Twin Falls Transitional Care Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Twin Falls, Idaho.
- Location
- 674 Eastland Drive, Twin Falls, Idaho 83301
- CMS Provider Number
- 135104
- Inspections on file
- 18
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Twin Falls Transitional Care Of Cascadia during CMS and state inspections, most recent first.
A resident with a guardian, diagnosed with Spotted Fever and diabetes, did not receive assistance or documentation regarding the formulation of an Advance Directive. Staff confirmed that no discussion or documentation occurred because the resident had a guardian.
Two residents with serious mental illness diagnoses did not have their conditions accurately reflected in their MDS assessments. The assessments failed to document required diagnoses and PASRR determinations, as confirmed by staff interviews.
A resident with multiple mental health diagnoses, including PTSD, depression, anxiety, and bipolar disorder, was not consistently referred for further evaluation as required by the PASARR program. Documentation errors and missed referrals resulted in the resident not being properly assessed for specialized services, despite ongoing mental health concerns and prescribed medications.
The facility did not resubmit required PASRR Level II documentation for three residents with mental health or intellectual disability diagnoses who remained in the facility beyond the 30-day hospital exemption period. These residents had conditions such as depression, anxiety, major depressive disorder, Parkinson's disease, and borderline personality disorder. Staff confirmed that updated assessments and supporting documents were not sent to the state authority as required.
Two residents with complex medical conditions did not receive respiratory care as ordered, including failure to change oxygen tubing and improper reuse of dropped oxygen cannula tubing by staff, resulting in noncompliance with infection control and physician orders.
Controlled medications were not properly tracked or secured due to missing required signatures on narcotic accountability records for two medication carts. Staff confirmed that two nurses were expected to sign these records when accepting or releasing the carts, but this was not consistently done.
A medication error rate above 5% was identified when a resident did not receive a prescribed chewable Calcium/Vitamin D tablet due to lack of supply, and a Lidocaine patch was not removed after the required 12 hours. An LPN also failed to document the application of the Lidocaine patch with date, time, and initials.
Surveyors found expired mouthwash and omeprazole suspension in the medication storage refrigerator, as well as an undated glucose test solution. The CNO confirmed that these items should have been removed or properly labeled.
Surveyors observed that opened and prepared food items, including dry scalloped potatoes, tea, juice, and pizzas, were not properly dated or stored according to facility policy and the Idaho Food Code. The Culinary Manager acknowledged that these items should have been dated but were not.
A resident with chronic heart and lung conditions had multiple medical record entries indicating oxygen was administered via nasal cannula, despite a physician's order specifying oxygen use only with BIPAP. Nursing staff documented the use of a nasal cannula over an extended period, even though no nasal cannula was present in the resident's room. Facility leadership confirmed these were documentation errors that were not identified or corrected.
The facility failed to maintain proper food handling and sanitation practices, with issues including improper cooling of leftovers, inadequate holding temperatures for cold foods, and unclean kitchen equipment and areas. The walk-in refrigerator was not at the required temperature due to torn gaskets, and the kitchen floor and equipment were found to be dirty. Additionally, cold food items were above the required holding temperature, and dishware had hard water residue.
A facility failed to accurately reflect a resident's condition in the MDS assessment, omitting documentation of scalp wounds despite ongoing treatment and monitoring. The resident, with multiple diagnoses including brain cancer and chronic respiratory failure, had scalp wounds requiring antibiotic treatment. Staff interviews confirmed the presence of these wounds, which were not healing due to hardware on the skull. The MDS Coordinator was unsure if the wounds needed to be documented, leading to an inaccurate assessment.
A facility failed to complete a new Level 1 PASARR for a resident who was newly diagnosed with PTSD, despite having a policy requiring such action for newly identified mental disorders. The resident was admitted with depression and anxiety, and the new diagnosis was documented in a quarterly MDS assessment. Staff acknowledged the oversight, which could potentially impact the resident's access to necessary mental health services.
