Timber Springs Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 1140 North Allumbaugh Street, Boise, Idaho 83704
- CMS Provider Number
- 135098
- Inspections on file
- 20
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Timber Springs Transitional Care during CMS and state inspections, most recent first.
A resident with a history of anxiety and recent suicidal ideation exhibited escalating behaviors and ultimately physically assaulted another resident, causing facial injuries. The facility failed to protect residents from abuse, resulting in harm and placing others at risk.
A resident with significant medical conditions was found to be living in a room that was repeatedly observed to be cluttered, unclean, and to have a persistent foul urine odor. Staff noted the presence of old food, sticky residue, and visible wheelchair marks, and confirmed that despite increased cleaning efforts, the odor and unclean conditions continued.
Two residents were involved in an incident where one physically assaulted the other, causing facial injuries. Despite documented behavioral concerns and threats from the aggressor, the facility did not implement interventions to prevent further abuse prior to the incident, relying only on the resident's arrest after the event.
The facility did not document or provide required health information to receiving hospitals during the transfer of two residents—one with epilepsy and anxiety who experienced neurological decline, and another with multiple chronic conditions who sustained injuries from a fall. In both cases, transfer paperwork was missing from the records, and staff confirmed the lack of documentation.
A resident with cerebral palsy and major depressive disorder had documented orders for hydroxyzine for anxiety and a diagnosis of severe dementia, but the MDS assessment failed to reflect the anxiety disorder, use of anti-anxiety medication, or dementia diagnosis. Staff confirmed these omissions in the MDS despite their presence in the medical record.
A resident with multiple chronic conditions was prescribed Xarelto for atrial fibrillation, with orders and a care plan directing staff to monitor and document signs and symptoms of anticoagulant complications. Review of the Treatment Administration Record revealed that staff failed to document this monitoring on several PM shifts, and the DON confirmed the documentation should have been completed.
A resident with multiple cancer diagnoses was administered the wrong nutritional supplement via PEG tube, as staff provided Glucerna 1.5 instead of the physician-ordered Jevity 1.5. Both a unit manager and an LPN confirmed the error, noting that the physician's order was not followed and the facility's policy to confirm orders prior to administration was not adhered to.
A resident with chronic respiratory failure was not receiving oxygen therapy as ordered by the physician. During medication administration, the resident was observed without oxygen in place and had an oxygen saturation of 80% on room air before oxygen was applied by an RN. The RN confirmed the resident was not wearing oxygen at the time and described the weaning process as a gradual reduction with monitoring.
A resident with dementia and Parkinson's disease had a pharmacy review recommending discontinuation of two medications due to lack of use. The pharmacist's recommendations were not acknowledged or acted upon by the Medical Director or DON, and there was no documentation to clarify whether the medications remained necessary.
A registered nurse administered digoxin to a resident with a history of cerebral infarction, hypertension, and atrial fibrillation without first obtaining an apical pulse, as required by physician order and standard protocol. Instead, the nurse relied on an electronic machine for vital signs and did not perform the necessary assessment before giving the medication.
A resident with cognitive impairment and multiple health conditions experienced ongoing oral pain and a broken tooth, but the facility did not arrange timely dental care despite documented complaints and visible symptoms. Staff provided pain relief and monitored for infection, but no dental appointment was scheduled until weeks after the initial complaint, and the DON could not explain the delay.
A resident with multiple chronic conditions was observed coughing during a meal without a beverage available, while another resident at the same table had two drinks. After the resident requested and received iced tea, her coughing stopped. The Dietary Manager indicated that CNAs are responsible for distributing beverages and that drinks are given when requested, but could not explain why some residents did not have drinks during dining.
Surveyors found that dietary staff did not follow proper hand hygiene and glove use protocols, failed to clean and sanitize food-contact equipment such as ice machines and cooking skillets, and stored expired or moldy food items. The dietary manager acknowledged the presence of dirty equipment and expired food but was unsure why corrective actions had not been taken. These deficiencies affected all residents consuming food prepared and stored by the facility.
A registered nurse worked multiple shifts and performed licensed nursing duties without a valid license, as the facility did not verify the nurse's licensure status in accordance with state law. The DON confirmed the lapse after several shifts had already been worked.
Staff failed to follow infection prevention and control protocols during medication administration, medication storage, and a sterile dressing change for two residents. This included returning a dropped tablet to a medication cup, storing open food and beverages in a medication cart, and not using sterile technique during a dressing change for a resident with an LVAD and immunodeficiency.
