Wellspring Health & Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Nampa, Idaho.
- Location
- 2105 12th Avenue Road, Nampa, Idaho 83686
- CMS Provider Number
- 135094
- Inspections on file
- 18
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Wellspring Health & Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that medications, including insulin pens and loose pills, were not properly labeled with resident names or open/discard dates, and expired medications were not disposed of as required. LPNs confirmed that some medications were left in carts without proper identification after residents declined doses, and the DON acknowledged that these practices did not follow facility policy.
The facility failed to protect residents from COVID-19 exposure by not relocating negative residents from positive roommates and not ensuring proper PPE use and hand hygiene. A resident did not receive a COVID-19 vaccine despite consent, and staff did not perform hand hygiene after incontinence care, risking infection spread.
A resident with multiple medical conditions, including reliance on a nasogastric (NG) tube for nutrition, experienced harm due to the facility's failure to verify tube placement before administering fluids. An LPN noticed the tube appeared longer and the marking was off but continued to flush the tube, resulting in water exiting the resident's nostrils and causing pain. The resident was later diagnosed with a pneumothorax, aspiration pneumonia, and sepsis. Facility staff confirmed that the standard practice of stopping fluid administration and verifying tube placement was not followed.
The facility failed to maintain a sanitary kitchen environment, with dirt found on a fan in the walk-in refrigerator and a white residue on a shelf below the steam table. Despite having a cleaning schedule, the CDM and RD could not explain these deficiencies, affecting 69 of 80 residents who consumed food prepared by the facility.
The facility did not ensure glucometers were calibrated as required for accurate blood glucose monitoring on two halls. Despite policy requiring nightly or manufacturer-guideline calibrations, records showed inconsistent calibrations from January to April 2024, and none from May to July 2024. Staff interviews revealed night shift nurses were responsible for calibrations, but the CNO confirmed they were not performed weekly as directed, highlighting the importance of calibration for accurate readings.
The facility failed to document, investigate, and resolve grievances about call lights voiced by residents during Resident Council meetings. Despite repeated concerns from residents about delays in call light responses, there was no systematic approach to address these issues. Interviews revealed a lack of communication and coordination among staff, with no documented follow-up or education on the matter.
A resident experienced a 9.2% weight loss in one month, but the facility failed to notify the physician as required by policy. The resident, who had dementia and aphasia, was at risk for weight loss. Despite the significant change, there was no record of physician notification, as confirmed by the CNO.
The facility failed to investigate allegations of verbal abuse and medication errors involving two residents. One resident was found with two Fentanyl patches, leading to Narcan administration and hospitalization, but no investigation was documented. Another resident alleged verbal abuse by a nurse, but the facility did not thoroughly document or investigate the incident, relying on verbal accounts without corroborating evidence.
The facility failed to develop comprehensive care plans for two residents, leading to missing critical care information. One resident's care plan lacked catheter care details despite physician orders, while another's omitted anticoagulant therapy information. The CNO acknowledged these omissions, which placed residents at risk of negative outcomes.
A resident with neuromuscular dysfunction of the bladder and cognitive impairment did not receive timely incontinence care, resulting in a 25-minute delay. The resident was found with dry fecal material, indicating prolonged incontinence. The facility lacked a specific incontinence care policy, and staff failed to provide immediate care, despite scheduled incontinence rounds.
The facility failed to follow physician orders for respiratory care for two residents, leading to lapses in documentation and maintenance of supplemental oxygen equipment. One resident's treatment was not consistently documented, while another was found with an empty humidifier, indicating a lack of clarity in staff responsibilities.
The facility failed to administer pneumococcal and influenza vaccines to three residents who had consented to receive them. Despite policies in place, the residents did not receive the vaccines they were due for, as confirmed by the CNO. This oversight involved residents with various medical conditions, including autism, epilepsy, and cerebral palsy.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of medications on two medication carts. Specifically, insulin pens were found without resident name labels, with open and discard dates not properly documented, and in some cases, the discard date exceeded the recommended 28-day period. Additionally, a pill cup containing a loose, unidentified pill was found in a medication cart drawer without a resident name, after a nurse left it there when a resident declined to take the medication and the nurse was called away. Expired medications were not disposed of as required, and some medications may have been pulled from the emergency kit without appropriate labeling. Interviews with LPNs and the DON confirmed that these practices were not in accordance with facility policy or pharmacy guidelines, which require medications to be labeled with the resident's name, open and discard dates, and to be discarded if not administered or if expired. The DON stated that insulin pens are to be discarded within 28 days of opening and that medications not administered at the time of removal from the cart should be discarded. The observed deficiencies had the potential to result in medication errors and improper administration.
