Weiser Care Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Weiser, Idaho.
- Location
- 331 East Park Street, Weiser, Idaho 83672
- CMS Provider Number
- 135010
- Inspections on file
- 17
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Weiser Care Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow the facility’s hand hygiene and infection control policies during housekeeping, medication administration, and laundry operations. A maintenance staff member cleaned one room, removed gloves, then donned new gloves to clean another room without performing hand hygiene in between. Laundry staff handled soiled linens on the dirty side of the laundry room without PPE and then moved to the clean side to fold laundered items, which leadership acknowledged posed a high risk for cross-contamination. An LPN repeatedly prepared and administered medications to multiple residents without performing hand hygiene before medication preparation or before entering and after exiting resident rooms, despite handling items such as cart keys, doorknobs, pitchers, and nutritional supplements. These failures affected all residents receiving medications and laundry services and created the potential for cross-contamination.
The facility failed to maintain a clean, sanitary, and homelike environment when housekeeping and laundry services were not provided as expected for two residents sharing a room. Facility policies required a safe, clean, and comfortable environment and daily room cleaning, including emptying trash and floor care. However, surveyors observed overfilled trash cans, a dirty paper product on the floor, a broken drawer with its outer section stuffed into the opening, and a pillowcase visibly soiled with brown residue on one resident’s bed. Both residents, one with diabetes, epilepsy, and muscle weakness and the other with dementia, legal blindness, PTSD, and Bell’s palsy, reported they were unsure when housekeeping last cleaned their room, and one was unsure when linens were last changed. The Maintenance Director confirmed the room had not been cleaned despite the expectation for daily housekeeping.
A resident with bipolar disorder, obstructive sleep apnea, and personal care needs, identified as an independent smoker, was educated on the facility’s smoking policy and informed that noncompliance would result in a 30-day written discharge notice. After the resident smoked on facility grounds, staff documented that a 30-day notice was issued, but there was no evidence that this notice was provided in writing as required by facility policy and regulation. The resident then requested to leave AMA, and while the record contained a discharge assessment and an AMA risk acknowledgment, it lacked documentation of the required written 30-day discharge notice, which the Administrator and Resource Nurse later confirmed they could not produce.
A deficiency was cited when a resident with dementia and PTSD had a positive PASRR Level I that required referral for a PASRR Level II evaluation, but the facility did not submit or obtain the Level II or provide it to the state agency upon request. Facility policy required that a positive Level I trigger a Level II evaluation and that its recommendations be incorporated into the person-centered care plan. The Medical Records Manager, responsible for PASRRs, reported she had been instructed to submit a Level II only when psychiatric medications were listed and acknowledged that the resident’s Level I should have been forwarded for Level II review.
A resident with a history of stimulant use, depression, and nutritional deficiency had a care plan directing staff to monitor and document specific withdrawal symptoms, including respiratory distress, cardiac decompensation, nausea/vomiting, anxiety, hostility, bloodshot eyes, pinpoint pupils, and diaphoresis. Review of the medical record showed no documentation that staff performed or recorded this required monitoring, and a Resource Nurse confirmed the absence of withdrawal monitoring in the record, demonstrating a failure to implement the comprehensive person-centered care plan as written.
A resident with asthma had a physician’s order for Symbicort inhaler twice daily with instructions to rinse and spit after use, consistent with the drug’s prescribing information to reduce the risk of oral Candida infection. During a medication pass, an LPN handed the inhaler to the resident, who took two puffs and declined water afterward. The LPN did not provide education about the need to rinse the mouth after inhalation and left the resident without reinforcing this instruction, later acknowledging that education should have been provided; the Resource Nurse and DON agreed the resident should have been educated to rinse after using the inhaler.
