Boundary County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Bonners Ferry, Idaho.
- Location
- 6640 Kaniksu Street, Bonners Ferry, Idaho 83805
- CMS Provider Number
- 135004
- Inspections on file
- 17
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Boundary County Nursing Home during CMS and state inspections, most recent first.
The facility failed to provide restorative nursing services as ordered for two residents with limited ROM and mobility needs, and failed to assess and initiate restorative services for another resident with severe dementia and hand clenching. One resident with osteoporosis, chronic pain, and a hip fracture had a care plan for ROM and strengthening exercises five times weekly but received far fewer sessions over multiple weeks. Another resident with advanced physical debility and chronic hand tremors was care planned for left‑hand ROM exercises five times weekly, yet records showed inconsistent and often insufficient sessions, while the Restorative Nurse reported a fixed three‑day weekly schedule that did not match the care plans. A third resident with severe Alzheimer’s dementia was repeatedly noted to have a clenched, painful left hand with fingernail marks, and although the Restorative Nurse documented considering a palm protector, there was no documentation of restorative services being initiated, no follow‑through on the palm protector, and no further documented communication with the provider about the ongoing hand pain and clenching.
Surveyors found that the facility failed to complete required trauma-informed assessments for three residents with histories of traumatic events and multiple medical conditions, including dementia, osteoporosis, chronic pain, and advanced physical debility. In each case, an Annually/Quarterly Trauma Evaluation form was present, but the Staff Assessment section—intended to document changes in sleep, appetite, behavior in specific situations, caregiver preference, and new pain or health complaints—was left blank, with no licensed nurse documentation, despite care plan directives for person-centered trauma evaluations and the ADON’s acknowledgment that licensed nurses are responsible for completing these assessments.
The facility failed to maintain medication error rates below 5% when an LPN, during a medication pass for a resident receiving Metamucil for constipation and a cranberry supplement for UTI prevention, was unable to identify the correct dosages for these ordered medications. Despite a policy requiring adherence to the rights of medication administration, including the right dose, the LPN reported that the orders should have been clarified to specify the exact dose, indicating medications were being prepared and administered without clear dosage understanding and contributing to an overall medication error rate above the acceptable threshold.
A nutritional aide was observed preparing and handling resident meal trays and assisting with food preparation while wearing a hair guard that did not fully contain her hair, leaving bangs exposed and not properly restrained as required by FDA Food Code. The Nutritional Services Director acknowledged she had not noticed the improper hair restraint use and confirmed that staff hair should be completely secured in accordance with facility food safety standards.
The facility failed to ensure its QAPI Committee effectively addressed ongoing systemic problems in the Restorative Nursing Program. A PIP established a benchmark that 75% of residents on restorative programs would have documentation completed per their individualized care plans, yet quarterly QAPI reports over multiple years consistently showed completion rates below this benchmark, including findings of only 63% and 67% completion. The same issues were repeatedly identified, such as staff not consistently charting in the new system, CNAs not checking the Restorative book for updates, charge nurses not proactively ensuring daily restorative completion, and persistent time and staffing constraints. Despite these recurring deficiencies, the QAPI Committee continued the same interventions without revising the PIP, escalating the problem, or implementing new strategies, as confirmed by the DON during interview.
A resident with CAD, major depressive disorder, and dementia had documentation in the care plan indicating the presence of a living will and DPOAHC, but only a single, untitled page in the hard copy chart referenced these documents without listing the location of the living will or the name of the DPOAHC. The form simply indicated that the resident had a living will and DPOAHC, leaving key fields blank. The DON stated this was the only documentation available and reported that the resident’s POA refused to provide a copy of the living will, yet no documentation of this refusal was found. The DON confirmed that no copy of the resident’s advance directives was maintained in the medical record.
Surveyors found that the facility did not notify the State Long-Term Care Ombudsman of a discharge for a resident with Alzheimer’s dementia and epilepsy whose spouse chose to take the resident home. Policy requires that written discharge notice, including reasons for the move, be provided to the resident and representative and that a copy be sent to the Ombudsman. Record review showed no documentation of Ombudsman notification, and the DON confirmed that such documentation was absent, creating the potential for adverse outcomes including the need for an advocate when the Ombudsman was not notified.
A resident with a history of anemia, moderate dementia, and chronic pain had active orders for aspirin for CAD and sertraline (Zoloft) for depression and chronic pain, but the comprehensive care plan was not revised to reflect current diagnoses and medication indications. The care plan continued to reference anemia and daily aspirin for antiplatelet therapy and included a directive to administer antidepressants for chronic pain without specifying sertraline’s use for both depression and chronic pain. An MDS nurse acknowledged that the resident no longer had an active anemia diagnosis and that the care plan should have been updated to clarify the current clinical rationale for aspirin therapy and the indication for sertraline.
A resident with COPD and OSA did not receive respiratory equipment care according to facility policy and supplier recommendations. Staff washed and air-dried the nebulizer apparatus but repeatedly left the mouthpiece and pieces on surfaces such as a bedside table and towel, and stored the reassembled device on a towel in a nightstand instead of in a labeled plastic bag as required. The same resident’s CPAP tubing, dated several months earlier, was not replaced at the three‑month interval specified in the chart, and staff incorrectly believed the tubing should be changed every six months. These failures placed the resident at risk of respiratory infection due to pathogen growth in the respiratory equipment.
The facility failed to ensure that the nurse overseeing the Restorative Nursing Program had documented competencies, qualifications, or a defined job description, despite policy assigning responsibility for restorative oversight to specific clinical staff. One resident with severe dementia developed left-hand clenching and pain; the Restorative Nurse documented assessments and the possible use of a palm protector, but there was no further documentation of restorative services, no record that restorative services were in place, and no follow-up provider communication beyond an earlier notification noted by the DON. Another resident with advanced debility, chronic pain, and hand tremors had a care plan for frequent restorative services, but documentation showed repeated refusals due to pain, painful palm protector application, and lack of a consistent pain-management plan before interventions. The Restorative Nurse reported evaluating the resident and notifying the provider to discontinue restorative services, yet no supporting provider notification documentation was available, while she also stated she independently assesses and determines residents’ appropriateness for restorative services without documented restorative-specific competencies.