Two residents in a LTC facility did not receive their prescribed restorative nursing programs, leading to potential declines in their physical abilities. One resident, with multiple sclerosis, did not receive recommended exercises for her knee, while another, with severe cognitive impairment and muscle contractures, was not provided with necessary positioning aids. Staff interviews revealed confusion and lack of communication, resulting in delays and non-compliance with care plans.
A resident with a history of falls and multiple diagnoses, including traumatic brain injury and dementia, did not have a fall mat in place as required by their care plan and physician orders. Observations and staff interviews revealed a lack of awareness and communication regarding the fall prevention measures, leading to the resident being found on the floor on two occasions without the mat in place. The CNO confirmed the mat was listed on the Kardex and should have been used.
The facility failed to provide proper catheter care for two residents, leading to potential risks of UTIs. One resident's catheter bag was consistently positioned incorrectly, contrary to the care plan, while another resident's catheter was not secured with a leg strap as ordered. Staff allowed resident preferences to override care plans without proper documentation or education, and there were inconsistencies in following physician orders and documenting refusals.
A resident with acute respiratory failure was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM. Staff interviews revealed a lack of adherence to physician orders, with an LPN failing to verify the correct oxygen setting and inaccurately documenting it. The CNO acknowledged the importance of following physician orders.
Failure to Assist Resident with Advance Directive Due to Guardianship
Penalty
Summary
The facility failed to ensure that a resident and their representative were provided assistance to exercise their right to formulate an Advance Directive. Record review revealed that a resident, admitted with diagnoses including Spotted Fever due to Rickettsia rickettssi and diabetes, had a POST and a Letter of Guardianship in their medical record, but there was no documentation of an Advance Directive or evidence that the facility had offered assistance to the resident or their guardian in formulating one. During staff interview, a CRN confirmed that because the resident had a guardian, Advance Directives were not discussed and no related documentation existed.
Inaccurate MDS Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with diagnoses including PTSD, major depressive disorder, and anxiety, the PASRR Level II assessment documented a serious mental illness, but the admission and quarterly MDS assessments did not indicate this diagnosis under the relevant sections. Specifically, the MDS did not reflect the PTSD diagnosis and incorrectly marked that the resident was not considered to have a serious mental illness by the PASRR process. For another resident with major depressive disorder and orthopedic conditions, the admission MDS assessment also failed to indicate that the resident was considered by the PASRR Level II process to have a serious mental illness. These inaccuracies were confirmed during staff interviews, where it was acknowledged that the MDS assessments should have been completed differently to accurately reflect the residents' diagnoses and PASRR determinations.
Failure to Refer Resident for Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for further evaluation as required by the Pre-admission Screening and Resident Review (PASARR) program when the resident was diagnosed with major mental illness and related conditions. Record review showed that the resident had multiple diagnoses, including post-traumatic stress disorder (PTSD), depression, anxiety, and bipolar disorder, with several PASARR Level I and II screenings conducted over time. Despite documentation of these mental health diagnoses and prescribed medications, several PASARR II forms indicated that no further evaluation for specialized services was needed, and concerns related to mental health were not always documented. Additionally, inconsistencies were found in the documentation of PTSD on the Minimum Data Set (MDS) assessments. Staff interviews revealed that errors in the PASARR process were not identified or corrected in a timely manner. The Social Services Manager acknowledged missing errors on previous PASARR forms, and facility leadership confirmed that staff should have identified and addressed these errors. As a result, the resident was not consistently referred for appropriate evaluation by the state-designated authority, as required for individuals with major mental illness or related conditions.
