, nor was self-administration documented in the care plan. During staff interviews, an RN confirmed that the resident should not have had medications left in the room, and the Director of Nursing stated that residents should not have medications left in their rooms. This indicates that medications were not stored appropriately as required.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to enhanced barrier precautions (EBP) protocols when providing care to a resident with multiple diagnoses, including acute cystitis and dysphagia. During observation, a CNA assisted the resident with a transfer from bed to wheelchair and then to the shower room, as well as with showering, without donning the required gown and gloves, despite an EBP sign on the resident's door instructing staff to wear this personal protective equipment during such activities. The CNA stated she believed gown and gloves were only necessary when assisting with catheter care. Another CNA confirmed that the EBP sign indicated staff should wear gown and gloves for bathing, transferring, and catheter care. The DON also stated that staff were expected to wear gloves and gowns when providing care to residents with EBP signage.
Improper Storage and Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper storage and use of Hoyer lift equipment, resulting in harm to a resident. The Space and Equipment policy, revised on 12/4/19, required that resident care equipment be stored out of egress areas while maintaining availability. However, on 12/17/24, a Hoyer lift was observed being stored in a resident's room, creating a potential fall hazard. The CRN confirmed that Hoyer lifts should not be stored in residents' rooms. This improper storage practice contributed to an incident involving a resident. The resident, who had multiple diagnoses including necrosis of the left femur and dementia, was injured during a Hoyer lift transfer on 6/26/24. The incident report documented that the lift tipped over, causing a laceration to the resident's head and bruising on the cheek. A nursing note indicated that CNA #2 used an improper technique during the transfer, leading to the accident. The resident required hospital treatment, receiving three staples to close the scalp laceration. The CRN stated that all CNAs should have been properly trained and had competencies completed on safe Hoyer lift transfers before use.
Deficiencies in CNA and Nurse Competencies for Equipment Use
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) were trained and had documented competencies to operate the facility's Hoyer lifts. This deficiency was highlighted when a Hoyer lift tipped over during a transfer of a resident with multiple diagnoses, including necrosis of the left femur and dementia, resulting in a laceration to the head and bruising on the cheek. Interviews with CNAs revealed that they had not been competency tested on the Hoyer lift at the facility, despite some having received training elsewhere. The facility's Competency Verification of Nursing Staff policy required completed competencies to be documented, but this was not adhered to prior to a specified date. Additionally, the facility did not ensure that licensed nurses had the appropriate competencies and skills to provide respiratory-related services. A resident with heart failure and respiratory failure reported issues with their AVAP machine, including difficulty breathing and discomfort due to cold air. Observations confirmed incorrect AVAP settings and an inactive humidifier. An LPN admitted to only being trained to turn the AVAP on and off and assist with the mask, lacking knowledge on operating the humidifier. The facility had no documented competencies or training for the AVAP machine for nursing staff.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by several observations during a kitchen inspection. The temperature log for the dish machine and the sanitizer log were missing recorded entries for specific dates, and the Culinary Manager (CM) was unaware of the reason for these omissions. Additionally, the ice machine had a significant amount of calcified water build-up, and the CM did not know the cleaning schedule for the machine, indicating a lack of proper maintenance. The floor between the kitchen and dishwashing area was observed to have a layer of dirt and grime, and the CM attributed this to a loose threshold, while the Administrator acknowledged the need for cleaning but cited the need for appropriate cleaning chemicals. Food handling practices were also found to be deficient. An RNA was observed pouring expired orange juice into cups for residents and admitted that the kitchen should not have sent out expired juice. The RNA also inadvertently placed her fingers inside the cups while serving, which was acknowledged as inappropriate by both the RNA and the CM. Furthermore, a cook was seen cracking raw eggs on a grill with both gloved and non-gloved hands, sometimes failing to wash hands before handling ready-to-eat foods. The cook and CM both recognized the need for handwashing after handling raw foods to prevent cross-contamination.