The facility did not consistently post complete daily nurse staffing information as required, omitting elements such as the facility name, current date, resident census, and the breakdown of staff hours by category (RN, LPN, CNA) on multiple days. Observations showed that the staffing postings were incomplete, and the DON confirmed that the postings were required to include all of these elements and that they did not. This failure had the potential to affect all residents by limiting access to accurate information about the staff available to meet their needs.
Surveyors found that two residents had duplicate PRN medication orders without clear instructions on which route to use first. One resident with severe dementia and constipation had multiple bisacodyl orders (scheduled oral tablets, PRN oral tablets, and a PRN suppository) on the MAR, with no indication of sequencing, while the care plan referenced prune juice and PRN Dulcolax use. Another resident with dementia, a sacral fracture, and chronic pain had both PRN rectal acetaminophen and scheduled oral acetaminophen ordered, again without guidance on which to administer first. The DON stated that the least invasive or oral options should be used first and acknowledged that the rectal PRN orders were likely unnecessary, but they remained active in the residents’ drug regimens.
A resident with severe dementia, recurrent UTIs, and bowel and bladder incontinence had a care plan directing staff to monitor for UTI signs and symptoms. Nursing documentation later described manic behavior, loudness, hallucinations, decreased oral intake, and urinary incontinence, after which staff performed a urine dip, notified the provider, obtained an order for a urine culture, and started Keflex. Record review showed no documented urinary symptoms meeting Revised McGeer’s Criteria for UTI without a catheter, despite the facility’s use of these criteria for antibiotic stewardship. The IP confirmed that the resident did not meet McGeer’s Criteria and acknowledged that nursing staff should not have done a urinalysis and did not follow the established criteria, resulting in inappropriate initiation of antibiotic therapy.
The facility did not ensure that CNAs received the required minimum of 12 hours of annual in‑service training. A review of three CNAs’ education records showed that one CNA had completed only 10.47 hours of training for the current annual period. The DON confirmed that this CNA had been skipping course content and going directly to the test, resulting in incomplete training hours. This deficiency had the potential to affect all residents receiving care from CNAs, as inadequate training places residents at risk for harm due to staff not being fully prepared to safely provide required services.
The facility failed to store, prepare, and serve food according to professional standards, with open and expired food items found unlabeled in storage areas. Additionally, a dietary staff member did not follow proper hand hygiene or glove use while preparing food, despite acknowledging the correct procedures.
A resident with dementia, depression, and anxiety was subjected to abuse by a CNA who forcefully removed the resident's sweatshirt against her wishes, resulting in physical harm. The resident's care plan emphasized promoting independence and explaining care, which was not followed. The facility's investigation confirmed the CNA's willful actions, leading to the substantiation of the abuse allegation.
Failure to Provide and Assess Restorative Nursing Services for Residents With Limited ROM
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services as ordered and to assess and initiate restorative services when indicated, in accordance with its Restorative Nursing Program policy. The policy, revised 10/19/25, states the program’s purpose is to maintain or improve residents’ optimal physical, mental, and psychological function. For one resident with age-related osteoporosis, chronic pain, and a left hip fracture, the care plan initiated 5/22/25 directed restorative nursing services 5 times per week, including seated marching with 2‑lb ankle weights, long arc quad exercises with 2‑lb weights, and sit‑to‑stand repetitions. However, review of restorative records from 2/1/26 through 4/25/26 showed the resident received significantly fewer sessions than ordered in multiple weeks, including weeks with zero or only one session, indicating the resident was not offered services as per the plan of care. Another resident with advanced physical debility, chronic pain, and chronic bilateral hand tremors had a restorative nursing program that included active ROM to the left hand (opening the hand wide, using a squeeze ball, and finger‑to‑thumb pinches), with a care plan initiated 6/25/25 specifying restorative services 5 times weekly and monthly/as‑needed review by the restorative nurse. Restorative records from 2/1/26 through 4/26/26 showed inconsistent provision of these services, with some weeks having no sessions and others fewer than five, despite the care plan requirement. During an interview on 4/30/26, the Restorative Nurse stated that residents receiving restorative services were scheduled only on Tuesdays, Thursdays, and Saturdays, and confirmed upon review of the schedules that these two residents did not receive restorative services as indicated in their plans of care. A third resident with severe Alzheimer’s dementia was observed on 4/28/26 lying in bed with the left hand closed in a fist. The resident’s representatives reported they had notified staff and were told occupational therapy would be consulted for a hand splint, and that they frequently placed a stuffed animal in the resident’s hand to help keep it open. Progress notes documented that on 4/13/26 staff noted the resident had been clenching the left hand, and the Restorative Nurse assessed that both hands were clasped but could be opened on request. A 4/20/26 note documented that the Restorative Nurse again assessed the left hand, which could be opened after touch but caused the resident to say “ow,” with fingernails making marks on the palm; the Restorative Nurse documented consideration of a palm protector. The DON later confirmed there were no further notes regarding a palm protector, restorative services had been discontinued on 4/26/26, there was no documentation that the resident was on restorative services, and there was no further communication with the physician beyond a notification in February 2026 about the resident’s hand pain and clenching. This reflects a failure to assess and initiate restorative services for this resident despite documented hand clenching and pain.
Incomplete Trauma-Informed Assessments for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents were comprehensively assessed for a history of trauma, including identification of trauma-related triggers, for three residents whose records were reviewed for trauma-informed care. For a resident with anemia, moderate dementia, chronic pain, and a documented history of sexual assault who reported feeling safe in the facility, the care plan did not document the need for an annual trauma evaluation. Although an Annually/Quarterly Trauma Evaluation form dated 4/24/26 was present in the record, the Staff Assessment section—intended to capture changes in sleep, appetite, behavioral patterns in response to specific situations, caregiver preference, and new complaints of pain or health problems—was left blank, with no documentation completed by a licensed nurse. A second resident with age-related osteoporosis, chronic pain, and a left hip fracture had a care plan noting reported traumatic events and a directive that licensed nursing staff complete a person-centered trauma evaluation annually per resident preference. An Annually/Quarterly Trauma Evaluation form dated 4/28/26 was found in this resident’s record, but the Staff Assessment section was also blank, with no licensed nurse documentation. A third resident with advanced physical debility, chronic pain, and chronic bilateral hand tremors had a care plan directing completion of a person-centered trauma evaluation annually, after a fall, or with a significant change, and documenting the resident’s request not to be evaluated quarterly. An Annually/Quarterly Trauma Evaluation form dated 1/27/26 was present, but again the Staff Assessment section was blank with no licensed nurse documentation. The ADON stated that trauma evaluations should be completed and confirmed that licensed nurses are responsible for documenting the assessment and determination.