A resident with severe cognitive impairment was inappropriately touched by another resident with moderate cognitive impairment. The first incident occurred near the nurses' station, and the second in the dining room, despite efforts to separate them. The facility's initial response included moving the offending resident to a different floor, but lapses in staff communication allowed further contact.
The facility failed to maintain kitchen equipment and environment, and store food in a safe and sanitary manner. Kitchen aides were observed changing gloves without washing hands, and one aide sneezed into her shoulder and continued food preparation. Food storage practices were deficient, with undated items and improper storage. Cleaning schedules were incomplete, leading to unsanitary conditions. These deficiencies posed a risk of food contamination for the 63 residents consuming food prepared by the facility.
The facility failed to assist residents in formulating advance directives, as required by policy. Six residents with various medical conditions, including end-stage renal disease and quadriplegia, did not have documentation of advance directive discussions in their records. Despite care plans indicating quarterly reviews of healthcare directives, there was no evidence of such reviews. The social worker's statements confirmed the lack of documentation and misunderstanding regarding POST forms.
The facility failed to maintain a clean and homelike environment for all 63 residents, as observed during a survey. Equipment such as a stand aide, ice chest stand, vital sign machine, and Hoyer lifts were found with dried food crumbs, brown substances, and dust, indicating non-compliance with the facility's cleaning policy. The DON stated that cleaning was the night shift's responsibility, but there was no documentation to verify that equipment was cleaned, posing potential harm and risk of cross-contamination.
The facility failed to provide necessary medical information during the transfer of three residents to the hospital. One resident with cellulitis, liver cirrhosis, and COPD was transferred twice without documentation of sent information. Another resident with respiratory failure was sent to the ER without a completed transfer checklist. A third resident with a fractured femur was transferred without documented information, as an LPN forgot to note what was sent.
The facility failed to ensure medications were labeled and dated, with expired medications found in a storage room and undated insulin pens on a medication cart. An LPN was unsure of the responsibility for checking expired medications, and another LPN admitted to not dating insulin pens due to quick usage.
A facility failed to maintain resident dignity during dining by serving meals at different times to residents seated at the same table. A resident with anxiety, depression, and paraplegia was observed waiting 16 minutes longer than another resident at the same table to receive his meal. The IP confirmed that meals should be served simultaneously, and the Dietary Aide noted that meal cards should have been organized by seating arrangement. The resident mentioned occasional delays in meal delivery.
The facility failed to notify physicians of significant weight changes for two residents, as required by their physician's orders. One resident with end-stage renal disease and another with multiple diagnoses, including viral encephalitis, had orders for daily weight monitoring and physician notification for specific weight gains. However, weights were not consistently recorded, and significant weight changes were not communicated to physicians, as confirmed by the DON.
A resident reported a medication error where her prescribed oxycodone was missing and replaced with a thyroid pill, which she was not prescribed. Despite reporting the incident to a nurse, the facility failed to document or investigate the grievance as required by their policy. The DON did not find any concerns in the records and did not interview other residents, indicating a failure to adhere to the grievance policy.
A resident with heart failure and kidney disease had deficiencies in their care plan documentation. The resident's use of dentures was not recorded, and there was no physician order for the oxygen they were using. The DON acknowledged these omissions.
The facility failed to follow physician orders for two residents. One resident did not receive prescribed bowel medications despite not having a bowel movement for several days, as confirmed by the DON. Another resident, with orders for half side rails to assist with bed mobility, was found without them, which was acknowledged by both the DON and an LPN.
A resident's oxygen tubing and nasal cannula were found lying on the floor, instead of being stored in the bag attached to the oxygen concentrator. The DON confirmed that the equipment should have been properly stored, highlighting a failure to maintain sanitary conditions for respiratory equipment.
The facility failed to attempt alternatives and obtain informed consent before using bed rails for two residents with multiple medical diagnoses. Despite assessing mobility and discussing risks, the assessments lacked documentation of risks versus benefits, alternatives attempted, and signed consent from the residents or their POAs, creating potential harm due to entrapment risk.
A facility failed to ensure a pharmacist recognized and reported medication irregularities for a resident's PRN psychotropic medication. The resident, with multiple diagnoses, had orders for Quetiapine without a stop date and received it frequently. The pharmacist's reviews lacked comments on the PRN use, and the DON found no documentation of a review. An email from the pharmacist confirmed no request for a 14-day PRN review was made, and the resident's record lacked necessary documentation.
A facility failed to limit PRN anti-psychotic medication to 14 days for a resident with anxiety, leading to frequent administration without reevaluation. The resident's PRN Quetiapine was given on multiple days over two months without a stop date or documented necessity, contrary to regulatory requirements. The DON acknowledged the oversight in the facility's review process.