Failure to Resubmit PASRR Level II for Residents Exceeding 30-Day Exemption
Penalty
Summary
The facility failed to resubmit the PASRR Level II evaluations for residents who were initially admitted under a 30-day hospital exemption but whose stays exceeded 30 days. This deficiency was identified through record review and staff interviews, and it was found to be true for three residents. For each of these residents, the original PASRR Level II documentation indicated that if the resident remained in the facility beyond 30 days, the facility was required to submit updated information, including the most current MDS, physician orders, social notes, and psychiatric information, to the state-designated authority (BLTC). However, this resubmission did not occur as required. The residents involved had significant medical and mental health diagnoses, including depression, anxiety, major depressive disorder, autonomic nervous system disorder, Parkinson's disease, and borderline personality disorder. Staff interviews confirmed that the required documentation was not submitted for these residents when their stays exceeded 30 days. Facility leadership acknowledged that the oversight should have been identified and addressed earlier, but the necessary updates were not made in a timely manner.
Failure to Provide Safe and Appropriate Respiratory Care and Adhere to Infection Control Practices
Penalty
Summary
The facility failed to provide respiratory care services as ordered by the physician and did not adhere to infection control and prevention practices for two residents requiring respiratory support. For one resident with autonomic nervous system disorder, Parkinson's disease, and borderline personality disorder, the care plan required weekly changes of disposable oxygen tubing and related supplies. However, observations revealed that the oxygen concentrator tubing and bubbler had not been changed as scheduled, with the last change documented over a week prior. The responsible nurse assigned the task to CNAs and only spot-checked a few rooms, failing to verify that the supplies for this resident had been changed. In another instance, a resident with congestive heart failure and chronic respiratory failure with hypoxia was observed when a CNA dropped the oxygen cannula tubing on the ground while filling the resident's portable oxygen unit. The CNA then picked up the tubing and reconnected it to the oxygen unit without replacing it, contrary to infection control protocols. The CNA acknowledged the error, and the charge nurse confirmed that the tubing should have been replaced before reuse.
Failure to Properly Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing signatures on narcotic accountability records for two of three medication carts reviewed. During audits of the 400 Hall and 100 Hall medication carts, it was observed that required signatures from two licensed nurses were not documented on the narcotic accountability records for multiple days. Staff interviews confirmed that two nurses were expected to sign the records when accepting or releasing the medication carts, but this procedure was not consistently followed. These findings were based on direct observation and staff statements during the survey.
Medication Error Rate Exceeds 5% Due to Missed and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 5.71% error rate during observed medication administration. For one resident, a prescribed daily dose of Calcium 600mg/Vitamin D 10 mcg in chewable form was not administered because the facility did not have the chewable tablets available. Additionally, the same resident's physician order for a Lidocaine 4% patch to be applied to the left leg base for 12 hours in the morning and removed in the evening was not followed; the patch was not removed after 12 hours as required. The LPN also did not date, time, or initial the Lidocaine patch upon application, as is standard practice. These actions and omissions were confirmed through staff interviews and direct observation.
Expired Medications and Unlabeled Biologicals Found in Medication Storage
Penalty
Summary
Surveyors observed that medications and biologicals in the facility's medication storage room were not properly managed according to professional standards. Specifically, a bottle of mouthwash and two bottles of omeprazole suspension were found in the medication refrigerator with expiration dates that had already passed, and these expired items had not been removed. Additionally, a set of glucose test solutions was found without a date indicating when it was opened. The Chief Nursing Officer (CNO) confirmed that the expired medications should have been removed and that the glucose test solution should have been dated when opened.
Failure to Properly Date and Store Food Items
Penalty
Summary
Surveyors determined that the facility failed to store food in a safe and sanitary manner, as required by the Idaho Food Code and the facility's own policies. During observations, an opened container of dry scalloped potatoes with a use-by date that had already passed was found in the dry food storage room. In the walk-in refrigerator, an undated container of tea and a tray of individually poured cups of juice, along with the tray itself, were not dated. Additionally, in the walk-in freezer, a bag containing pizzas that had been opened was not dated. The Culinary Manager confirmed that these food items should have been properly dated but were not.