Failure to Ensure Accurate Medication Dosage Identification During Medication Pass
Penalty
Summary
The facility failed to ensure medication error rates were kept below 5%, as evidenced by an LPN’s inability to identify correct dosages for ordered medications during a medication pass. The facility’s Medication Administration Policy, revised 4/15/26, required adherence to the rights of medication administration, including right drug, right dose, right time, right route, right patient/resident, and verification of accuracy if a resident questions a medication. During observation of a medication pass for Resident #3, who had physician orders for Metamucil 1 capsule by mouth daily for constipation and a cranberry supplement 2 capsules for cystitis (UTI) prevention, the LPN preparing and administering the medications was unable to identify the correct dosage for both the cranberry and Metamucil supplements. When questioned about the orders, the LPN stated that the orders should have been clarified to include the specific dose to administer, demonstrating that the medications were being prepared and administered without clear understanding of the correct dosage. This failure occurred despite the facility’s policy requiring verification of the right dose prior to administration and contributed to a medication error rate greater than 5%, with the potential to affect all residents receiving medications in the facility by increasing the risk of adverse health outcomes.
Improper Hair Restraint Use During Food Preparation
Penalty
Summary
Surveyors identified a deficiency related to food safety practices when a nutritional aide was observed preparing and handling resident meal trays without a properly positioned hair restraint. During a tray line observation at midday, the aide’s hair guard was placed only over the center of her head, leaving her bangs exposed and not fully contained within the hair restraint. This positioning did not meet the FDA Food Code requirements that food employees wear hair restraints designed and worn to effectively prevent hair from contacting exposed food. During the same observation period, the nutritional aide left the tray line station to assist with preparing mashed potatoes for residents while continuing to wear the improperly positioned hair guard, with hair not fully restrained as required. The Nutritional Services Director later stated she had not noticed that the aide’s hair was not fully contained within the hair guard and confirmed that the employee’s hair should have been completely secured inside the hair restraint in accordance with facility policy and food safety standards.
Ineffective QAPI Oversight of Restorative Nursing Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure its QAPI Committee effectively identified, monitored, and corrected ongoing systemic issues in the Restorative Nursing Program. The facility’s Quality Management Plan stated that the Interdisciplinary Quality Program was intended to provide a systematic, coordinated, facility‑wide approach to quality care and sustainability, including resolving identified areas of concern. A Performance Improvement Plan (PIP) initiated in January 2024 set a benchmark that 75% of residents on a Restorative Program would have documentation completed per their individualized plan of care. However, quarterly QAPI reports from 2024 through 2026 repeatedly documented that this benchmark was not met, including specific findings such as only 63% of residents having documentation of receiving restorative services in one quarter and a 67% completion rate in another, both below the 75% benchmark. Record and PIP review showed that the same issues were identified in every quarterly report from January 2024 through March 2026, including staff not always charting what they did in the new charting system, CNAs not consistently checking the Restorative book for changes, charge nurses not being proactive in ensuring daily restorative service completion, and ongoing time constraints and staffing issues. Despite these repeated findings and the continued failure to meet benchmarks across multiple consecutive quarters, the QAPI Committee continued the same interventions quarter after quarter without revising the PIP, escalating the issue, or implementing new strategies. During an interview, the DON confirmed that the plan had been in place for several years and that audits were conducted monthly and reviewed with the committee, but the documentation showed no evidence of effective corrective actions or sustained performance improvement related to restorative services.
Failure to Maintain Complete Advance Directive Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a copy of a resident’s advance directive in the medical record as required by the State Operations Manual (SOM). The SOM defines an advance directive as a written instruction such as a living will or durable power of attorney for health care (DPOAHC), and clarifies that a POLST is not an advance directive. The resident involved was admitted with multiple diagnoses including coronary artery disease, major depressive disorder, and dementia. The resident’s care plan, revised on 1/27/26, documented that there was one page of a living will and DPOAHC in the chart. On review of the hard copy chart, surveyors found only a single, untitled page dated 2/6/25 that referenced the existence of a living will and DPOAHC but did not identify the location of the living will or the name of the DPOAHC. The form indicated “yes” to the resident having a living will and DPOAHC, but the lines for the location of the living will and the name of the person holding the DPOAHC were left blank. When questioned, the DON stated that this was all the documentation the facility had and reported that the resident’s POA had refused to bring in a copy of the living will. When surveyors requested documentation of this refusal, none was provided. The DON confirmed that the facility did not have a copy of the resident’s advance directives.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
Surveyors determined that the facility failed to notify the State Long-Term Care Ombudsman of a resident’s discharge as required. The State Operations Manual, Appendix PP, specifies that before a facility transfers or discharges a resident, it must provide written notice of the transfer or discharge to the resident and the resident’s representative, including the reasons for the move, and must send a copy of this notice to a representative of the Office of the State Long-Term Care Ombudsman. Resident #23, who had multiple diagnoses including Alzheimer’s dementia and epilepsy, was admitted on a specified date and was later discharged when her spouse elected to take her home for care. Review of the resident’s medical record showed no documentation that the Ombudsman had been notified of this discharge. During an interview on 4/30/26 at 11:11 AM, the DON confirmed there was no documentation that the Ombudsman had been notified of Resident #23’s discharge, and the report notes this failure created the potential for adverse outcomes including the need for an advocate when the Ombudsman was not notified.