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by several observations of disrepair and unsafe conditions. In one instance, a loose baseboard was observed in a resident's room, and the resident confirmed that it had been in that condition for some time. Additionally, multiple rooms were found with significant damage to walls and doors, including holes and deep gouge marks with missing paint. These issues were acknowledged by the Maintenance Director and the Administrator, who stated that repairs should be made when reported or when a resident moves out. Furthermore, a sharps container in a resident's bathroom was found to be overfilled, with needles protruding from the top. An LPN and the CRN both acknowledged that the sharps container should have been changed sooner, indicating a lapse in maintaining a safe environment. These observations highlight the facility's failure to adhere to its policy of maintaining a sanitary, orderly, and comfortable interior, potentially compromising the dignity and safety of its residents.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could lead to negative outcomes due to inaccurate assessments. Resident #27, who was diagnosed with depression, bipolar disease, and schizophrenia, had a PASARR Level II completed on 10/12/18. However, the MDS assessments dated 2/20/23, 1/4/24, and 11/11/24 incorrectly documented that there was no completed PASARR Level II. The Clinical Resource Nurse (CRN) confirmed that these sections were coded incorrectly and should have been marked as 'yes'. Additionally, Resident #41, with diagnoses including heart failure and diabetes, was incorrectly documented as having an active diagnosis of pneumonia in the MDS assessments dated 7/24/24, 8/19/24, and 11/4/24, despite the pneumonia having resolved. Similarly, Resident #52, who had chronic venous insufficiency and other conditions, was also incorrectly documented as having an active diagnosis of pneumonia in the MDS assessments dated 8/21/24 and 11/6/24, even though the pneumonia had resolved. The CRN confirmed these inaccuracies in the MDS coding for both residents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to potential negative outcomes. Resident #33, admitted with a fractured pelvis and requiring assistance with personal care, did not have oral care documented in her care plan, and there was no record of her receiving oral care or seeing a dentist. Resident #34, diagnosed with dementia and kidney failure, had no care plan addressing dementia, and the multidisciplinary care conference did not document any reference to this condition. Resident #220, with a right tibia fracture and end-stage renal disease, had physician's orders for TED hose to manage edema, but this was not included in the care plan. Resident #226, suffering from irritable bowel syndrome with diarrhea and polyneuropathy, reported frequent diarrhea, yet his care plan did not address these issues. The facility's failure to include these critical aspects in the residents' care plans was acknowledged by the Administrator and CRN, indicating a lack of comprehensive planning for the residents' needs.
Failure to Update Resident Care Plans
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 three residents. Resident #1, who was initially admitted with a fracture of the lower end of the left tibia and required assistance with personal care, experienced a fall and subsequently required a two-person assist when toileting. However, the care plan, dated several months prior, still documented the need for extensive assistance with one to two staff, and was not updated to reflect the change in assistance required. Similarly, Resident #33, who was admitted with a fracture of the pelvis and required assistance with personal care, had a care plan that included hospice staff providing a shower or bed bath once a week. After coming off hospice, the care plan was not updated to reflect this change. Resident #226, admitted with irritable bowel syndrome with diarrhea and polyneuropathy, had a care plan initiated that did not document any individualized focus, goals, or interventions. The care plan was left as a template and not tailored to the resident's specific needs. The facility's policy required care plans to be revised quarterly, annually, with significant changes, or more frequently as needed, but this was not adhered to, placing residents at risk of adverse outcomes due to outdated care plans.