Inaccurate Oxygen Therapy Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure accurate data entry in a resident's medical record, specifically for a resident with chronic congestive heart failure and chronic obstructive pulmonary disease. The resident had a physician's order for BIPAP with home settings and oxygen at 2 liters with humidification. However, multiple entries in the resident's medical record documented the use of oxygen via nasal cannula, which was inconsistent with the physician's order and the actual care provided. These entries were made by various nursing staff over a period of time. Upon review, it was observed that there was no nasal cannula present in the resident's room, and the Chief Nursing Officer confirmed that the oxygen order was for use with BIPAP only. The Clinical Registered Nurse acknowledged that the documentation of oxygen via nasal cannula was a documentation error and should have been identified and corrected. This inaccurate documentation resulted in the resident's medical record not reflecting the actual care provided.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to proper procedures for cooling leftovers, maintaining appropriate food holding temperatures, and ensuring cleanliness and maintenance of kitchen equipment and areas. During a kitchen tour, it was observed that the walk-in refrigerator was not maintaining the required temperature, measuring at 48 degrees F, due to torn gaskets. The floor of the refrigerator was also found to be dirty with food debris and rust. Additionally, the range ovens and walls around the steam table and coffee station were soiled, and the kitchen floor had scuff marks, cracked tiles, and food debris. These conditions were acknowledged by the staff, indicating a lack of adherence to the facility's sanitation policies. Furthermore, the facility did not follow proper cooling procedures for leftovers, as evidenced by breakfast gravy placed in the refrigerator that remained at 65 degrees F after five hours, contrary to the policy requiring cooling to 41 degrees F within six hours. Cold food items on the breakfast tray line were also found to be above the required holding temperature of 41 degrees F, with items like pears, strawberries, and cottage cheese measuring between 43 and 46 degrees F. Additionally, beverage pitchers and dishware were noted to have a white residue due to hard water, which had not been addressed for several months. These deficiencies in food handling and sanitation practices placed residents at risk for potential food contamination and adverse health outcomes.
Inaccurate MDS Assessment for Resident with Scalp Wounds
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, identified as Resident #16. This resident was admitted with multiple diagnoses, including brain cancer, right hemiplegia and hemiparesis following a stroke, and chronic respiratory failure with hypoxia. The quarterly MDS assessment documented that the resident was severely cognitively impaired and rarely able to make herself understood. However, the assessment failed to document the presence of current open lesions or wounds, despite physician orders and care plans indicating the need for topical antibiotic treatment for scalp wounds and monitoring for signs of infection. The resident's medical records, including physician orders and progress notes, indicated ongoing treatment and monitoring for scalp wounds, which were not reflected in the MDS assessment. Interviews with staff, including an LPN and a nurse practitioner, confirmed the presence of scalp wounds that had been present for over a year and were not healing due to hardware on the skull. The MDS Coordinator, who had recently started working remotely, was unsure if the MDS coding instructions required the resident's skin wounds to be documented in the assessment. This oversight in the MDS assessment process had the potential for negative outcomes due to the inaccurate reflection of the resident's condition.