Failure to Update Care Plan With Current Diagnoses and Medication Indications
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was revised to reflect accurate and current information for one resident. The resident was admitted with multiple diagnoses including anemia, moderate dementia, and chronic pain, and had physician orders for aspirin 81 mg daily for CAD and sertraline (Zoloft) 50 mg daily for depression and chronic pain. The comprehensive care plan continued to list a problem statement indicating a history of anemia with a requirement for daily aspirin for antiplatelet therapy, initiated several years earlier, and included a directive for licensed nursing staff to administer antidepressants for chronic pain. However, the care plan was not updated to specify that sertraline was being administered for both depression and chronic pain, and it was not revised to reflect that the resident no longer had an active diagnosis of anemia or to clarify the current clinical rationale for aspirin therapy. During an interview, the MDS nurse acknowledged that the care plan should have been revised to accurately reflect the resident’s current diagnoses and medication indications. This failure created the potential for inaccurate care planning and inconsistent implementation of care, as the written care plan did not align with the resident’s current clinical status and medication orders as identified through record review and staff interview.
Improper Nebulizer Storage and Overdue CPAP Tubing Replacement
Penalty
Summary
The facility failed to follow its own policy for cleaning and storing nebulizer equipment and did not replace CPAP tubing according to documented recommendations for a resident with obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD). The facility’s nebulizer policy required staff to disassemble the nebulizer, wash it with mild soap and water, rinse, air dry on a towel, and then store the completely dry equipment in a plastic bag labeled with the resident’s name and date. The resident’s care plan also directed staff to wash the nebulizer tubing and mouthpiece with soap and water after each use and allow the pieces to dry between uses. Surveyors observed the resident’s nebulizer mouthpiece resting directly on top of a book without a barrier on a bedside table, and on another day observed the nebulizer pieces on a white washcloth/towel on top of the bedside nightstand. RN #1 stated that after use, the nebulizer apparatus was washed, laid out to dry on a towel, then reassembled and stored on a towel in the resident’s nightstand, and was observed placing the reassembled nebulizer on a towel in the nightstand drawer rather than in a labeled plastic bag as required by policy. The DON stated nebulizers should be stored in a bag. The facility also failed to change the resident’s CPAP tubing according to the schedule documented in the resident’s chart. The resident’s care plan indicated use of a CPAP machine for OSA and directed staff to obtain CPAP supplies per Lincare recommendations and for licensed nurses to check monthly and reorder or replace as needed. Surveyors observed the CPAP machine on the bedside nightstand with tubing dated “12/29.” RN #1 stated she believed the tubing was changed every six months. Upon review of the hard copy chart with the MDS nurse and RN #1, it was found that Lincare’s recommendation was to change CPAP tubing every three months. Both RN #1 and the MDS nurse confirmed that, based on the 12/29 date, the tubing should have been changed in March but had not been replaced. The report states that these failures placed the resident at risk of respiratory infection due to growth of pathogens in the respiratory equipment.
Lack of Qualified Oversight and Documentation in Restorative Nursing Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff directing and overseeing the Restorative Nursing Program possessed appropriate competencies, as required by facility policy. The Restorative Nursing Program policy identified the Restorative Nurse, Restorative Aide, therapy staff, and the DON as responsible for program oversight, including assessment and re-evaluation when functional decline is noted. However, the facility could not provide a job description, qualifications, training, or education documentation related to restorative services for the Restorative Nurse whose personnel record was reviewed. For one resident with severe Alzheimer’s dementia, staff documented new issues with left-hand clenching. Nursing progress notes showed that the Restorative Nurse assessed the resident’s hands, noting that the resident could open the left hand only with touch and that fingernails were making marks on the skin, with the resident verbalizing pain (“ow”) when opening the hand. The Restorative Nurse documented she would consider a palm protector, but there was no further documentation regarding this intervention, no evidence the resident was on restorative services, and the DON later stated restorative services were discontinued without supporting documentation from the Restorative Nurse. The DON also stated that although the provider had been notified of the resident’s hand pain earlier in the year, there was no further documented communication with the physician. For another resident with advanced physical debility, chronic pain, and chronic bilateral hand tremors, the care plan called for restorative services five times weekly, with the Restorative Nurse to review the program monthly and as needed. The restorative program included active range-of-motion exercises and use of a squeeze ball and finger-to-thumb pinches, but restorative documentation showed the resident frequently refused due to pain. Nursing notes indicated the Restorative Nurse would evaluate the need for increased pain medication, that the resident refused a palm protector due to painful manipulation, and that the resident did not tolerate passive range of motion with difficulty applying the palm protector. Staff interviews confirmed the resident was often in pain during palm protector application and did not have a set pain-management plan prior to restorative interventions. The Restorative Nurse stated she notified the provider and completed an evaluation that led to discontinuation of restorative services, but no documentation of provider notification was produced, and the Restorative Nurse described herself as the one who assesses and informs the provider about appropriateness for restorative services, despite the absence of documented competencies or role description.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a manner that informed residents, visitors, and resident representatives of the staff available to meet resident needs. The State Operations Manual (SOM), Appendix PP, requires that facilities post daily, in a location readily accessible to residents and the public, the facility name, current date, total number of hours worked by each staff category per shift (RN, LPN, CNA), and the resident census. On multiple observed dates and times (4/26/26, 4/27/26, and 4/28/26), the posted staffing information did not include all of these required elements, specifically omitting the facility name, current date, census, and the breakdown of licensed and unlicensed staff by category (RN, LPN, CNA). During an interview on 4/29/26 at 5:33 PM, the DON acknowledged that the posting is required to include the facility name, current date, census, and the number of licensed and unlicensed staff by category and confirmed that the posting did not contain all required elements. This failure had the potential to affect all residents who receive services in the facility by limiting access to accurate staffing information, as the incomplete postings did not fully reflect the staff available to meet resident needs as required by regulation.
Duplicate PRN Medication Orders Without Clear Administration Guidance
Penalty
Summary
The facility failed to ensure residents’ drug regimens were free from unnecessary duplicate medication orders, specifically for constipation and pain management. For one resident with severe dementia and constipation, the care plan directed staff to monitor for constipation and to use prune juice and consider PRN Dulcolax tablets if no bowel movement occurred by the third day. However, the Medication Administration Record (MAR) contained three separate bisacodyl (Dulcolax) orders: a PRN rectal suppository, scheduled oral tablets twice daily, and an additional PRN oral tablet, with no documentation indicating which medication should be administered first. During interview, the DON stated that the least invasive medication was always administered first and explained that prune juice and milk of magnesia had been used before a rectal suppository was given, and that the suppository was likely used because the resident already had scheduled oral bisacodyl tablets. Another resident with dementia, a right sacral fracture, and chronic pain had a care plan directing nurses to assess pain three times daily and as needed, and to monitor for non-verbal signs of pain. The MAR for this resident showed two acetaminophen orders: a PRN rectal suppository and scheduled oral tablets for chronic pain, again without any indication of which route should be used first. In interview, the DON stated that the oral tablet should be administered first and acknowledged that the suppository had not been used during a 90‑day look‑back period and was probably not necessary. The DON also confirmed that the resident had received oral PRN acetaminophen and that a subsequent assessment documented zero pain, indicating the medication was effective, yet the duplicate rectal PRN order remained active without clear guidance on its use.
