Meridian Meadows Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Idaho.
- Location
- 2656 E Magic View Drive, Meridian, Idaho 83642
- CMS Provider Number
- 135147
- Inspections on file
- 20
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Meridian Meadows Transitional Care during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing staff, especially on weekends and during evening/night shifts, resulting in missed and delayed care. Confirmed grievances included a resident not receiving overnight incontinence care and being found wet in the morning, a resident’s catheter bag filling to 2,000 mL before being emptied, long call‑light response times, rushed CNA care, and delays in getting residents out of bed when two‑person assistance was needed. Staffing schedules showed consistently lower staffing hours on weekends despite a stable census, and residents who usually ate in an independent dining room were moved to an assisted dining room on weekends due to lack of supervision, corroborated by a posted weekend closure notice. Residents, family members, and staff all reported that low staffing on weekends and certain night‑shift hours led to longer waits for assistance and unavailability of staff when needed.
A resident with palliative care needs, CHF, and acute kidney disease had new PRN lorazepam oral concentrate orders for anxiety and terminal agitation entered without documented informed consent. Record review showed no evidence that the resident or representative was informed of the risks and benefits of lorazepam or that consent was obtained before the medication was added as an active order. A CRN confirmed that no signed consent documenting understanding of the lorazepam treatment risks and benefits was present, resulting in a deficiency related to informing residents about their care and treatments.
A resident with type 1 DM, partial left-sided paralysis, and ataxia was observed keeping and taking glucose tablets independently whenever they felt their blood sugar was low. Facility policy required an IDT assessment, documentation on a Medication Self-Administration Safety Screen, physician orders, and care plan entries before any self-administration of medications, with periodic reassessments. The only assessment on file showed the resident required supervision for medications and did not list glucose tablets as approved for independent use, and no reassessments had been completed for several years. A physician note documented the resident was taking glucose tablets when blood sugars were in the 60s, yet there were no corresponding IDT assessments, orders, or care plan documentation authorizing this self-administration.
A resident with leukemia, dementia, anxiety, and depression was observed in bed with a transfer pole on one side and a 1/4 bed rail on the other, which the facility’s Restraint Free Environment policy defined as a physical restraint. Facility policy required a comprehensive assessment and alignment with the care plan for assistive device use, but the resident’s record contained no restraint assessment or informed consent for the 1/4 bed rail. A CRN confirmed that no restraint assessments had been completed for this device, and the report notes this practice had the potential for physical and psychosocial harm if the resident were injured, trapped, or felt unnecessarily restrained.
A resident with leukemia, dementia, anxiety, and depression was observed in bed using a transfer pole and a 1/4 bed rail, but these assistive devices were not documented in the resident’s comprehensive care plan. Record review confirmed the absence of any care plan addressing the transfer pole or 1/4 bed rail, and the CRN acknowledged that a care plan for these devices should have been in place.
The facility failed to meet professional standards of practice when staff did not clarify physician orders for oral medications for a resident who was documented as NPO with dysphagia, esophageal disease, and a gastrostomy. Despite the care plan indicating nothing by mouth, orders for prednisone and magnesium glycinate specified administration by mouth, and nursing staff did not verify or correct these routes before implementation, as required by professional nursing standards.
A resident with diabetes and muscle wasting, care planned as needing partial to moderate assistance with ADLs, was observed on multiple occasions with long, thick, yellow, and dirty fingernails, despite a facility nail care policy requiring assessment and routine cleaning/inspection of nails and specifying that licensed nurses provide nail care for diabetic residents. The resident initially reported not knowing he could request nail trimming and later stated he had asked for his nails to be cut. An LPN acknowledged the nails needed care and indicated nurses perform nail care but relied on a physician order to determine frequency; record review by the LPN and ADON confirmed there was no physician order for diabetic nail care in the resident’s chart, contrary to the ADON’s expectation that such an order should have been present from admission.
A resident with type 1 DM, partial left-side paralysis, and ataxia after a stroke was observed with glucose tablets on his desk and reported taking them whenever he felt his blood sugar going low. A physician note referenced the resident taking glucose tablets when blood sugars were in the 60s, but a review of current physician orders showed no active order for glucose tablets, which was confirmed by the CRN and DON.