The facility failed to safely manage smoking paraphernalia and maintain accurate smoking assessments for two residents who smoked off-campus. One resident with multiple chronic conditions, including kidney disease, diabetes, COPD, CHF, and asthma, had conflicting documentation between her care plan and smoking assessment regarding whether she was an independent or dependent smoker, while her assessment also allowed her to keep smoking accessories locked in her room despite the facility’s smoke‑free policy. Another resident with a history of stimulant use, depression, and nutritional deficiency, who had acknowledged the smoke‑free policy and was care planned as an independent smoker, was observed asleep in bed holding a vape device. The DON later stated she was unaware this resident was using a vape and confirmed the expectation that all smoking paraphernalia be stored safely.
A deficiency occurred when a physician did not document a response to a pharmacist’s recommendation following a monthly drug regimen review for a resident receiving budesonide (Symbicort) for COPD. The facility’s policy required providers to document acceptance or rejection of pharmacist recommendations in the medical record. The pharmacist advised adding a “rinse mouth and spit after use” instruction to the steroid inhaler order, consistent with the drug’s prescribing information regarding risk of oral Candida infections, but the order was never updated and no physician response was recorded. The DON reported that nurses were trained to advise mouth rinsing as a standard of practice, yet the lack of an updated order and documented provider response remained for this resident.
A resident with COPD and incomplete quadriplegia was maintained on a daily nicotine transdermal patch and had a PRN order for nicotine gum while also continuing to smoke cigarettes. The MAR showed the patch was administered, and the DON reported the resident was an infrequent smoker but could not provide documentation of infrequent smoking during the period when nicotine replacement therapy was in place. Surveyors found this combination of active nicotine replacement orders and ongoing smoking did not ensure the resident’s drug regimen was free from unnecessary medications and placed the resident at risk for adverse outcomes from overmedication.
A cognitively intact resident with a history of MI and diabetes was found with a seven-day pill container containing tablets on the bedside table, contrary to facility policy requiring medications to be stored in locked compartments. When questioned, the resident reported not knowing what medications were in the container and stated that staff administered his medications. An LPN and the DON later acknowledged that such a pill container with medications should not have been kept in the resident’s room, leading surveyors to cite a deficiency for improper medication storage.
The facility did not ensure that two residents had arbitration agreements specifying a mutually convenient venue for hearings. Instead, their agreements required arbitration to be held in the county where the facility is located before three arbitrators from the American Arbitration Association, without reference to mutual agreement or convenience. During review, the Admission Coordinator acknowledged that these residents should have been asked to sign the updated version of the agreement that includes a mutually agreed upon, convenient venue.
A resident with multiple diagnoses, including muscle weakness and lower back pain, had a urine specimen collected for suspected UTI, with the lab indicating a culture and sensitivity (C&S) would be completed. Before C&S results were available, staff informed the provider that the urine was positive for bacteria, and the provider ordered a 7-day course of IM Rocephin. The C&S was later cancelled due to no sample to perform the test. This sequence of events did not follow the facility’s Antibiotic Stewardship Policy, which required use of McGeer’s Criteria and review of culture and sensitivity reports to guide appropriate antibiotic therapy.
The facility did not have an RN on duty for 8 consecutive hours on two days, as required. The CNO worked from home and was unaware that the hours needed to be consecutive, leading to potential unmet nursing needs for all residents.
The facility did not post nurse staffing information daily or retain it for 18 months as required by policy. The Daily Posted Staffing sheet was outdated, and the Administrator admitted the medical records person missed posting weekend hours. The facility also failed to keep staffing records for the required duration.
The facility failed to properly store and label food, as observed with an undated open soy sauce container, violating the Idaho Food Code and facility policy. Additionally, refrigerator temperatures were not checked for three days, risking contamination and food spoilage for 25 residents.
The facility did not ensure a safe, clean, and homelike environment for two residents, leading to potential safety risks. A resident with dementia, diabetes, and osteoarthritis had a room with damaged walls, while another resident with a shoulder infection and diabetes had a room with a missing baseboard, posing a risk of skin tears. Staff acknowledged these issues should have been addressed.
A facility failed to complete a comprehensive MDS assessment for a resident who developed a stage 3 pressure ulcer. Despite the significant change in condition, the quarterly MDS did not document the ulcer, and a significant change MDS was not completed within the required timeframe. This oversight was confirmed by the Regional Clinical Nurse.