A facility failed to coordinate care with a hospice provider for a resident with multiple diagnoses, including metabolic encephalopathy and depression. The resident's care plan did not document the responsibilities between the facility and the hospice agency, leading to potential inadequate care. The DON confirmed the absence of necessary documentation.
The facility did not ensure accurate daily posting of census information for each shift, affecting 63 residents and others interested in reviewing census levels. The daily census and staffing posting was found blank for all shifts. The Administrator stated that the SDC was responsible for filling out these forms, but the SDC confirmed she never did. The DON acknowledged that the census should have been listed.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving resident-to-resident physical abuse. One resident, who had a history of anxiety, cerebral infarction, and recent suicidal ideation, exhibited escalating behaviors including threats of self-harm and confrontational interactions with nursing staff regarding pain medication. Despite these documented behaviors and changes in mood, the resident was not effectively monitored or managed to prevent harm to others. This culminated in an incident where the resident physically assaulted another resident, resulting in facial bruising, laceration, and redness to the eye and nose area. The assaulted resident had a history of Parkinson's disease and dementia but was assessed as having no cognitive impairment at the time. The facility's failure to prevent this abuse constituted a violation of the resident's rights and placed all residents at risk for ongoing abuse and potential harm.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident with multiple diagnoses, including end stage heart failure, cirrhosis of the liver, and immunodeficiency. The resident's room was repeatedly observed to be cluttered, unclean, and to have a persistent foul urine odor. Staff documented the presence of half-eaten old food items, sticky residue on furniture, sticky floors with visible wheelchair track marks, and a strong urine smell. These conditions were noted on multiple occasions over several days. Staff interviews confirmed the ongoing issue, with a housekeeper reporting that despite increased cleaning frequency, the urine odor and visible uncleanliness persisted. An LPN stated that the odor was due to urine, as the resident sometimes spilled urine on himself, and staff attempted to empty urinals to reduce the smell. The room was located at the end of the hallway and the odor was noticeable upon approach. The deficiency was identified through direct observation and staff interviews.
Failure to Implement Interventions to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement interventions to prevent further resident-to-resident abuse incidents, as evidenced by two residents involved in an altercation. One resident with a history of anxiety, fluctuating moods, and suicidal ideation exhibited escalating behaviors, including verbal threats and expressions of self-harm, prior to the incident. Despite these documented behaviors and interactions with nursing staff regarding pain management and mental health concerns, no additional interventions were put in place to address the resident's risk of aggressive behavior toward others. The deficiency was identified when the resident physically assaulted another resident, resulting in facial injuries. Facility policies required immediate and effective measures to prevent further abuse while investigations were ongoing, but the only action taken prior to the incident was the resident's arrest after the assault. The administrator confirmed that no other interventions were implemented to prevent further potential abuse between residents.
Failure to Document and Provide Pertinent Health Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that pertinent health information was provided to the receiving health facility during the transfer of two residents. For one resident with a history of epilepsy and anxiety, there were two separate incidents where the resident became non-responsive and exhibited neurological symptoms, prompting transfer to the hospital. In both cases, although the resident’s representative was notified and transfer forms were completed, there was no documentation in the medical record that pertinent medical information was provided to the receiving hospital at the time of transfer. A staff member later confirmed that while the required forms were sent and a report was called in, this was not documented as required. Another resident, who had multiple diagnoses including partial paralysis, dementia, cirrhosis, depression, and anxiety, was transferred to the hospital after sustaining a fall resulting in a head laceration and rib fracture. The resident’s record did not include documentation of the hospital transfer paperwork, and the Director of Nursing confirmed that there was no hospitalization paperwork from the facility to the hospital for this incident. These findings were based on policy review, record review, and staff interviews.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident with multiple diagnoses, including cerebral palsy and major depressive disorder. Record review showed that the resident had physician orders and documentation for hydroxyzine, an anti-anxiety medication, as well as a diagnosis of severe, unspecified dementia. However, the resident's admission MDS did not indicate the presence of an anxiety disorder, the use of anti-anxiety medication, or a diagnosis of dementia. Staff interviews confirmed that the MDS assessments did not include these diagnoses or treatments, despite being documented in the resident's medical record.