A resident receiving palliative care with multiple comorbidities, including CHF and acute kidney disease, had physician orders for specific left heel wound care that were not followed when an RN omitted the ordered normal-saline–moistened gauze and instead applied only a clean dry dressing. The same resident’s wound vac was discontinued per provider order, and prior wound care orders were stopped, but no new wound treatment was implemented for several days, with the new left heel dressing regimen not started until four days later. The ADON reported difficulty communicating with the hospice agency to clarify wound care orders and acknowledged not seeking a temporary order from the facility’s medical director.
A resident with chronic respiratory failure with hypoxia and CHF had a physician order for oxygen at 0–2 LPM via nasal cannula as needed to maintain SpO2 ≥ 88%, with pulse oximetry checks each shift. Documentation showed SpO2 readings of 90–95% and that the resident was occasionally given 3 LPM of oxygen. Surveyors observed the resident with an oxygen concentrator running at 2.5 LPM while not wearing the nasal cannula, and later with oxygen in use while the concentrator was set at 3 LPM. The DON reviewed the record and confirmed the order was for 0–2 LPM and that the concentrator should have been set within that range, demonstrating that oxygen therapy was not consistently provided per the physician’s order.
The facility did not ensure that an RN was on duty for at least 8 consecutive hours per day as required. Review of nursing schedules over a three-week period showed multiple days without 8 consecutive hours of RN coverage. During an interview, the staffing coordinator reported being unaware that RN coverage hours had to be consecutive, resulting in noncompliance with RN staffing requirements that could affect all residents needing higher-level nursing assessment or intervention.
Surveyors found that the facility did not prevent duplicate medication orders or ensure monitoring for medication side effects for two residents. One resident on palliative care with CHF and acute kidney disease had two PRN orders for lorazepam oral concentrate written for the same dose and frequency, one for anxiety and one for terminal agitation, with no documented monitoring for sedation, respiratory status, cognitive changes, or other adverse effects despite FDA guidance. Another resident with diabetes, CHF, and mild cognitive impairment had two overlapping PRN orders for bisacodyl suppositories, which the CRN acknowledged were in error.
The facility failed to ensure medications were securely stored and free of expiration. A resident with dysphagia and a gastrostomy, who required assistance to store medications securely, was observed with medication cups containing white powder residue and multiple Jevity containers on the bedside nightstand. The resident reported that nurses sometimes left medications on the nightstand and that he occasionally obtained his own medications from the hallway and kept them there until use, without being instructed to store them elsewhere. Additionally, surveyors found multiple expired Bacitracin ointment packets in a medication cart drawer; an LPN confirmed they were expired, and the DON acknowledged there was no set schedule for checking carts for expired medications, relying instead on nurses to notice during med pass.
A resident receiving hospice services, with diagnoses including leukemia, dementia, anxiety, and depression, did not have a Hospice Election form maintained in the facility’s records as required. SOM Appendix PP and the facility’s hospice services agreement required a designated interdisciplinary team member to obtain and keep specific hospice documents, including the hospice election form, for each hospice patient. Record review showed the form was missing, and the CRN acknowledged it was not on file and stated she did not believe it needed to be included in the hospice documentation kept at the facility.
The facility failed to maintain an effective QAPI performance improvement plan (PIP) for systemic staffing concerns, despite its QAPI plan requiring a data‑driven process to identify and address gaps in care systems and ensure adequate staffing. Facility staffing data showed low weekend staffing, and resident council minutes over several months documented repeated complaints about weekend short staffing, delayed medication administration, missed snacks, and closure of the independent dining hall when staffing was insufficient. A resident reported that residents stopped complaining when the facility did not respond to their concerns. The Administrator stated a staffing PIP had been opened and then closed once residents stopped complaining, and acknowledged that independent dining was closed when there were not enough staff, while also indicating no specific staffing system gaps or metrics were identified before closing the PIP.
Staff failed to follow infection prevention and control practices during medication administration and wound care. An LPN administered medications to two residents without performing hand hygiene upon entering their rooms, only cleaning hands after leaving, despite facility expectations for hand hygiene on room entry and exit. A resident with chronic wounds, MDRO risk, and orders for Enhanced Barrier Precautions received wound care from an RN who did not wear a gown, contaminated gloves by handling the bed controls and bed surfaces, placed wound-care supplies directly on the bed, used unsanitized scissors taken from a pocket, and reapplied gloves without performing hand hygiene.