A facility failed to follow its wound care policy for a resident with wounds, risking infection and skin breakdown. The policy requires regular documentation and dressing changes, but bandages dated over ten days old were observed. An RN confirmed that bandages should be changed every three days, indicating a lapse in care for the resident with multiple diagnoses, including a shoulder infection and diabetes.
A facility failed to ensure NAs had the necessary competencies, as observed when an NA improperly used peri-care wipes during catheter care, contrary to guidelines. Additionally, a resident's privacy was compromised when CNAs left window blinds open during a transfer and catheter care, exposing the resident to the outside.
The facility failed to ensure medications were properly dated and not expired. During a medication cart audit, expired Bisacodyl suppositories and undated insulin pens were found. An RN acknowledged the expired medication should have been removed, and another RN confirmed the insulin pens should have been dated when opened.
The facility failed to maintain proper infection control practices, as observed in several instances. An Activities Assistant did not wash hands after removing gloves before serving a resident, and a Lead Cook handled clean dishes without changing gloves after wiping dirty counters. Additionally, two residents were not offered hand hygiene before meals. These lapses were acknowledged by staff, highlighting a breach in infection control protocols.
A resident with Myasthenia Gravis and a pelvis fracture, who uses a wheelchair, was unable to reach the sink faucet, soap, and paper towel dispenser in her room. The facility's administrator was unaware of this accessibility issue, which led to a deficiency in providing a functional environment for the resident.
Failure to Follow Hand Hygiene and Laundry Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hand hygiene and infection control policies during housekeeping, medication administration, and laundry operations. The facility’s Hand Hygiene policy, revised 9/15/25, required staff to perform hand hygiene at critical moments, including immediately before and after touching a resident, after contact with objects and surfaces in the resident’s environment, and immediately after PPE removal. During observation on 02/17/26, the Maintenance Director cleaned a resident room by wiping surfaces, sweeping, cleaning the toilet, using an aerosol bottle, and mopping while wearing gloves. After completing these tasks, he removed his gloves, moved to the next room, applied new gloves, and began cleaning without performing hand hygiene between glove removal and donning new gloves. He later stated he normally performs hand hygiene before applying clean gloves and acknowledged he did not do so in this instance, which did not comply with the facility’s policy. Additional deficiencies were identified in the laundry room and during medication administration. During a laundry room inspection on 02/20/26, the Maintenance Director explained that dirty laundry is sorted on the dirty side, washed, then moved to the clean side for drying and folding, and confirmed that laundry staff do not use PPE while sorting dirty laundry. The Maintenance Director and the Administrator both acknowledged there is a high risk for cross-contamination when staff handle dirty laundry without PPE and then move to the clean side to fold clean clothing. On 02/18/26, an LPN was observed repeatedly preparing and administering medications to multiple residents without performing hand hygiene before preparing medications, before entering resident rooms, or after exiting resident rooms, despite touching items such as a medication cart key, a medication room doorknob, a pitcher, and nutritional supplement containers. The LPN later stated that hand hygiene should be performed before and after exiting resident rooms and before preparing medications, and the Infection Preventionist similarly stated that hand hygiene should be performed before entering and after exiting resident rooms and before preparing medications. These observations showed that the facility failed to ensure infection control practices were followed for hand hygiene and PPE use, affecting all residents receiving medications and laundry services and creating the potential for adverse outcomes related to cross-contamination.