Failure to Monitor and Document Anticoagulant Therapy
Penalty
Summary
The facility failed to follow professional standards of nursing practice for monitoring anticoagulant therapy for one resident. The resident, who had multiple diagnoses including cerebral palsy, atrial fibrillation, COPD, diabetes, schizophrenia, and hypertension, was prescribed Xarelto (Rivaroxaban) for atrial fibrillation. Physician orders and the resident's care plan required staff to monitor, document, and report signs and symptoms of anticoagulant complications. However, a review of the Treatment Administration Record (TAR) from July through September showed that staff did not document monitoring for anticoagulant signs and symptoms on several PM shifts. During an interview, the Director of Nursing confirmed that the TAR should have been marked as completed on those dates.
Failure to Follow Physician Orders for Tube Feeding
Penalty
Summary
The facility failed to follow physician orders for a resident who required tube feeding due to multiple cancer diagnoses, including cancer of the mouth and esophagus. The resident's care plan specified tube feeding as ordered, with a physician order directing the administration of Jevity 1.5 nutritional supplement at a specific rate and volume. However, during observation, the resident was found to be receiving Glucerna 1.5 instead of the prescribed Jevity 1.5 via PEG tube. This was confirmed by both the unit manager and an LPN, who acknowledged that the incorrect nutritional supplement was being administered and that the physician's order had not been followed. The facility's policy required staff to confirm the physician's order prior to administration, but this was not done in this instance.
Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
Staff failed to provide oxygen therapy as ordered by the physician for a resident with chronic respiratory failure, respiratory disorder, and cognitive impairment. The resident's care plan directed staff to provide oxygen as ordered, with an initial physician order for continuous oxygen at 5 liters per minute via nasal cannula. A subsequent order instructed staff to wean oxygen therapy for saturation levels over 94% and to administer 1-3 liters per minute as needed to maintain oxygen saturation between 88-93%. During a medication administration observation, the resident was found resting in bed without oxygen in place. An RN administered medications and then checked the resident's oxygen saturation, which was 80% on room air. The RN then applied oxygen via nasal cannula. The RN confirmed that the resident was not wearing oxygen at the time of medication administration and described the weaning process as a gradual reduction of oxygen flow with monitoring, not complete removal without monitoring.
Failure to Act on Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the Medical Director and Director of Nursing Services acted upon pharmacist recommendations for a resident reviewed for unnecessary medications. According to the facility's policy, a medication regimen review (MRR) must include a review of the resident's medical chart, and any identified irregularities are to be documented and sent to the attending physician, Medical Director, and Director of Nursing Services for action. For one resident with multiple diagnoses, including dementia and Parkinson's disease, a pharmacy consultation report recommended discontinuing two medications due to lack of use in the past 60 days. However, there was no documentation of the provider's response to these recommendations, and the DON confirmed that the pharmacy recommendation had not been acknowledged, leaving it unclear whether the medications were still necessary.
Failure to Obtain Apical Pulse Prior to Digoxin Administration
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to obtain an apical pulse prior to administering digoxin to a resident. The resident, who had a history of cerebral infarction, hypertension, and atrial fibrillation, had a physician's order for digoxin with specific instructions to notify the provider if the heart rate was less than 40 beats per minute. During medication administration, the RN used an electronic machine to obtain the resident's vital signs and associated the pulse from the machine with the administration of digoxin, rather than obtaining an apical pulse as required. When questioned, the RN admitted to not obtaining an apical pulse before administering the medication. The Director of Nursing (DON) later confirmed that an apical pulse should be obtained prior to administering digoxin. The failure to follow this protocol resulted in a significant medication error for the resident observed during the medication pass.
Failure to Provide Timely Dental Care for Resident with Oral Pain
Penalty
Summary
The facility failed to ensure that a resident received timely routine and emergency dental care. The resident, who was cognitively impaired and had multiple diagnoses including diabetes, COPD, and depression, was documented as edentulous but retained a few lower front teeth. The care plan noted the resident's refusal to wear dentures and identified her as being at nutritional risk. In July, the care plan was updated to reflect complaints of lower gum pain, and staff were directed to monitor for oral and dental problems. On August 17, a progress note documented the resident's report of mouth pain due to a broken tooth, with visible redness and bleeding at the site. Staff were instructed to provide pain relief and monitor for infection, and a dental follow-up was recommended. Despite these documented issues and the resident's ongoing complaints, there was no evidence in the medical record that the facility attempted to arrange a dental appointment prior to September 10. The resident's representative expressed concern about the lack of dental care, noting the resident had only four lower teeth and a recently broken tooth. The DON confirmed the resident had recently started complaining of oral discomfort but did not provide a reason for the delay in scheduling a dental appointment in July or August.