Inadequate Infection Control and Vaccination Oversight
Penalty
Summary
The facility failed to protect residents who tested negative for COVID-19 from being exposed to positive roommates, and did not implement proper infection control measures. Observations revealed that staff inconsistently wore appropriate PPE, such as face shields or goggles, when entering rooms with COVID-19 positive residents. Additionally, staff were seen not performing hand hygiene before and after donning and doffing PPE, which is against the facility's policy and CDC guidelines. The facility had available private and double occupancy rooms but did not relocate residents to prevent exposure. The facility also failed to provide COVID-19 vaccinations to all residents who requested them. One resident, who had multiple medical conditions and relied on a legal guardian for healthcare decisions, did not receive the vaccine despite consent being given. This oversight placed the resident at risk of serious illness, as she later contracted COVID-19. Furthermore, the facility did not ensure proper hand hygiene after providing incontinence care. Staff were observed not changing gloves or washing hands after providing care to a resident, which could lead to the spread of infection. The resident involved was cognitively impaired and dependent on staff for toileting, highlighting the importance of adhering to hygiene protocols to protect vulnerable individuals.
Failure to Verify NG Tube Placement Leads to Resident Harm
Penalty
Summary
The facility failed to ensure appropriate treatment for a resident receiving nutrition through an enteral tube, leading to complications. The resident, who had multiple diagnoses including acute respiratory failure with hypoxia, a tracheostomy, and was ventilator-dependent, relied on a nasogastric (NG) tube for nutrition, hydration, and medication. The facility's policy required verification of the NG tube's placement before administering any fluids, using methods such as assessing the tube's mark in relation to the nostril, measuring the visible portion of the tube, and ensuring it was anchored. However, the policy was not followed, as evidenced by an incident where an LPN noticed the tube appeared longer, and the marking was off, yet proceeded to flush the tube, resulting in water exiting the resident's nostrils and causing significant pain. The resident was subsequently sent to the emergency department, where they were diagnosed with a right-sided pneumothorax, aspiration pneumonia, and sepsis. Interviews with facility staff revealed that the LPN did not adhere to the standard practice of stopping fluid administration and seeking an x-ray to verify tube placement upon suspecting displacement. The Clinical Resource Nurse and the CNO confirmed that the correct procedure was not followed, which contributed to the resident's harm and placed other residents at risk for similar complications.
Sanitation Deficiency in Kitchen Equipment and Environment
Penalty
Summary
The facility failed to maintain the kitchen equipment and environment in a sanitary manner, which had the potential to affect 69 of 80 residents who consumed food prepared by the facility. During a follow-up kitchen inspection and tray line observation, surveyors noted a build-up of dirt above the second fan in the walk-in refrigerator and a white, powdery residue on the shelf below the steam table where steam table pans were stored. These observations indicate a lapse in the facility's adherence to the FDA Food Code Section 6-501.12, which emphasizes the importance of regular cleaning to ensure the sanitary preparation of food. The Certified Dietary Manager (CDM) confirmed that the fan had been cleaned by maintenance at the beginning of the month, but could not explain the presence of dirt on the fan. Similarly, the Registered Dietitian (RD) was unable to identify the white substance on the shelf. The RD stated that the kitchen's cleaning schedule is completed daily and weekly, and is recorded, with the CDM being diligent about ensuring cleanliness. Despite these assurances, the presence of dirt and residue suggests a failure in the execution of the cleaning schedule, potentially compromising food safety and resident health.
Failure to Calibrate Glucometers as Required
Penalty
Summary
The facility failed to ensure that glucometers were calibrated to maintain accuracy and reliability for blood glucose monitoring on two of its halls, specifically the 100 Hall and 200 Hall. The facility's policy, revised on March 4, 2024, required staff to calibrate glucometers nightly or according to the manufacturer's guidelines. However, a review of the Blood Glucose Control Record logbook revealed that glucometer calibrations were inconsistently performed from January 2024 through April 2024, with no calibrations conducted in May, June, and July 2024. Interviews with staff, including an RN and an LPN, indicated that night shift nurses were responsible for conducting glucometer calibration checks. The Chief Nursing Officer (CNO) confirmed that calibrations should be done weekly on Tuesdays and documented, but acknowledged that the records showed calibrations were not being performed as directed. The CNO emphasized the importance of calibration to ensure accurate and correct readings.
Failure to Address Resident Grievances on Call Light Response
Penalty
Summary
The facility failed to ensure grievances regarding call lights, voiced by residents during Resident Council meetings, were documented, investigated, resolved, and followed up on. The Resident Council minutes from January 2024 through June 2024 consistently documented residents' concerns about call lights not being answered to their satisfaction. Despite these repeated concerns, there was no evidence of a systematic approach to address and resolve these grievances. Interviews with staff revealed a lack of communication and coordination in handling these issues, with the Licensed Master Social Worker (LMSW) not being involved in grievances brought up in Resident Council and the Activities Director (AD) assuming department managers would resolve the issues without any tracking system in place. The deficiency was further highlighted during interviews with residents and staff. A resident reported experiencing delays of up to one hour for call lights to be answered. The LMSW, responsible for grievances, indicated that concerns related to resident care were brought to morning meetings but was not involved in Resident Council grievances. The AD, who attended all Resident Council meetings, noted that everyone had trouble with call lights and assumed department managers would resolve the issues. However, there was no documented follow-up or education regarding the call light concerns, as confirmed by the Chief Nursing Officer (CNO), who acknowledged the absence of documented education or follow-up and the need for a plan to ensure concerns were addressed.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in weight loss for a resident, which was a deficiency identified during a survey. According to the facility's policy, immediate notification to the physician is required upon recognition of a significant change in status, such as a weight loss of more than 5% body weight. The resident in question was admitted with multiple diagnoses, including dementia and aphasia, and was documented as being at risk for weight loss. On July 1, 2024, the resident's weight was recorded at 126 pounds, indicating a 9.2% weight loss in one month. However, there was no record of notification to the resident's doctor regarding this weight loss. The Chief Nursing Officer confirmed the absence of such notification during an interview on July 26, 2024.
