Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Nampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny Ridge | 0.8 mi | ★★★★★ | 16 | 0 |
| Meadow View Nursing And Rehabilitation | 3.4 mi | ★★★★★ | 13 | 0 |
| Orchards Of Cascadia, The | 3.9 mi | ★★★★★ | 7 | 1 |
| Karcher Post Acute | 4.9 mi | ★★★★★ | 21 | 0 |
| Cascadia Of Nampa | 5.1 mi | ★★★★★ | 16 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.