Failure to Provide Hydration Beverages During Meals
Penalty
Summary
The facility failed to ensure that residents received hydration beverages during dining, as observed with one resident who did not have any beverages at her dining area while another resident at the same table had two. The resident, who had multiple diagnoses including atrial fibrillation, coronary artery disease, hypertension, renal insufficiency, and hyperlipidemia, was seen coughing during lunch without access to a drink. When asked by the Dietary Manager if she was okay, the resident requested iced tea, and her coughing stopped after drinking it. The Dietary Manager stated that beverages are provided upon request and that CNAs are responsible for distributing them, but could not explain why some residents, including the coughing resident, did not have drinks available during the meal.
Deficiencies in Food Safety Practices and Equipment Sanitation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including improper cleaning and sanitizing of ice machines and cooking equipment, inappropriate glove use by dietary staff, and storage of expired food and spices. Observations revealed that a dietary aide failed to perform hand hygiene between changing tasks and glove use while serving and preparing resident food, contrary to FDA Food Code requirements. The dietary manager stated that handwashing was not performed because the aide had not left the workstation and was serving food for less than four hours. Additionally, expired and moldy food items, such as salad mix, baking soda, tomatillos, and yams, were found in the kitchen, with the dietary manager indicating that another facility was responsible for identifying and discarding expired items. Further inspection showed that the ice machine in the second-floor meal kitchen had black residue inside, despite being reportedly cleaned monthly, and cooking skillets in the assisted living kitchen were found with encrusted black residue and scratched Teflon surfaces. The dietary manager acknowledged that the equipment was visibly dirty and should have been cleaned or discarded, but was unsure why this had not occurred. These findings were based on direct observation, record review, and staff interviews, and affected all residents consuming food prepared and stored by the facility.
Failure to Ensure RN Maintained Valid License
Penalty
Summary
The facility failed to ensure that all registered nurses were working with a valid nursing license, as required by state law. A review of the Division of Occupational Licenses database revealed that one registered nurse's professional license had expired. Despite this, the nurse continued to work at the facility and performed licensed nursing duties over the course of six shifts. The Director of Nursing (DON) confirmed that the nurse was only reassigned after the expired license was discovered, indicating that the nurse had already provided care without a valid license prior to the reassignment.
Failure to Implement Infection Control Practices During Medication Administration and LVAD Dressing Change
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration, medication storage, and a sterile dressing change for two residents. During medication administration, a registered nurse picked up a tablet that had fallen onto the medication cart surface with a gloved hand and returned it to the medication cup, then continued preparing and administering medications without sanitizing the cart immediately prior to use. Additionally, an audit of the medication cart revealed the presence of an open energy drink and an open bag of pretzels stored in the cart, contrary to facility expectations that no food or beverages be stored with medications. For a resident with multiple diagnoses including end stage heart failure, cirrhosis of the liver, and immunodeficiency, staff failed to follow sterile technique during a dressing change for a Left Ventricular Assist Device (LVAD). The nurse placed the dressing package directly on the bed without a barrier, did not establish a sterile field, and performed the dressing change using clean rather than sterile technique, despite facility policy and the LVAD Management Manual requiring sterile procedures for such dressing changes.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. Resident #63, who was severely cognitively impaired, was inappropriately touched by Resident #42, who was moderately cognitively impaired. The incident occurred while both residents were near the nurses' station, and staff members initially did not notice the inappropriate behavior. When a staff member observed Resident #42 massaging Resident #63's breasts, the residents were separated, and the nurse was alerted. Despite the inappropriate contact, Resident #63 did not show signs of distress or injury, and both residents were assessed as unable to make decisions due to their cognitive impairments. A second incident occurred when Resident #42 managed to access the dining room where Resident #63 was seated. Although staff did not witness the event, Resident #63's disheveled blouse and her verbal response suggested possible inappropriate contact. The nurse's assessment again found no physical injury, but Resident #63 confirmed that Resident #42 had touched her breast. The facility's investigation concluded that Resident #42 mistakenly believed Resident #63 was his deceased wife, which led to the inappropriate behavior. The facility's initial response to the first incident included separating the residents and moving Resident #42 to a different floor. However, the second incident highlighted a lapse in staff awareness and communication, as some staff members were unaware of Resident #42's relocation and inadvertently directed him back to the area where Resident #63 was present. This oversight allowed Resident #42 to have further contact with Resident #63, leading to the second reported incident.
Removal Plan
- The nurse assessed both residents for harm and evidence of injury.
- Administrator, Regional Director of Operations notified.
- Families of both residents notified.
- The State Agency Long Term Care Program was notified via the portal.