Failure to Complete New PASARR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure a new Level 1 Preadmission Screening and Resident Review (PASARR) was completed for a resident who had a newly identified mental illness. This deficiency was identified for one resident, who was admitted with diagnoses including depression and anxiety. A quarterly MDS assessment later documented that the resident was moderately cognitively impaired and had a diagnosis of Post Traumatic Stress Disorder (PTSD). Despite this new diagnosis, the resident's record did not include documentation of a new Level 1 PASARR being completed. The facility's PASARR policy requires that any resident with a newly evident or possible serious mental disorder be referred to the appropriate state-designated mental health authority for review. However, the staff, including the SSM, CNO, and CEO, acknowledged that a new PASARR Level 1 should have been completed following the resident's new PTSD diagnosis. The failure to complete the necessary PASARR assessment could potentially result in the resident not receiving specialized services for their mental health needs.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to implement a restorative nursing program for two residents, leading to potential declines in their physical abilities. Resident #308, who was admitted with multiple sclerosis and other conditions affecting mobility, was recommended for a restorative nursing program after being discharged from physical therapy. Despite the recommendation, the program was not initiated, and the resident did not receive the necessary exercises for her right knee, which was sore and stiff. Interviews with staff revealed confusion and lack of communication regarding the implementation of the program, resulting in a delay that could cause increased stiffness and discomfort for the resident. Resident #47, who was severely cognitively impaired and had muscle contractures, was also not receiving the prescribed restorative interventions. The resident's care plan included the use of a small abductor wedge, a ball for neck support, and hand splints to prevent further contractures and skin breakdown. Observations showed that these interventions were not being applied, and staff interviews indicated a lack of awareness and documentation regarding the resident's needs and refusals. The deficiency in providing restorative nursing services was attributed to a lack of follow-up and communication among staff members. The Director of Rehabilitation Services and the Chief Nursing Officer acknowledged the oversight and the importance of adhering to physician orders and therapy recommendations. The failure to implement the restorative programs as planned created a potential for residents to experience a decline in their physical condition, which was not documented or addressed in a timely manner.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement a fall intervention for a resident with multiple diagnoses, including traumatic brain injury and dementia, who was at high risk for falls. The resident's care plan and physician orders specified the use of a low bed with a fall mat on the floor for safety. However, during observations, the fall mat was not in place next to the resident's bed, and staff interviews revealed a lack of awareness regarding the requirement for the mat. The resident had a history of falls, and on two occasions, was found on the floor without the fall mat in place. Interviews with staff, including a CNA, RN, LPN, and the CNO, indicated confusion and lack of communication regarding the resident's fall prevention measures. The CNO confirmed that the fall mat was listed on the Kardex and should have been in place, as per the care plan and physician order. The failure to ensure the fall mat was in place as required by the care plan and physician order constituted a deficiency in providing adequate supervision and preventing accident hazards for the resident.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to potential risks of urinary tract infections. Resident #158, who was admitted with a history of sepsis related to a urinary tract infection and obstructive uropathy, had a physician's order to keep his catheter bag below the bladder for proper drainage. However, observations revealed that the catheter bag was consistently positioned at waist level on the resident's wheelchair, contrary to the care plan. Despite staff awareness of the correct positioning, they allowed the resident's preference to override the care plan without proper documentation or education on the potential consequences. Resident #39, admitted with obstructive and reflux uropathy, had a physician's order to secure his indwelling catheter with a leg strap to prevent movement and urethral traction. Observations on multiple occasions showed that the catheter was not secured with a leg strap, and the resident confirmed that staff were not following the order. An LPN admitted to documenting that catheter care was provided without verifying if the tubing was secured, highlighting a lapse in adherence to physician orders and documentation protocols. Interviews with staff, including CNAs, LPNs, and the CNO, revealed inconsistencies in following physician orders and documenting resident refusals. The facility's policy required documentation of refusals and notification of the physician, which was not consistently followed. The lack of adherence to care plans and physician orders for both residents created a potential risk for urinary tract infections due to improper catheter care.
Failure to Administer Oxygen Therapy Per Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy according to the physician's orders. This deficiency was identified for a resident who was admitted with multiple diagnoses, including acute respiratory failure with hypercapnia. The physician's order specified that the resident should receive oxygen at 2 liters per minute (LPM) via nasal cannula continuously. However, observations on three consecutive days revealed that the resident was receiving oxygen at 3 LPM, contrary to the physician's order. Interviews with staff members, including an LPN and the ACON, indicated a lack of awareness and adherence to the physician's orders. The ACON was unsure of the correct oxygen setting without reviewing the orders, and the LPN admitted to not closely checking the oxygen setting, despite documenting that it was at the correct level. The CNO confirmed that staff should follow physician orders and not incorrectly sign off on the MAR/TAR. This oversight created the potential for the resident to experience hyperoxia due to the excess supply of oxygen.
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Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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.
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