Failure to Maintain Clean and Homelike Environment in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, comfortable, sanitary, and homelike environment, as required by its Homelike Environment and Housekeeping & Laundry Services policies. These policies state that residents have the right to a safe, clean, comfortable, and homelike environment that promotes dignity, independence, and quality of life, and that the facility must maintain a sanitary, orderly, and comfortable interior environment at all times. The daily cleaning task list requires staff to empty trash cans, dust, check the floor, and wet mop the floor in each resident room. During observation of the shared room of Resident #5 and Resident #7, surveyors noted two trash cans overfilled with garbage, a dirty paper towel or toilet tissue on the floor in front of the closet, a broken drawer with the outer section stuffed into the drawer area, and a visibly soiled pillowcase with brown residue on Resident #7’s bed. Resident #5, who had diagnoses including diabetes, epilepsy, and muscle weakness, and Resident #7, who had dementia, legal blindness, PTSD, and Bell’s palsy, both stated they were unsure when housekeeping had last cleaned their room, and Resident #7 was unsure when staff had last cleaned his bed linens. The Maintenance Director later stated that the expectation was for housekeeping staff to clean resident rooms daily and acknowledged that this room had not been cleaned as expected.
Failure to Provide Required 30-Day Written Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to provide a required 30-day written notice of discharge to a resident prior to discharge. The facility’s “Notice of Discharge and/or Transfer” policy, dated 10/7/25, stated that systems are implemented to provide written notification to residents prior to transfer. Resident #58 was admitted with multiple diagnoses including bipolar disorder, obstructive sleep apnea, and a need for assistance with personal care. The resident’s care plan, dated 10/23/25, documented that he was an independent smoker who had been educated on the facility’s smoking policy. On 10/29/25 at 10:53 AM, a progress note documented that the resident was educated on appropriate smoking areas and informed that noncompliance would result in issuance of a 30-day written notice as required by policy and regulation. A subsequent progress note on 10/29/25 at 5:10 PM documented that the resident was issued a 30-day notice due to smoking on facility grounds, but the note did not indicate that a written notice was provided. Another progress note at 5:40 PM the same day documented that the resident requested to leave the facility against medical advice. The record contained a discharge assessment (unsigned by the resident) and an acknowledgment of risk for leaving AMA signed by the resident, but there was no documentation of a written 30-day discharge notice. On 2/20/26 at 11:01 AM, the Administrator and Resource Nurse confirmed they were unable to provide documentation that a written 30-day discharge notice had been given to the resident.
Failure to Submit Required PASRR Level II Evaluation
Penalty
Summary
Surveyors found that the facility failed to provide a PASRR Level II to the designated state agency for one resident whose record was reviewed for PASRR documentation. The facility’s PASRR Process policy, revised 8/29/25, stated that a positive PASRR Level I requires an in-depth evaluation by the state-designated authority (PASRR Level II) and that recommendations from the Level II determination must be incorporated into the person-centered care plan. Resident #7 was admitted with multiple diagnoses, including dementia and PTSD. A PASRR Level I dated 8/13/25 documented these diagnoses and referred the resident for further evaluation through a PASRR Level II, but when surveyors requested a copy of the PASRR Level II on 2/19/26, the facility was unable to provide it. The Medical Records Manager, who stated she was responsible for completing residents’ PASRRs, reported she had been instructed to submit a PASRR Level II only if psychiatric medications were listed and confirmed that Resident #7’s PASRR Level I should have been forwarded for a Level II review. This failure to follow the facility’s PASRR policy and to submit the required PASRR Level II for the resident with dementia and PTSD led to the cited deficiency related to coordination of assessments with the pre-admission screening and resident review program and referral for services as needed.
Failure to Implement Care Plan Monitoring for Withdrawal Symptoms
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan for one resident. The facility’s RAI and Comprehensive Care Plans Policy required that care plans be developed and implemented consistent with each resident’s specific condition, risks, and needs. Resident #42, admitted with diagnoses including other stimulant use, depression, and nutritional deficiency, had a care plan revised on 10/13/25 that directed staff to monitor and document for potential signs of withdrawal, including respiratory distress, cardiac decompensation, nausea/vomiting, anxiety, hostility, bloodshot eyes, pinpoint pupils, and diaphoresis. Record review showed no documentation that staff monitored for or recorded any signs or symptoms of withdrawal as required by the care plan, and on 2/20/26 the Resource Nurse confirmed that the resident’s record did not include monitoring for withdrawal symptoms. This failure to carry out the care plan’s specified monitoring for withdrawal constituted noncompliance with the facility’s policy and the requirement to implement a comprehensive care plan according to the resident’s identified needs.