Surveyors found that the facility did not follow its own immunization policy requiring education and documentation regarding influenza and pneumococcal vaccines. Three residents with significant medical conditions, including muscle wasting, osteonecrosis, cancer, CAD, osteoarthritis, protein-calorie malnutrition, and dementia, had no documentation that they or their representatives received CDC Vaccine Information Statements, supplemental explanations, or an opportunity to accept or decline the vaccines based on education about risks and benefits. A CRN confirmed that there were no records of vaccine education or consent for these residents in their medical charts.
Surveyors determined that the facility did not follow its COVID-19 vaccination policy for two residents with multiple comorbidities, including muscle wasting, osteonecrosis, osteoarthritis, protein-calorie malnutrition, and dementia. Record review showed no documentation that these residents were educated on the risks, benefits, and potential side effects of the COVID-19 vaccine, nor that they were offered the opportunity to accept or decline vaccination, and the CRN confirmed there were no such records on file.
Three residents experienced neglect when a staff member performed a mechanical lift transfer alone, resulting in a fall and fracture for a resident with hemiplegia, and two other residents with significant medical conditions were not provided timely incontinence care during an overnight shift, as confirmed by grievance review and camera footage.
The facility did not report allegations of neglect to the State Agency within the required timeframe for two residents. One resident with significant neurological and physical impairments suffered a fall and fracture during a transfer, and the incident was reported late. Another resident's neglect allegation was not reported separately as required. The administrator confirmed these reporting failures.
A medication cart was found unlocked and unattended in the facility, creating a potential risk for unauthorized access to medications. An RN acknowledged forgetting to lock the cart, and the DON confirmed the failure to follow protocol.
The facility failed to ensure CMAs had the necessary competencies for insulin administration. All four CMAs reviewed lacked documented competency in insulin administration, despite facility policies prohibiting CMAs from calculating dosages and administering medications via parenteral routes. One CMA was observed calculating and administering insulin injections to two residents without proper training. The Administrator confirmed the absence of specific competency training for insulin administration.
Insufficient Weekend and Night Staffing Leading to Missed and Delayed Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff were available each day to meet resident needs according to their plans of care, particularly on weekends and during evening/night shifts. Review of grievances over a six‑month period documented confirmed incidents of missed or delayed care, including a resident not receiving incontinence care between 6:00 PM and 6:00 AM and being found wet the next morning, and another resident reporting that his catheter bag was allowed to fill to 2,000 mL before a CNA arrived to empty it. Additional grievances confirmed long call‑light wait times, rushed care by CNAs, and delays in getting residents out of bed when two‑person assistance was required. A three‑week staffing schedule review showed consistently lower total staffing hours on weekends compared to weekdays, while the census remained relatively stable. Residents and family members reported that staffing was low on weekends, that staff were not available when needed throughout the day, and that rooms were often unorganized and residents not ready for scheduled outings. Residents who normally ate in the independent dining room reported being required to eat in the assisted dining room on weekends due to lack of supervision, and this was corroborated by a kitchen whiteboard stating the independent dining room was closed on Saturdays and Sundays. During interviews, night‑shift licensed nurses reported that each wing had one CNA and one nurse on duty and acknowledged that between 4:00 AM and 6:00 AM residents might wait longer for assistance as more residents began calling for help. A CNA stated the facility was often low‑staffed on weekends and not always appropriately staffed from 6:00 PM to 10:00 PM, resulting in longer wait times to meet resident needs. The staffing coordinator confirmed that staffing was based on census and that the facility did not have many weekend staff. Resident council feedback further documented repeated concerns about low weekend staffing, closure of the independent dining room on weekends, and staff observed sitting at the nurses’ station charting while call lights remained unanswered.
Failure to Obtain and Document Informed Consent for Lorazepam Use
Penalty
Summary
Surveyors found that the facility failed to ensure a resident was informed in advance of care and treatment, including the risks and benefits, before initiating a new medication. One resident with multiple diagnoses, including palliative care encounter, congestive heart failure, and acute kidney disease, had physician orders for lorazepam oral concentrate 2 mg/mL, to be given 0.5 mL by mouth every 8 hours as needed for anxiety and every 8 hours as needed for terminal agitation for 180 days. Record review showed no documentation that the resident or the resident’s representative had been informed of the risks and benefits of lorazepam or had provided consent prior to lorazepam being added as an active order. In an interview, the clinical resource nurse confirmed that neither the resident nor the representative had signed a consent documenting understanding of the risks and benefits of the lorazepam treatment. This failure to obtain and document informed consent for lorazepam use for this resident, whose record was reviewed for informed consent, was identified as a deficiency related to ensuring residents are fully informed and understand their health status, care, and treatments.