Failure to Follow McGeer’s Criteria for Antibiotic Use in Suspected UTI
Penalty
Summary
The facility failed to implement antibiotic stewardship and ensure appropriate clinical indications for antibiotic use for a resident evaluated for a suspected urinary tract infection (UTI). The resident had multiple diagnoses including severe dementia, recurrent UTIs, and insomnia, and a care plan dated 12/9/19 documented bowel and bladder incontinence related to impaired cognition, with directions for staff to monitor for signs and symptoms of UTI. On 3/16/26 at 6:14 PM, a nursing progress note documented that the resident was exhibiting manic behavior, was loud, hallucinating, and had decreased oral intake. The note also documented urinary incontinence, that a urine dip was performed, the provider was notified, an order was obtained for a urine culture, and Keflex was started. Record review showed there was no documentation of worsening urinary symptoms that met the Revised McGeer’s Criteria for UTI without an indwelling catheter, which the facility had adopted for antibiotic stewardship. The Infection Preventionist (IP) confirmed on 4/30/26 at 3:48 PM that the facility followed McGeer’s Criteria for antibiotic stewardship and presented a quarterly antibiotic tracking report indicating the resident did not meet McGeer’s Criteria. When asked, the IP stated that nursing staff should not have done a urinalysis on this resident and acknowledged that the nurses did not follow McGeer’s Criteria. This sequence of actions and lack of required clinical indications led to the determination that the facility failed to ensure appropriate antibiotic use.
Failure to Ensure Required Annual CNA In‑Service Training Hours
Penalty
Summary
The facility failed to ensure that CNAs received the required minimum of 12 hours of annual in‑service training, including dementia care and abuse prevention, as evidenced by a review of training records and staff interviews. On 04/29/26, surveyors requested annual education records for three CNAs and found that one CNA had completed only 10.47 hours of training for the current annual period, which did not meet the 12‑hour requirement. During an interview, the DON confirmed that this CNA did not have the required annual CNA training hours and explained that the CNA had been skipping the course content and proceeding directly to the test, resulting in incomplete training hours. This deficient practice was identified as having the potential to affect all residents receiving care from CNAs, as inadequate training places residents at risk for harm due to staff not being fully prepared to safely provide required services.
Food Safety and Infection Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The walk-in refrigerator contained open containers of food, such as a block of cheese and a container of dill pickles, without any dates indicating when they were opened. Additionally, expired cheese and a bottle of Italian dressing with a broken lid were found. The Certified Dietary Manager (CDM) acknowledged that these items should have been discarded or properly labeled. Similar issues were found in the walk-in freezer and dry goods storage, where open containers of cookies, cardiac pork, dry pasta, corn flakes, bran flakes, granola, and pecans were not labeled with open dates, and some items were past their expiration dates. The CDM admitted uncertainty about the safety of these items for consumption. The facility also failed to ensure proper infection control practices in food services. Dietary Staff #1 was observed coughing without a mask and engaging in food preparation tasks without following proper hand hygiene or glove use. This included reaching into a blender with bare hands, cleaning a countertop without proper handwashing, and handling food items like bread and eggs without gloves or washing hands between tasks. The CDM confirmed that staff should always wear gloves when handling food, and Dietary Staff #1 acknowledged the correct handwashing process but did not adhere to it during the observed tasks.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a certified nursing assistant (CNA) and a resident with dementia, depression, and anxiety. The resident, who was admitted with these diagnoses, had a care plan that emphasized the importance of allowing her to make choices and promoting her independence. The care plan also noted that the resident might reject care due to difficulty understanding and instructed staff to explain all care before providing it. Despite these directives, the resident reported that a CNA forcefully removed her sweatshirt against her wishes, resulting in physical harm. The incident occurred when the resident refused to change her sweatshirt, preferring to sleep in it and change it the next morning. The CNA insisted on changing the sweatshirt, leading to a physical altercation where the CNA pulled the sweatshirt off, causing bruising and purpura on the resident's arm. The facility's investigation confirmed the CNA's actions were willful and resulted in physical injury to the resident. The CNA admitted to grabbing the resident's arm during the incident, and the allegation of abuse was substantiated by the facility's administration.
Latest citations in Idaho
A resident admitted with a diagnosis of PTSD and severe cognitive deficits had an admission MDS and an Interim History and Physical documenting PTSD, but the Idaho PASRR Level I form incorrectly indicated no major mental illness, even though PTSD is listed on the form as a major mental illness. The SSD stated he reviewed hospital records and the chart but missed the PTSD diagnosis and did not mark it on the PASARR, contrary to facility expectations and policy requiring accurate pre-admission screening for serious mental disorders and appropriate follow-up evaluation when a Level I screen is positive.
A resident with COPD and dementia, receiving scheduled nebulizer treatments, was found on multiple occasions to have a nebulizer mask stored on top of the machine rather than in a sanitary manner. A CNA and a nurse aide in training confirmed the mask’s placement, and an LPN reported that masks were routinely cleaned, dried, and then stored on top of the machine. The DON later acknowledged that masks should be washed, dried, and placed on a clean surface, and facility policy required oxygen and respiratory supplies to be stored in a plastic bag when not in use.