Failure to Maintain Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that resident meals were palatable and maintained at the correct temperatures, as required by the 2022 FDA Food Code. This deficiency was identified through observations and interviews with residents and staff. Three residents reported that their meals were often cold, with one resident describing the cream of wheat as a lump and another stating the food was soggy. A tray from the last meal cart delivered on the 200 hall was tested, revealing that the gravy was at 120 degrees F and scrambled eggs were at 115 degrees F, both below the required 135 degrees F. The Dietary Manager confirmed that these temperatures were not in compliance with the standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by several observations. Staff did not consistently assist residents with hand hygiene before meals, as seen when a resident was served a meal without being offered hand hygiene. Additionally, during incontinent care, CNAs did not change gloves or perform hand hygiene between tasks, increasing the risk of cross-contamination. Enhanced Barrier Precautions were not adhered to, with staff entering rooms without donning appropriate PPE, despite signage indicating the need for gowns and gloves. Improper storage of medical equipment was also noted, with oxygen supplies and bed pans being stored on the floor, contrary to infection control policies. Equipment such as a sit-to-stand device was not cleaned after use, and medication administration practices were compromised when a nurse used her bare finger to handle a resident's medication. These lapses in infection control practices had the potential to impact all residents by increasing the risk of cross-contamination and infection.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the required Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) to residents, which are essential for informing them of their potential financial liability when Medicare Part A benefits end. Specifically, two residents, one with a left femur fracture and traumatic brain injury, and another with dementia and kidney failure, did not receive the ABN after their Medicare A benefits ended, despite continuing their stay in the facility. This oversight was identified through a Skilled Nursing Facility Beneficiary Notification Review, which documented the end of their Medicare A benefits. Additionally, another resident with a urinary tract infection and chronic obstructive pulmonary disease signed the NOMNC after their Medicare A benefits had already ended, rather than 48 hours prior to the end of covered skilled nursing services as required. The facility administrator confirmed the absence of the ABNs for the two residents and acknowledged the timing error in the NOMNC for the third resident. These deficiencies in providing timely and appropriate beneficiary notifications could lead to financial harm or distress for the residents involved.
Failure to Maintain Resident Privacy and Timely Mail Delivery
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information. During an observation on hall 400, a computer on top of a medication cart was left open with resident information visible, and the medication cart was unlocked with keys left in the lock. RN #1 acknowledged that she should have closed the computer screen, locked the cart, and taken the keys with her. Additionally, RN #1 did not provide privacy for Resident #53 during a lab draw and insulin administration, as she left the door open while performing these tasks. Resident #53 had multiple diagnoses, including osteomyelitis and diabetes. Furthermore, the facility did not ensure timely delivery of mail to residents. During a Resident Council meeting, residents reported that mail was not delivered on Saturdays. The Administrator confirmed that while mail was delivered to the facility on Saturdays, it was not distributed to the residents. This failure to deliver mail in a timely manner affected all residents who receive mail at the facility.
Failure to Review Hospital Discharge Instructions for Foley Catheter
Penalty
Summary
The facility failed to ensure that a resident's hospital discharge instructions were reviewed upon readmission to assure physician orders were in place to meet their medical needs. This deficiency involved a resident with multiple diagnoses, including osteomyelitis of the right ankle and foot and diabetes, who was readmitted to the facility. The hospital discharge orders included instructions for bladder training and discontinuation of a foley catheter when able. However, upon review, the facility's physician orders did not document an order for the foley catheter, its care, or its removal. Additionally, the resident's progress notes and care plan lacked documentation regarding foley catheter care or removal. A CRN acknowledged the absence of the foley catheter order in the facility's records, and the MDS Coordinator confirmed the resident had a catheter upon readmission.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the ability of a resident to carry out activities of daily living. This deficiency was identified for one resident who was not included in a restorative nursing program despite having a medical history that included a fracture of the lower end of the left tibia and a need for assistance with personal care. The resident's Annual MDS indicated he could walk 150 feet with touch assistance, but the Quarterly MDS later documented that walking 10 feet had not been attempted due to medical condition or safety concerns. A staff member confirmed that the resident was not on a restorative program, although he should have been, which placed him at risk for decreased range of motion and functional ability.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss in three residents, which is a deficiency in care. Resident #34, who was admitted with diagnoses including dementia and kidney failure, experienced a weight loss of 9.58% over a 15-day period. Despite the care plan's directive to notify the physician of weight changes, there was no documentation that this was done. Similarly, Resident #59, with diagnoses of kidney failure and nutritional deficiency, lost 11.14% of his weight over approximately two months. The care plan required notification of the physician and registered dietitian for significant weight changes, but the medical record lacked evidence of physician notification. Resident #62, also diagnosed with dementia and kidney failure, experienced a 12.99% weight loss over a period of about six weeks. Again, there was no documentation that the physician was informed of this significant weight loss. In all three cases, the Certified Registered Nurse (CRN) confirmed that the physician should have been notified of the residents' significant weight losses, indicating a lapse in following the care plan directives and ensuring proper medical oversight.