Failure to Investigate Allegations of Abuse and Medication Errors
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse and medication errors involving two residents. For Resident #81, who was admitted with a diagnosis of low back pain and prescribed a Fentanyl patch, there was a significant incident where the resident was found lethargic and confused with low oxygen saturation. Upon examination, two Fentanyl patches were discovered on the resident, leading to the administration of Narcan and subsequent hospitalization. Despite the severity of the incident, there was no documentation or investigation found by the current administration, and the previous administration's investigation was not documented or available for review. In the case of Resident #44, who was admitted with multiple diagnoses including osteomyelitis and paraplegia, a grievance was filed alleging verbal abuse by a nurse. The resident reported that the nurse yelled and got in his face after he requested pain medication. The grievance report indicated that the CNO spoke with the nurse involved, who denied the allegations and claimed the resident was the one being aggressive. However, there was no documentation of interviews with other staff or residents who might have witnessed the incident, and the CNO did not document her conversation with the resident's roommate, who reportedly supported the nurse's account. The lack of thorough investigation and documentation in both cases highlights a failure to adhere to the facility's policies on handling allegations of abuse and medication errors. This deficiency in the investigative process potentially compromised resident safety and failed to address the serious nature of the allegations adequately.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for two residents, which placed them at risk of negative outcomes. Resident #26, who was admitted with multiple diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, acute kidney failure, and chronic kidney disease, did not have catheter care, maintenance, or monitoring included in their care plan. Despite having physician orders for enhanced barrier precautions and specific catheter maintenance tasks, these were not reflected in the care plan. The Chief Nursing Officer (CNO) was unable to explain the omission when questioned. Similarly, Resident #74, who was on long-term anticoagulant therapy with Apixaban for DVT prophylaxis, did not have this critical information documented in their care plan. The CNO acknowledged that the resident was receiving Apixaban and that the care plan should have included monitoring for bruising, bleeding, and other adverse effects. The care plan was supposed to be created and updated by all nursing staff in a timely manner, but this was not done, leading to a lack of essential information in the resident's care plan.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident diagnosed with neuromuscular dysfunction of the bladder, who was cognitively impaired and totally dependent on two staff members for toileting. During an observation, the resident was found to be incontinent of bowel, with fecal material on both buttocks, some of which was dry, indicating the resident had been in this state for some time. Despite being noted as incontinent at 12:15 PM, incontinence care was not provided until 12:40 PM, a delay of 25 minutes. The facility's Quality of Life policy, revised in October 2022, states that necessary services should be provided to maintain personal hygiene for residents unable to carry out their activities of daily living. However, no specific policy for incontinence care was provided during the survey. The staff involved included an LPN and a CNA, who initially did not provide care, with the CNA stating she was the shower aide. Incontinence rounds were reportedly conducted at specific times, but the delay in care suggests a failure to adhere to these schedules or adequately respond to the resident's needs.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to ensure compliance with physician orders for the maintenance of supplemental oxygen and respiratory care for two residents. Resident #48, who was admitted with acute and chronic respiratory failure, had a physician's order for oxygen therapy that required monitoring every shift. However, the Pulmonary Administration Record (PAR) showed multiple dates where treatment and monitoring were not documented, indicating a lapse in care. The respiratory therapist confirmed the absence of documentation but could not explain why the care and monitoring were not recorded. Resident #231, admitted with acute respiratory failure and diabetes, had orders to change oxygen/nebulizer tubing and humidification bottles weekly. During an observation, the resident was found receiving oxygen with an empty humidifier, which also had crystallization at the bottom. An LPN filled the humidifier with distilled water and noted that the night shift staff should have been checking it. The Assistant Chief Nursing Officer (ACNO) stated that CNAs should check the humidifier and inform the nurse when it is empty, indicating a lack of clarity in staff responsibilities.
Failure to Administer Vaccines to Consenting Residents
Penalty
Summary
The facility failed to ensure that residents who were offered and consented to receive pneumococcal and influenza vaccines actually received them. This deficiency was identified for three residents whose records were reviewed. The facility's policy required offering pneumococcal immunizations based on CDC guidelines unless contraindicated or previously administered. However, the records for these residents showed that they did not receive the vaccines they were due for, despite having consented to them. Resident #52, who relied on a legal guardian for healthcare decisions, was due for a PPSV23 booster but did not receive it. Resident #64, who could make his own healthcare decisions, consented to pneumococcal vaccines but did not receive the PCV20 vaccine he was due for. Resident #73, who also depended on a legal guardian, was due for both the PCV20 and influenza vaccines but did not receive them. The Chief Nursing Officer confirmed the lack of documentation for the administration of these vaccines.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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