Staff failed to consistently implement and follow Enhanced Barrier Precautions (EBP) during wound care for two residents. For a resident with an indwelling urinary catheter and an EBP order, an RN and a CNA removed their gowns after catheter care and performed a heel and toe dressing change wearing only gloves, despite a door sign requiring gown and gloves for wound care and other high-contact care. For another resident with multiple open leg wounds and active wound care orders, an RN and a nurse aide performed dressing changes with gloves only, without gowns, and there was no EBP signage or order in place. Interviews with nursing staff, the IP, and the DON revealed inconsistent understanding and application of the facility’s EBP policy, which requires gown and gloves for high-contact care activities, including wound care and device care, for residents with chronic wounds or indwelling devices.
A resident with diabetes, chronic kidney disease, and a history of breast cancer had previously received PPSV23 and PCV13 at the appropriate age, but review of the EMR and vaccine consent form showed the pneumococcal section was marked as "not needed" and no additional pneumococcal vaccine was offered. The ADON/IP acknowledged that, according to CDC guidelines, the resident was not fully vaccinated and should have been offered PCV20, and the DON stated her expectation that vaccine status be reviewed on admission and tracked to ensure residents are fully vaccinated.
Two residents who experienced emergent hospital transfers for issues including abnormal critical labs, uncontrollable pain, and SOB with low O2 saturation were not provided with required written bed-hold policies and transfer notices. One resident had severely impaired cognition, and another was cognitively intact and later died at the hospital. Progress notes documented the transfers and that contacts or family were notified, but there was no documentation that written notices addressing bed-hold, appeal rights, or ombudsman information were given, despite facility policies requiring such written information at admission and again at or shortly after transfer. The Administrator confirmed that bed-hold notices were not sent for these residents.
Two residents who required staff assistance with ADLs did not receive showers and hair washing as care-planned and expected. One resident with dementia and cervical spine conditions was observed with flaky skin and greasy hair, and the family’s shower calendar showed only four showers in a month despite an expectation of three per week, with no refusals documented in the record or care plan. Another cognitively intact resident with quadriplegia and spinal stenosis reported rarely receiving scheduled showers, and was observed with long, greasy hair, again with no refusals documented. The DON and Administrator acknowledged CNAs believed they could not provide baths without a dedicated bath team and historically had no room assignments, despite facility policy requiring provision and documentation of ADL care and refusals.
Surveyors found multiple expired medications, including various insulin products, Trulicity injection pens, and a large bottle of Gabapentin solution, stored in a medication room refrigerator and still available for use. The MDS coordinator confirmed the drugs were expired. The DON reported that no one had been specifically assigned to check the refrigerator for expired medications, while an LPN stated she only reviewed medication carts and did not check refrigerated stock. Facility policies required checking expiration/beyond-use dates before administration, dating multi-dose containers when opened, discarding them within specified time frames, and returning or destroying outdated medications, but these procedures were not followed for the medications in the refrigerator.
Surveyors found that the facility did not maintain sanitary conditions in the walk-in freezer and ice machine area. Ice buildup on freezer lines was encroaching on a box of burritos, and an ice scoop holder attached to the ice machine contained standing water with two scoops resting in it and no visible drainage. The Dietary Manager acknowledged the recurring ice buildup and reported that the standing water issue had not previously been raised. These practices did not follow the facility’s policies for food safety, storage, and ice machine preventative maintenance and had the potential to affect 46 residents who consumed food from the kitchen.
A resident with dementia, malnutrition, anemia, CKD3, and other comorbidities was care planned as at risk for nutritional decline and dehydration, with weekly weights and RD review ordered. An RD later documented poor PO intake averaging about 31%, fluid intake around 612 ml with meals, and no routine supplements in place, and recommended starting 2 oz Med Pass BID between meals with nursing to document consumption. No Med Pass order was entered into the EMR, and the resident did not receive the supplement, while experiencing a 10‑lb (6.8%) weight loss over several months. Interviews showed the RD typically communicated recommendations via email and NAR meetings, but NAR meetings had not been held consistently and no email or other system ensured the recommendation was received or implemented; requested policies on RD recommendations/supplement orders and weight loss were not provided.
A resident with multiple cardiopulmonary diagnoses received continuous O2 at 1.5 LPM via nasal cannula without a physician order or corresponding MAR documentation, despite the care plan and MDS indicating a need for and receipt of oxygen therapy. Surveyors observed the resident on oxygen on several occasions, initially without humidification and later with humidification. An LPN and the DON both confirmed at the bedside that the resident had been on oxygen since admission without a provider order, and that no monitoring was documented, contrary to facility policy requiring verification of a provider order before initiating or changing oxygen therapy.
Failure to Update PASARR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to ensure that a PASARR Level I screen was accurately completed and updated to reflect a major mental illness diagnosis for one resident. The resident’s admission MDS, with an ARD of 03/30/26, showed a diagnosis of Post-Traumatic Stress Disorder (PTSD) and a BIMS score of 3/15, indicating severe cognitive deficits. An Interim History and Physical dated 03/25/26 also documented PTSD as a diagnosis. However, the Idaho PASRR Level I form dated 03/19/26 indicated “No” under the section asking whether the individual had any major mental illnesses, despite PTSD being listed on the form as a qualifying major mental illness and despite the resident having that diagnosis. The Social Services Director reported that he reviewed hospital records and the resident’s chart to ensure that diagnoses on the admitting PASARR matched the resident’s conditions, and he confirmed the resident was admitted with PTSD. He acknowledged that he missed the PTSD diagnosis and that it should have been marked on the PASARR. During an interview, the DON and Administrator stated the expectation that all PASARRs be correct and that, if not correct at admission, a new PASARR should be submitted. The facility’s PASRR policy specified that potential admissions are to be screened for serious mental disorders or intellectual disabilities prior to admission and that a positive Level I screen requires a Level II evaluation by the state-designated authority prior to admission unless otherwise authorized.
Improper Storage of Nebulizer Mask and Respiratory Supplies
Penalty
Summary
Surveyors identified a deficiency in the sanitary storage of respiratory equipment for one resident receiving respiratory care. The resident was admitted with COPD and unspecified dementia and had care plan focuses for terminal prognosis due to COPD and shortness of breath, with interventions including administration of inhalers and nebulized medications as ordered. Physician orders included scheduled ipratropium-albuterol nebulizer treatments twice daily for COPD. During multiple observations in the resident’s shared room, the nebulizer mask was seen lying on top of the nebulizer machine rather than being stored in a sanitary manner. Staff interviews confirmed the observed storage practice. A CNA and a nurse aide in training each verified that the nebulizer mask was lying on top of the machine at the times of observation. An LPN stated that masks were cleaned after use, dried, and then stored on top of the machine, and acknowledged this could be an infection control issue. During a later observation, the LPN again confirmed the mask was on top of the machine. In an interview, the DON, with the Administrator present, stated the mask should be washed, dried, and placed on a clean surface and acknowledged it could be an infection control issue, and the facility’s written policy specified that oxygen and respiratory supplies were to be stored in a plastic bag when not in use.