Deficiency in CNA Training and Evaluation
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of in-service education per year for one of two Certified Nursing Assistants (CNAs) reviewed, specifically CNA #1. CNA #1, hired on February 1, 2022, had only completed 6 hours of in-service training for the 2022-2023 period and had no documented training hours for 2023-2024. Additionally, the facility did not ensure that each CNA's performance was evaluated at least once every 12 months. Both CNA #1 and CNA #4, whose personnel records were reviewed, lacked documentation of annual performance evaluations. CNA #4 was hired on June 17, 2023, and also did not have an annual evaluation completed. The HR/Payroll coordinator and the Administrator acknowledged these oversights, indicating that the training and evaluations should have been completed. This deficiency created the potential for incompetent CNAs providing care and increased the risk for harm to all residents living in the facility.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurate and posted daily for each shift. This deficiency was identified through observation and staff interviews. On the morning of December 16, 2024, it was observed that the Daily Staffing form displayed was dated December 14, 2024, indicating that the staffing information had not been updated for two days. During an interview, the Administrator acknowledged that the Daily Staffing form should have been updated every morning.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure the medical necessity for the administration of psychotropic medication for a resident. The facility's policy on psychoactive drug use, revised on 10/15/22, states that such drugs should only be used when necessary to treat a specific condition. However, a resident was prescribed Risperdal, an antipsychotic medication, without a documented medical symptom or basis for its use. The resident's Acknowledgement of Psychoactive Medication Use form for Risperdal did not specify the medical symptom being treated. A Pharmacy Medication Regimen Review form later documented the prescription of Risperdal for major depressive disorder, while a physician order dated 4/3/24 indicated its use for dementia with agitation and distress. The resident's care plan noted the use of antipsychotic medications for dementia with agitation and distress, demonstrated by delusions and yelling out. Behavioral documentation from June to December 2024 recorded episodes of delusions, all of which were resolved with reassurances or allowing the resident to rest. On 12/19/24, a CRN stated that dementia was not an appropriate diagnosis for the use of Risperdal, suggesting that the medication should have been discontinued or a proper diagnosis should have been provided. This oversight created the potential for negative side effects from unnecessary psychotropic medication use.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored appropriately and properly labeled, affecting three residents and one medication cart. In one instance, a tube of Calcipotriene ointment belonging to a discharged resident was found in another resident's bathroom. Another resident had a bottle of Tums on her bedside table without a documented order or self-administration assessment. Additionally, a tube of generic brand hemorrhoid ointment was found on a third resident's bedside table without an order. The facility's policy requires a self-administration assessment, an order, and care planning for medications at the bedside, which was not followed in these cases. In the medication cart, deficiencies included a bottle labeled in black marker as Sodium bicarb, which was shared between carts instead of having separate, properly labeled bottles. Loose tablets, including a Tylenol tablet and half a Metoprolol 25 mg tablet, were found on the bottom of the cart drawers. The LPN acknowledged that the tablets should not have been there and that the sodium bicarbonate should have been in a properly labeled bottle. These observations indicate a failure to adhere to the facility's Medication Management policy and proper medication storage protocols.
Failure to Accommodate Dietary Needs for Resident with Intolerances
Penalty
Summary
The facility failed to accommodate the dietary needs of a resident with lactose intolerance and gluten sensitivity. The resident, who was admitted with multiple diagnoses including surgical aftercare, lactose intolerance, and gluten sensitivity, reported that her family had to bring her food because the facility served her meals containing gluten and lactose. On one occasion, when she complained, the facility provided her with a grilled cheese sandwich, which was inappropriate for her dietary restrictions. The menu for the days in question included items such as coffee cake, cheese croissant sandwiches, and cheese enchiladas, none of which were suitable for a gluten and lactose-free diet. The culinary manager acknowledged that the cooks should have been monitoring dietary notes and that the substitute meal provided was not appropriate for the resident's needs.
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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