- Staff members were interviewed.
- Care plans for both residents were reviewed and updated.
- Social Services interviewed other residents and no further concerns were found.
- Staff education was provided to remind and redirect Resident #42 to stay downstairs.
- Frequent checks were initiated for both residents.
- Resident #42 was fully moved downstairs to a new room with all of his belongings set up to his preferences.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain kitchen equipment and environment, and store food in a safe and sanitary manner, as observed during a survey. Kitchen aides were seen changing gloves without washing hands in between tasks, and one aide sneezed into her shoulder and continued food preparation without washing hands. Additionally, handwashing was improperly conducted in a food preparation sink, and dirty dishes were placed in the same sink, indicating a lack of understanding of proper handwashing and equipment use. Food storage practices were also deficient, with pantry shelves not meeting the required height off the floor, and personal items improperly stored in food areas. The facility's food date marking system was inadequate, with many items undated or improperly stored, including spices, meats, and other perishables. The facility's cleaning schedules were incomplete, and there was a lack of documentation for cleaning tasks, leading to unsanitary conditions in the kitchen, such as dirt residue and black spots in the walk-in refrigerator and freezer. The facility's failure to adhere to FDA Food Code standards for hand hygiene, food storage, and cleaning frequency posed a risk of food contamination and potential food-borne illnesses for the 63 residents consuming food prepared by the facility. The staff's lack of adherence to proper food safety protocols and inadequate training contributed to these deficiencies, as evidenced by the observations and staff interviews conducted during the survey.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided assistance to exercise their right to formulate an advance directive. This deficiency was identified for six residents whose records were reviewed. The facility's policy required that upon admission, the facility should determine if a resident has an advance directive and, if not, offer assistance in formulating one. However, the records for these residents did not include documentation that an advance directive was offered or discussed with them or their representatives. The residents involved had various medical conditions, including end-stage renal disease, quadriplegia, respiratory failure, and others. Despite the facility's policy stating that any decision-making regarding residents' choices should be documented in their medical records, there was no evidence that discussions about advance directives took place. Additionally, care plans for some residents indicated that healthcare directives should be reviewed quarterly, but there was no documentation to support that these reviews occurred. The social worker's statements further confirmed the lack of documentation and misunderstanding regarding the use of POST forms as advance directives.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for all 63 residents, as observed during a survey. The facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised in September 2022, requires that resident-care equipment be cleaned and disinfected according to CDC recommendations and OSHA standards. However, observations revealed that various equipment, including a stand aide, ice chest stand, vital sign machine, and Hoyer lifts, were found with dried food crumbs, a brown substance, an empty straw wrapper, and dust, indicating a lack of adherence to the cleaning policy. The Director of Nursing (DON) stated that the night shift was responsible for cleaning the transfer equipment and that vital sign machines were supposed to be cleaned after each use. However, there was no list or check-off sheet to verify that the equipment was cleaned, suggesting a lack of systematic oversight and documentation. This deficiency created the potential for harm, as residents could feel embarrassed or disrespected by the unclean environment, and there was a risk of cross-contamination from microorganisms.
Failure to Provide Necessary Medical Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary medical information was provided to the receiving hospital for three residents during their transfers. Resident #8, who had multiple diagnoses including cellulitis, liver cirrhosis, and COPD, was transferred to the hospital on two occasions without documentation that pertinent information was sent. The Director of Nursing (DON) confirmed that the required documents, such as the resident's face sheet, physician's orders, and other relevant forms, were not documented as sent with Resident #8. Similarly, Resident #42, with diagnoses including respiratory failure and liver disease, was sent to the emergency room due to shortness of breath, but the transfer form checklist was not completed, and there was no documentation of the medical information provided to the hospital. Resident #54, who had a fractured left femur and a history of stroke, was also transferred without documentation of the information sent, as the LPN forgot to document the progress note. These omissions in documentation and communication could potentially hinder timely and effective treatment at the receiving hospital.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications available for residents were properly labeled and dated, as observed in one of two medication storage rooms and one of two medication carts inspected. During an inspection of the first-floor medication storage room, several expired medications were found, including a bottle of Aspirin and three bottles of Saw Palmetto supplement, all expired in March 2024, and a box of acetaminophen suppositories expired in December 2022. An LPN present during the inspection was unsure of whose responsibility it was to check for expired medications and acknowledged that expired medications should have been destroyed. Additionally, during an inspection of a medication cart, three insulin pens were found undated. Another LPN stated that insulin pens are usually dated when opened, but in the case of a specific resident, the insulin was used so quickly that they typically did not date it, although they acknowledged that they should have.