Failure to Implement and Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use and implementation of Enhanced Barrier Precautions (EBP) during wound care. One resident with an indwelling urinary catheter had an active order and care plan for EBP, and a door sign specifying that gown and gloves were required for high-contact resident care activities, including wound care and device care. During an observation, an RN and a CNA entered this resident’s room, performed hand hygiene, donned gown and gloves, and completed catheter care in accordance with the posted EBP instructions. However, after completing catheter care, the RN instructed the CNA that they could remove their gowns because EBP was “only for the catheter,” and both staff removed their gowns and gloves, performed hand hygiene, and then donned only clean gloves to perform a dressing change on the resident’s right heel and pinky toe, despite the door sign indicating gown and gloves were required for wound care. A second resident had multiple open wounds on both lower extremities that required cleansing, application of collagen with wound gel and alginate, and coverage with border gauze dressings. Progress notes documented that these wounds originated as skin tears and were slowly healing, and active wound care orders were in place. During an observation of wound care for this resident, an RN and a nurse aide performed hand hygiene and donned gloves but did not wear gowns. There was no EBP sign or PPE set up outside the room, and there was no order for EBP in the electronic medical record, even though the resident had open wounds requiring dressing changes. In interviews, the RN stated that EBP was required for chronic wounds such as pressure, venous, and arterial wounds, and that EBP for the first resident applied only to catheter care. The CNA reported that she relied on the door sign and believed she only needed to gown for catheter care, brief care, or toileting, and not for transferring if she was not in contact with the catheter. The Infection Preventionist explained that EBP was used for chronic wounds and indwelling devices and stated that staff would only need to gown when providing care to the Foley catheter, while the DON stated that EBP was for residents with devices or dressing changes to prevent MDROs and that staff should wear gown and gloves even when not providing direct catheter care. The facility’s written EBP policy specified that EBP applies to residents with chronic wounds and/or indwelling medical devices and that PPE for EBP is necessary when performing high-contact care activities, including wound care and medical device care, which was not consistently followed in the observed wound care encounters.
Failure to Offer Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its pneumococcal vaccination policy for one resident. The resident was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and a history of malignant neoplasm of the breast, and was over the age threshold referenced in CDC guidance. Record review showed the resident had previously received PPSV23 on 06/07/04 and PCV13 (Prevnar 13) on 11/04/14, both administered when the resident was older than the specified age. The resident’s Informed Consent Form for vaccines, dated 09/17/25, had the pneumococcal section marked as “not needed,” despite documentation of prior PPSV23 and PCV13 doses. During interviews, the ADON/Infection Preventionist stated she tracks resident vaccine records on a spreadsheet and confirmed that, based on CDC recommendations, the resident was not fully vaccinated and should have been offered PCV20. She also stated she did not know why “not needed” was written on the consent form. The DON stated her expectation was that residents’ vaccine status would be reviewed on admission, tracked when due, and that the IP nurse would review pneumonia vaccine status to determine if residents were fully vaccinated and offer the vaccine if not. Review of the facility’s pneumococcal vaccination policy and the CDC Adult Immunization Schedule showed that, for adults who previously received both PCV13 and PPSV23 with PPSV23 given at age 65 or older, one dose of PCV20 or PCV21 should be considered at least five years after the last pneumococcal vaccine dose, indicating the resident met criteria to be offered an additional pneumococcal vaccine dose.
Failure to Provide Required Bed-Hold and Transfer Notices for Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold policies and transfer notices to two residents and/or their resident representatives when the residents were emergently transferred to the hospital. One resident had severely impaired cognition with a BIMS score of 3/15 and was transferred to the hospital due to abnormal critical lab results, then later returned to the facility. Documentation showed that the facility called the contact on file and a POA returned the call, but there was no documentation that a written transfer notice or bed-hold information was provided. The facility’s own policy required that written transfer/discharge notices include the reason for transfer, effective date, receiving location, a statement of the right to appeal, and contact information for the state LTC ombudsman and protection and advocacy agencies, as well as sending a copy to the ombudsman. A second resident, who had intact cognition with a BIMS score of 15/15, was transferred to the hospital on one occasion for uncontrollable pain and returned to the facility, and on another occasion for SOB, tremors in both arms, and oxygen saturation below 88%, after which the resident expired at the hospital. Progress notes documented the transfers and that the family was notified, but there was no documentation that written transfer notices or bed-hold policies were provided at either transfer. The facility’s bed-hold policy required that all residents or their representatives, regardless of payor source, receive written information about facility and state bed-hold policies twice: in advance of transfer (e.g., in the admission packet) and again at the time of transfer, or within 24 hours for emergency transfers. During an interview, the Administrator confirmed that bed-hold notices had not been sent for these two residents.
Failure to Provide Required Showering and Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide required assistance with showering and personal hygiene for two residents who were dependent on staff for ADLs. One resident was observed with flaky skin and greasy hair, and the resident’s family member reported the resident was supposed to receive three showers or baths per week but was “lucky to get one.” The family maintained a calendar showing the resident received only four showers in the month of April. The resident’s admission record showed diagnoses including traumatic spondylolisthesis of the cervical spine, unspecified dementia, and cervical spinal stenosis. The quarterly MDS documented moderate cognitive impairment with a BIMS score of 10 and a need for substantial/maximal assistance with showering/bathing, with no documentation of care refusals. The resident’s care plan identified an ADL self-care performance deficit related to impaired balance, limited mobility, limited ROM, and neck pain, and contained no documentation of rejection of care or a pattern of negative responses. A second resident was observed with waist-length hair that appeared greasy at the crown and in need of washing. This resident stated she was supposed to receive three showers or baths per week but was “lucky” to get one, and reported staff told her they were short-staffed and that there was no bath team. Her admission record listed diagnoses including quadriplegia at C5–C7, bipolar disorder, and spinal stenosis. Her quarterly MDS documented that she was cognitively intact with a BIMS score of 15 and required partial/moderate assistance for showering/bathing, with no documentation of refusing care. Her care plan identified an ADL self-care performance deficit related to incomplete quadriplegia and did not document any concerns with rejection of care for ADLs, including showering. The DON and Administrator acknowledged that CNAs believed they were short-staffed without a bath team and were unaccustomed to providing baths and grooming when the bath team was unavailable, and that previously there had been no CNA room assignments, resulting in a lack of accountability for residents’ care. The facility’s ADL policy required that residents unable to perform ADLs independently receive services necessary to maintain grooming and personal hygiene and that refusals be documented in the clinical record.