Failure to Educate Resident on Mouth Rinsing After Corticosteroid Inhaler Use
Penalty
Summary
The facility failed to ensure a medication was administered according to professional standards of practice for one resident receiving a corticosteroid inhaler. The Symbicort prescribing information and the physician’s order both specified that the resident should rinse her mouth with water and spit after inhalation to reduce the risk of localized Candida albicans infection in the mouth and throat. Resident #29, who had a diagnosis of asthma and an order for Symbicort two puffs orally twice daily with mouth rinsing afterward, was observed taking two puffs from her inhaler and returning it to the LPN. After administering the inhaler, LPN #1 told the resident she would get her some water, but when the resident stated she did not need the water, the LPN left without providing education on the importance of rinsing her mouth after using the inhaler. In a subsequent interview, LPN #1 acknowledged that the resident did not want the water and admitted she should have educated the resident about rinsing her mouth but did not do so. The Resource Nurse and the DON also stated that the resident should have been educated to rinse her mouth after using the inhaler.
Failure to Safely Manage Smoking Paraphernalia and Smoking Assessments
Penalty
Summary
The facility failed to ensure smoking paraphernalia was stored in a safe location and to maintain accurate smoking assessments for residents who smoke off-campus. The facility’s Non-Smoking Campus Policy, revised 9/12/25, stated that smoking, including e‑cigarettes and vaping devices, was not permitted anywhere on the premises and that the facility maintained a smoke‑free environment. Despite this, Resident #6’s care plan dated 1/8/26 documented that she was an independent smoker who could smoke when off the facility’s property as she desired, while nursing progress notes dated 1/15/26 documented she was a dependent/assisted smoker and to review the evaluation. A smoking assessment dated 1/15/26 documented Resident #6 was a dependent smoker who required assistance but could keep her smoking accessories locked in her room. On 2/17/26 at 10:15 AM, the Administrator stated residents who chose to smoke off-campus were assessed for independent or dependent smoking status, and on 2/19/26 at 4:48 PM, the DON stated Resident #6’s 1/15/26 smoking assessment was not accurate as she was an independent smoker. The facility also failed to ensure safe storage of smoking paraphernalia for Resident #42. Resident #42, admitted with diagnoses including other stimulant use, depression, and nutritional deficiency, had a care plan revised 10/15/25 documenting she was an independent smoker and had been educated on the facility’s smoke/nicotine use policy. A Smoke‑Free Acknowledgment in her record documented the facility’s smoke‑free policy and expectations. On 2/18/26 at 10:35 AM, Resident #42 was observed lying on her bed asleep with a vape device in her right hand. On 2/20/26 at 12:10 PM, the DON stated she was not aware that Resident #42 was using a vape and confirmed that although Resident #42 was an independent smoker, the expectation was that all smoking paraphernalia be stored safely.
Failure to Obtain Physician Response to Pharmacist Recommendation for Steroid Inhaler Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician responded to a pharmacist’s documented recommendation following a monthly drug regimen review. The facility’s Pharmacist Consultation Policy, revised 9/16/25, required that irregularities identified by the pharmacist be reported to the provider and that the provider document acceptance or rejection of the recommendations in the medical record. For one resident reviewed for unnecessary medications, Resident #48, the pharmacist completed a Consultation Report on 11/11/25 recommending that the resident rinse and spit after use of budesonide (Symbicort) to align with the medication’s prescribing information, which warns of localized Candida albicans infections of the mouth and throat and advises rinsing the mouth after inhalation. Resident #48 had a physician’s order dated 9/26/25 for budesonide (Symbicort) inhalation twice daily for COPD. The pharmacist’s Consultation Report specifically requested consideration of adding “rinse mouth out and spit after use” to the budesonide order, but there was no documentation that the physician responded to this recommendation, and the resident’s medication order was not updated to include the mouth-rinsing instruction. A handwritten “Standard of Care” notation appeared at the bottom of the Consultation Report, and during an interview, the DON stated that nurses were expected and trained to advise residents to rinse their mouths after using a steroid inhaler, but acknowledged that the physician’s order had not been updated because it was only a pharmacist recommendation. This lack of documented physician response and order update was identified for 1 of 6 residents reviewed for unnecessary medications and created the potential for the resident to develop oral thrush.