Failure to Serve Meals Simultaneously Affects Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times. This was observed with Resident #5, who was admitted with multiple diagnoses including anxiety, depression, and paraplegia. On June 24, 2024, at 12:30 PM, Resident #5 and Resident #23 were seated across from each other in the main dining room. Resident #23 was served her meal and began eating, while Resident #5 did not receive his meal tray and was observed quietly watching Resident #23 and other residents eat. Resident #5's meal was served 16 minutes later, at 12:46 PM, by which time Resident #23 was almost finished with her meal. The Infection Preventionist (IP) confirmed that residents seated at the same table should be served simultaneously, and the Dietary Aide acknowledged that meal cards should have been organized according to seating arrangements. Resident #5 mentioned that his meal tray was sometimes delivered late, though not often.
Failure to Notify Physicians of Significant Weight Changes
Penalty
Summary
The facility failed to notify physicians of significant weight changes for two residents, as required by their physician's orders. Resident #12, who has end-stage renal disease and type 2 diabetes mellitus, had a physician's order to have their weight monitored daily and to notify the physician if there was a weight gain of more than 2-3 pounds in 24 hours or 5 pounds in one week. However, the resident's treatment administration record (TAR) showed that weights were not taken or recorded on multiple dates, and there were several instances where the resident's weight gain exceeded the parameters set by the physician's order. Despite these significant weight changes, there was no documentation indicating that the physician was notified, as confirmed by the Director of Nursing (DON). Similarly, Resident #48, who has multiple diagnoses including viral encephalitis and type 2 diabetes mellitus, also had a physician's order for daily weight monitoring with similar notification requirements for weight changes. The TAR for this resident also showed that weights were not recorded on several dates, and there were multiple instances of weight gain exceeding the physician's parameters without any documented notification to the physician. The DON confirmed that all communication with physicians should be recorded in the residents' progress notes, but there was no evidence that the physician was informed of the weight changes for Resident #48.
Failure to Investigate Resident Grievance Regarding Medication Error
Penalty
Summary
The facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them, as evidenced by the case of a resident who reported a medication error. The resident, who was cognitively intact and had multiple diagnoses including opioid dependence, anxiety, depression, and morbid obesity, stated that a nurse left her medication cup on her bedside table, which led to her accidentally knocking it over. Upon picking up the medications, she noticed her prescribed oxycodone was missing and instead found a thyroid pill, which she was not prescribed. The resident reported the incident to a nurse, but there was no grievance report filed regarding this issue. The facility's grievance policy required the grievance officer to review and investigate complaints and submit a report within five working days. However, the incident involving the resident's missing oxycodone was not documented in the facility's grievance file. The Infection Preventionist (IP) recalled the resident reporting the incident and stated she informed the Director of Nursing (DON) the following day. Despite this, the DON did not find any concerns in the Narcotic book or Electronic Medical Record and did not interview other residents to verify the resident's claim. The lack of documentation and investigation into the resident's grievance indicates a failure to adhere to the facility's grievance policy.
Deficiency in Resident-Centered Care Plan Documentation
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans, as evidenced by deficiencies found in the care plan of a resident with multiple diagnoses, including heart failure and kidney disease. The resident was observed with upper and lower dentures, yet the care plan initiated did not document the presence of dentures. Additionally, the resident was seen using oxygen via a nasal cannula at 2 liters per minute, but there was no physician order for oxygen in the resident's record. The Director of Nursing confirmed that the dentures should have been documented in the care plan and that an order for oxygen should have been present.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, leading to deficiencies in their care. Resident #53, who was admitted with multiple diagnoses including hypertensive chronic kidney disease, pressure ulcer, and morbid obesity, did not receive bowel medications as ordered by the physician. The physician's orders included Lactulose Solution, Colace Oral Capsule, and Dulcolax Suppository for bowel care. However, records indicated that Resident #53 did not have a bowel movement for four consecutive days on two separate occasions, and there was no documentation that the prescribed medications were administered during these periods. The Director of Nursing (DON) confirmed that the resident should have received the medications as ordered. Resident #27, admitted with diagnoses including heart failure and kidney disease, had a physician's order for half side rails on both sides of the bed to assist with bed mobility. An observation revealed that the side rails were not installed, and the DON acknowledged that they should have been present and documented in the resident's care plan. An LPN also confirmed the absence of the side rails, indicating a failure to follow the physician's order for this resident.