Expired Medications Not Removed From Medication Room Refrigerator
Penalty
Summary
Surveyors identified a failure to properly manage and discard expired medications stored in a medication room refrigerator. During an observation of the medication storage room refrigerator with the Minimum Data Set Coordinator, multiple expired medications were found, including one Lispro insulin vial and one Lantus insulin vial, both with expiration dates of 01/23/26 and no open dates on the vials. An Apidra Solostar insulin pen with an expiration date of 02/04/26, a Trulicity 3 mg/0.5 ml injection pen carton with two pens remaining and an expiration date of 01/16/26 with no open date on the carton, and a 500 ml bottle of Gabapentin solution with 450 ml remaining and an expiration date of 10/02/23 with no open date on the bottle were also present. These medications remained stored in the refrigerator and available for use despite being outdated. During interviews, the MDS Coordinator confirmed that the medications in the storage refrigerator were expired and stated that an LPN was responsible for monitoring medication expiration dates for medications stored there. The DON reported that she did not think anyone had been assigned to check the medication storage refrigerator for expired medications and acknowledged that expired medications should have been destroyed by staff or returned to the pharmacy. The LPN later stated that she reviewed all medication carts for expired medications but did not check the medications stored in the refrigerator. Review of facility policies showed requirements that expiration or beyond-use dates be checked prior to administration, that multi-dose containers be dated when opened and discarded within 28 days unless otherwise specified, and that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, which were not followed in this instance.
Unsanitary Walk-In Freezer and Ice Scoop Storage Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in food storage and ice handling areas. During an initial kitchen tour, the walk-in freezer was found to have ice buildup on the freezer lines that extended far enough to encroach on the upper stacked box of burritos. The Dietary Manager acknowledged during interview that this ice buildup had occurred before. At the end of the tour, inspection of the ice machine revealed an ice scoop holder mounted on the side of the machine containing two ice scoops, with approximately 20 milliliters of standing water in the bottom of the holder and the scoops in direct contact with the water, and no visible way for the water to drain. The Dietary Manager stated that no one had ever mentioned the standing water in the scoop holder before. These conditions were inconsistent with the facility’s written policies on food safety and storage and on ice machine preventative maintenance, which require that food and supplies be stored and handled to ensure safety and sanitation and that exterior surfaces, including the catch basin, be wiped down with a clean cloth and food-safe sanitizer. The deficiency had the potential to affect 46 residents who consumed food from the kitchen.
Failure to Implement RD Supplement Recommendation for Resident With Weight Loss
Penalty
Summary
The facility failed to implement a registered dietician’s (RD) recommendation to address gradual weight loss for one resident. The resident was admitted with dementia with behavioral disturbance, malnutrition, anemia, osteoporosis, B vitamin deficiency, history of alcohol abuse, peripheral vascular disease, hypertension, and stage 3 chronic kidney disease. Her care plan identified her as at risk for nutritional decline and dehydration or potential fluid deficit, with approaches including weekly weights, completion of a Mini Nutritional Assessment, provision of meals per physician diet order with intake documentation, and RD review as indicated. A quarterly MDS showed severely impaired cognition, risk for pressure ulcers, receipt of a therapeutic diet, and a need for set-up or clean-up assistance with eating. On a nutritional review, the RD documented that the resident’s average intake was about 31%, average fluid intake with meals was about 612 ml, and that there were no routine supplements in place, although the RD felt she would benefit from additional support. The RD recommended initiating 2 oz Med Pass BID between meals and directed nursing to document the amount consumed. However, there was no corresponding Med Pass order in the EMR, and the resident did not receive the supplement. The resident experienced a 10‑lb (6.8%) weight loss over four months, with a low of 128.4 lbs. Interviews revealed that the RD expected recommendations to be implemented within 48 hours and typically communicated them via email to nursing and through Nutrition At Risk (NAR) meetings, but there had been no consistent NAR meetings and no email or other system in place to ensure the RD’s recommendation for Med Pass was communicated and implemented. Requested policies on RD recommendations/supplement orders and weight loss were not provided before survey exit.
Oxygen Therapy Administered Without Physician Order or Documentation
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician’s order, in accordance with professional standards of practice and facility policy, before administering oxygen to a resident. The resident was admitted with diagnoses including pulmonary hypertension, malignant neoplasm of the cardia and lower third of the esophagus, abnormal lung findings, and chronic systolic congestive heart failure. The resident’s care plan documented a potential for altered respiratory status and the need for oxygen therapy via nasal cannula, and the admission MDS indicated the resident received oxygen while in the facility. However, review of the electronic medical record, including the Order Recap Report, MAR, and progress notes for the relevant period, revealed no physician order for oxygen and no documentation that oxygen was being administered or monitored. Surveyor observations on multiple dates showed the resident receiving oxygen via nasal cannula at 1.5 LPM, initially without humidification and later with humidification. During interviews at the bedside, an LPN confirmed the resident was receiving oxygen at 1.5 LPM, acknowledged there was no physician’s order for oxygen, and stated the resident had been on oxygen since admission, with no MAR documentation of monitoring. The DON also confirmed the resident was receiving oxygen at 1.5 LPM without a corresponding physician’s order and stated that an order should have been obtained before oxygen was administered. Review of the facility’s “Oxygen Administration, Safety, Storage & Maintenance” policy showed that staff were required to verify a provider order prior to initiating or changing oxygen therapy, which was not followed in this case.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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