Unnecessary Nicotine Therapy While Resident Continued to Smoke
Penalty
Summary
The facility failed to ensure a resident’s medication regimen was free from unnecessary medications when a resident received nicotine replacement therapy while also smoking cigarettes. The resident, who had multiple diagnoses including incomplete quadriplegia and COPD, was admitted with orders for a 14 mg/24 hr nicotine transdermal patch to be applied daily and nicotine polacrilex gum 4 mg to be given every 3 hours as needed for nicotine craving. The electronic health record documented that the resident was assessed for independence with smoking on two occasions, and the MAR showed that the nicotine patch was administered as ordered. The DON stated the resident was an infrequent smoker but acknowledged the facility could not provide documentation that the resident smoked infrequently while still using the nicotine patches and having an active order for nicotine gum. This resulted in the resident simultaneously having and using nicotine patches, having an order for nicotine gum, and continuing to smoke cigarettes, which the surveyors determined did not meet the requirement that each resident’s drug regimen be free from unnecessary drugs and placed the resident at risk for adverse outcomes from overmedication.
Improper Storage of Medications in Resident Room
Penalty
Summary
The facility failed to ensure medications were safely stored in locked compartments in accordance with its Medication Storage & Labeling policy and professional standards. The policy, released on 10/13/25, required that general medications be stored in locked compartments such as cabinets, carts, or a medication room. During a survey, a seven-day pill container containing white and blue tablets was observed on top of the bedside table of Resident #18, who was awake in bed at the time. Resident #18 had been admitted with multiple diagnoses, including myocardial infarction and diabetes, and a comprehensive MDS assessment documented that he was cognitively intact. When initially asked about the pill container, Resident #18 did not respond. Later, when an LPN asked if he knew what medications were inside the pill container, Resident #18 stated he did not know. He also stated he had not taken any of the medications from the pill container because staff were administering his medications. The presence of the pill container with medications in the resident’s room was acknowledged by nursing leadership, who stated that the pill container with medication inside should not be in the resident’s room. The surveyors determined that this constituted a failure to store medications in locked compartments as required, resulting in a deficiency related to medication storage.
Failure to Use Arbitration Agreements With Mutually Convenient Venue
Penalty
Summary
The facility failed to ensure that its Arbitration Agreement provided for a venue that was convenient to both parties, as required for a neutral and fair arbitration process. Record review showed that one resident admitted on an unspecified date signed an Arbitration Agreement on 8/26/25, and another resident admitted on an unspecified date had a representative sign an Arbitration Agreement on 9/19/25. Both agreements stated that any arbitration hearing would be held in the county where the facility is located before a board of three arbitrators selected from the American Arbitration Association (AAA), without reference to mutual agreement or convenience of venue. During an interview on 2/19/26, the Admission Coordinator reviewed these agreements and produced the facility’s updated Arbitration Agreement, which specified that hearings would be held in a mutually agreed upon venue convenient to both parties before three arbitrators selected from the AAA. The Admission Coordinator stated that the two residents should have been asked to sign the new Arbitration Agreement when the facility updated it. This deficiency was identified for 2 of 3 residents whose arbitration agreements were reviewed, indicating that the facility did not obtain updated agreements reflecting the mutually convenient venue requirement for those residents.