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored in a sanitary manner, which was observed during a survey. Specifically, the oxygen tubing and nasal cannula for a resident with multiple diagnoses, including heart failure and kidney disease, were found lying on the floor in the resident's room. This observation was made in the presence of the Director of Nursing (DON). The DON acknowledged that the oxygen tubing and nasal cannula should have been placed in the bag attached to the oxygen concentrator when not in use. This oversight created the potential for respiratory infections due to the growth of pathogens in the respiratory treatment equipment.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that alternatives to bed rails were attempted and that residents were thoroughly assessed for the risk of entrapment before the placement of bed rails. This deficiency was identified for two residents, both of whom had multiple medical diagnoses. Resident #47, who was moderately cognitively intact, had a physician order for bed rails to assist with bed mobility. However, the Siderail Enabler Assessment did not document the risks versus benefits or any alternatives attempted, and there was no signed consent from the resident or their POA. Similarly, Resident #56, who was cognitively intact, had a physician order for bed rails, but the assessment lacked documentation of risks versus benefits and alternatives, and there was no signed consent. The Director of Physical Therapy and the DON acknowledged that while they assessed the residents' mobility and discussed potential risks, the assessments did not include signatures from the residents or their POAs. The DON mentioned that a trapeze was considered as an alternative but was not feasible due to the facility's ceiling height. This oversight created the potential for harm due to the risk of entrapment and the lack of opportunity for the residents or their representatives to make informed decisions regarding the use of bed rails.
Failure to Review PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a licensed pharmacist recognized and reported medication irregularities related to PRN psychotropic medication for a resident. The resident, who was admitted with multiple diagnoses including opioid dependence, anxiety, depression, and morbid obesity, had physician's orders for Quetiapine, an antipsychotic medication, both as a scheduled dose and as a PRN dose for anxiety. The PRN order did not include a stop date, and the resident received the PRN medication on multiple occasions over two months. However, the pharmacist's medication reviews for March, April, and May did not include any comments or recommendations regarding the PRN Quetiapine. The Director of Nursing (DON) was unable to find documentation that the pharmacist had reviewed the PRN Quetiapine for the resident. An email from the pharmacist indicated that a request for a 14-day PRN review was not sent, and while the resident's continued use of Seroquel was noted by a nurse practitioner, it did not specifically address the PRN use. The resident's record lacked documentation from the pharmacy regarding the review of the PRN Seroquel, and there was no new order to continue the PRN medication.
Failure to Limit PRN Anti-Psychotic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN anti-psychotic medications were limited to 14 days, as required by the State Operations Manual. This deficiency was identified for a resident who was admitted with multiple diagnoses, including opioid dependence, anxiety, depression, and morbid obesity. The resident had a physician's order for Quetiapine, an anti-psychotic medication, to be taken both regularly and as needed (PRN) for anxiety. However, the PRN order did not include a stop date, and the medication was administered frequently without reevaluation by the attending physician or prescribing practitioner. The resident's medication administration records (MAR) showed that the PRN Quetiapine was given on 15 out of 31 days in May and 7 out of 25 days in June. Despite the frequent use of the PRN medication, the nurse practitioner's progress notes did not document the necessity of continuing the PRN Quetiapine. The Director of Nursing (DON) acknowledged that the facility's process should include reviewing PRN anti-psychotic medications during psychotropic reviews, but this was not done in this case, leading to the deficiency.
Lack of Coordination with Hospice Provider
Penalty
Summary
The facility failed to ensure proper coordination of care with a hospice provider for a resident receiving hospice services. This deficiency was identified during a review of the resident's records and staff interviews. The resident, who had multiple diagnoses including metabolic encephalopathy, a left thigh fracture, alcohol dependence, and depression, was admitted to the facility and later assessed to be receiving hospice services. However, the resident's care plan lacked documentation outlining the responsibilities and care coordination between the facility and the hospice agency. During a review of the resident's record, the Director of Nursing (DON) confirmed the absence of documentation delineating duties between the facility and the hospice provider.
Failure to Post Accurate Daily Census Information
Penalty
Summary
The facility failed to ensure that census information was accurately posted daily for each shift, which had the potential to affect the 63 residents residing in the facility, as well as their representatives, visitors, and others who wanted to review the facility's census levels. On a specific day, the daily census and staffing posting, located on the first floor across from the nursing station, was observed to have a blank resident census area for the day, evening, and night shifts. The Administrator indicated that the Staff Development Coordinator (SDC) was responsible for filling out and posting these forms daily. However, the SDC confirmed that she never filled out the census information on the forms. The Director of Nursing (DON) reviewed the form and stated that the census should have been listed.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