Antibiotic Initiated Without Required Culture and Sensitivity Results
Penalty
Summary
The facility failed to follow its Antibiotic Stewardship Policy by initiating antibiotic therapy without culture and sensitivity results to guide treatment for one resident. The policy, revised on 6/16/25, stated the facility would improve antibiotic use through an Antibiotic Stewardship Program, utilize McGeer's Criteria to validate infections, and routinely review culture and sensitivity reports as part of infection surveillance. For urinary tract infections without an indwelling catheter, McGeer's Criteria require at least one clinical sign or symptom and at least one microbiologic criterion, including specific quantitative culture results. The facility's care plan for the resident, dated 12/29/25, directed staff to monitor, document, and report signs and symptoms of urinary tract infection to the provider as needed. The resident was admitted with multiple diagnoses including muscle weakness, lower back pain, and a need for assistance with personal care. A urine specimen was collected on 1/8/26, with the laboratory report indicating that a culture and sensitivity test would be completed. On 1/9/26, a nursing progress note documented that the provider was informed the urine was positive with bacteria and ordered Rocephin 1 gram intramuscularly for 7 days, while the facility was still waiting for the culture and sensitivity results. A subsequent laboratory report dated 1/14/26 documented that the culture and sensitivity was cancelled due to no sample to perform the test. On 2/20/26, the ADON confirmed that the provider ordered antibiotic therapy before culture and sensitivity results were available to determine appropriate therapy.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of staffing records and staff interviews, revealing that on two specific days, 9/7/24 and 9/8/24, the facility did not meet this requirement. On 9/7/24, the Chief Nursing Officer (CNO) was scheduled to work for only 6 hours, and on 9/8/24, another RN was scheduled to work intermittently. Furthermore, the CNO admitted to working from home on both days and was unaware that the 8 hours of RN coverage needed to be consecutive. This oversight created the potential for harm if nursing needs, whether routine or emergency, went unmet, potentially affecting all residents in the facility.
Failure to Post and Retain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted daily for each shift and retained for review for 18 months, as required by their policy. The policy, dated 11/28/17, mandates the daily posting of the total number and actual hours worked by RNs, LPNs, CNAs, and the resident census, with records to be kept for a minimum of 18 months or as required by state law. On 9/22/24, it was observed that the Daily Posted Staffing sheet was dated 9/20/24, indicating a failure to post the nursing hours for the last two days. The Administrator acknowledged that the medical records person was responsible for posting the weekend nursing hours on Friday but had missed it. Additionally, the Administrator confirmed on 9/25/24 that the facility had not retained the Daily Posted Staffing Sheets for the required 18 months.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to appropriately store and label food, as observed during a survey. Specifically, an open container of soy sauce was found in the food storage area without a date, which is a violation of the Idaho Food Code and the facility's own policy. The Idaho Food Code requires that refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours must be clearly marked with a date to indicate when it should be consumed, sold, or discarded. The facility's policy also mandates that opened food products should be labeled with their contents and use-by dates. During the survey, it was noted that the soy sauce container was not dated, and the lead staff member acknowledged that it should have been. Additionally, the survey revealed that the temperatures of the back hall snack refrigerator had not been checked and documented for three consecutive days. The Culinary Manager confirmed that the nursing staff was responsible for checking and documenting the refrigerator and freezer temperatures but failed to do so. This oversight in monitoring refrigerator temperatures and the lack of proper food labeling and storage practices had the potential to affect 25 of 26 residents who received meals and snacks at the facility, placing them at risk for potential contamination and use of spoiled foods, which could lead to adverse health outcomes, including food-borne illnesses.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents, leading to a potential safety risk and diminished quality of life. Resident #28, who has dementia, diabetes, and osteoarthritis, was found to have a room with scrapes, chipped paint, and holes in the walls. The Administrator and CNO acknowledged that the walls should have been repaired after the previous resident moved out. Resident #199, with a right shoulder infection and diabetes, had a room where the baseboard by the sink was missing, and part of it was sticking out, posing a risk of skin tears. The Maintenance Manager confirmed that the baseboard should have been fixed.
Failure to Complete Significant Change MDS for Pressure Ulcer
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident who experienced a significant change in condition after developing a pressure ulcer. The resident, who was admitted with diagnoses including dementia, diabetes, and osteoarthritis, developed a silver dollar-sized open wound on the right buttock, which progressed to a stage 3 pressure injury. Despite this significant change, the resident's quarterly MDS did not document the presence of a pressure ulcer, and a significant change MDS was not completed within the required 14 days of diagnosing the pressure ulcer. This oversight was confirmed by the Regional Clinical Nurse, who acknowledged that the MDS should have been modified to reflect the resident's condition accurately.
Failure to Follow Wound Care Policy
Penalty
Summary
The facility failed to adhere to its comprehensive person-centered care plan for a resident with wounds, leading to a potential risk of infection and skin breakdown. The facility's policy on the prevention and treatment of pressure ulcers and other skin alterations requires documentation of wound evaluations with each dressing change or at least weekly. This documentation should include details such as the location, size, exudate, pain, wound bed, and surrounding tissue. However, during an observation on 9/22/24, it was noted that the bandages on the resident's legs and left toe were dated 9/11/24, indicating they had not been changed in accordance with the policy. An RN confirmed that skin tear bandaging should be changed every three days, highlighting a lapse in following the care plan for the resident, who was admitted with multiple diagnoses including a right shoulder infection and diabetes.
Deficiency in Nursing Assistant Competency and Resident Privacy
Penalty
Summary
The facility failed to ensure that Nursing Assistants (NAs) performed tasks for which they had the necessary knowledge, skills, and competencies. This deficiency was observed in one of the six NAs at the facility. The facility's policy on indwelling catheters, revised on 4/12/22, emphasized infection control and proper hygiene practices, including cleaning the catheter-urethral interface daily with soap and water. However, during an observation on 9/24/24, NA #2 was seen using peri-care wipes incorrectly by wiping toward, rather than away from, the urinary meatus, contrary to the guidelines outlined in the facility's policy and other authoritative sources like the CDC and AHRQ. Additionally, the facility failed to maintain the privacy and dignity of a resident during care procedures. On the same day, CNA #1 and NA #2 used a Hoyer lift to transfer a resident from a wheelchair to a bed, leaving the window blinds open and exposing the resident's bottom and perineum area to the outside. This lack of privacy continued as they prepared the resident for catheter care, again with the window blinds open, exposing the resident's urinary meatus area. Both CNA #1 and NA #2 acknowledged that they should have closed the window blinds before transferring the resident and performing catheter care.
Medication Management Deficiency
Penalty
Summary
The facility failed to ensure medications available for residents were properly dated and not expired, as observed during a survey. During an audit of the back hall medication cart, a box of Bisacodyl suppositories with an expiration date of November 2023 was found, indicating it should have been removed from the cart. RN #1 acknowledged that the expired medication should have been taken off the cart. Additionally, during the front hall medication cart audit, two insulin pens were found without dates in the top drawer. RN #2 was unsure if the insulin pens had been used and confirmed that they should have been dated when opened. This oversight was reiterated by RN #2, who stated that the insulin pen was not dated as required.
Infection Control Lapses in Hand Hygiene and Kitchen Practices
Penalty
Summary
The facility failed to adhere to infection control and prevention practices, impacting the safety and sanitation of the environment. An Activities Assistant was observed removing gloves without washing hands before serving a resident lemonade, only sanitizing her hands after delivering the drink. In the kitchen, a Lead Cook was seen wiping dirty counters and handling clean dishes without changing gloves or washing hands. Additionally, the Business Office Manager delivered breakfast meals to two residents without offering them hand hygiene before eating. These actions were acknowledged by staff, indicating a lapse in following proper infection control protocols.
Inaccessible Facilities for Wheelchair-Bound Resident
Penalty
Summary
The facility failed to provide a functional environment for a resident, leading to a deficiency in meeting the resident's physical needs. This issue was identified during an observation on September 24, 2024, when a resident who uses a wheelchair was unable to reach the sink faucet and handles, soap, or paper towel dispenser in her room. The resident had been admitted with multiple diagnoses, including Myasthenia Gravis and a left pelvis fracture, which necessitated the use of a wheelchair. The facility's administrator acknowledged the issue, stating he was unaware that these items were inaccessible to residents in wheelchairs.
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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.
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