Failure to Assess and Authorize Resident Self-Administration of Glucose Tablets
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for resident self-administration of medications, specifically glucose tablets. The facility’s policy required that residents may only self-administer medications after an IDT assessment, documented on a Medication Self-Administration Safety Screen, with corresponding care plan documentation and physician orders. The policy also required periodic reassessment at least quarterly, annually, with significant change, or after a medication error. For the resident in question, the Medication Self-Administration Safety Screen on file indicated the resident required supervision to take medications and did not list glucose tablets as a medication that could be stored and taken independently. No updated self-administration assessments had been completed since 2023. The resident, who had type 1 DM, partial left-sided paralysis, and ataxia following a stroke, was observed with a bottle of glucose tablets on his desk and stated he took them whenever he felt his blood sugar going low. A physician progress note documented that the physician had seen the resident for low blood sugars and referenced that the resident was taking glucose tablets whenever his blood sugar was in the 60s. Despite this, there were no IDT assessments, physician orders, or care plan documentation authorizing or addressing self-administration of glucose tablets. The CRN and DON confirmed there were no Medication Self-Administration Safety Screen assessments related to the resident’s ability to self-administer glucose tablets, resulting in unmonitored treatment of hypoglycemia and unsafe medication practices.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints unless needed for medical treatment by not assessing the safety of bed rail use or obtaining informed consent prior to use. Facility policy on Use of Assistive Devices, dated 12/29/25, required that assistive devices be used based on a comprehensive assessment and in accordance with the resident’s plan of care, and the Restraint Free Environment policy, reviewed 12/31/25, defined bed rails as a type of physical restraint. Resident #18, admitted with diagnoses including leukemia, dementia, anxiety, and depression, was observed in bed with a transfer pole on the left side and a 1/4 bed rail on the right side of the bed. Review of the resident’s record showed no documentation of a restraint assessment or consent form for the 1/4 bed rail, and on 4/3/26 the CRN confirmed that no restraint assessments had been completed for this bed rail. The report states this deficient practice had the potential for physical and psychosocial harm if the resident were injured, trapped, or felt she was being restrained unnecessarily. This deficiency was cross-referenced to F656.
Care Plan Omission for Resident Assistive Bed Devices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident’s comprehensive, person-centered care plan accurately reflected the use of assistive devices. One resident, admitted with multiple diagnoses including leukemia, dementia, anxiety, and depression, was observed in bed with a transfer pole on the left side of the bed and a 1/4 bed rail on the right side. Review of the resident’s care plan showed no documentation of the transfer pole or the 1/4 bed rail. In a subsequent interview, the CRN confirmed that there was no care plan implemented related to the 1/4 bed rail and transfer pole and acknowledged that there should have been. This lack of documentation and care planning for the assistive devices constituted the cited failure and had the potential to result in unmet care needs and increased risk to resident safety, as noted in the survey findings.
Failure to Clarify Oral Medication Orders for NPO Resident
Penalty
Summary
The facility failed to ensure physician orders met professional standards of quality by not clarifying medication routes for a resident who was NPO and had swallowing difficulties. Record review showed that a resident readmitted with dysphagia, disease of the esophagus, and a gastrostomy had a nutritional care plan, revised 4/3/26, documenting the resident was NPO (nothing by mouth). Despite this, physician orders directed that prednisone 5 mg be given by mouth daily for renal insufficiency and magnesium glycinate 100 mg be given by mouth at bedtime for insomnia. According to the National Council of State Boards of Nursing, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it. On 4/2/26 at 11:32 AM, the DON and CRN confirmed that the resident does not take anything by mouth and acknowledged that the provider’s orders should have been clarified prior to implementation. This failure created the potential for harm if the resident were to receive oral medications despite having difficulty swallowing.
Failure to Provide Required Fingernail Care for Dependent Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide fingernail care to a resident who was dependent on staff for assistance with activities of daily living (ADLs), as required by facility policy. The facility’s Nail Care policy, implemented in December 2024 and revised in December 2025, required assessment of residents’ nails on admission and readmission, ongoing routine cleaning and inspection of nails during ADL care, and that only licensed nurses trim or file fingernails of residents with diabetes. The resident in question was admitted with multiple diagnoses including muscle wasting/atrophy and diabetes and had an ADL care plan indicating a need for partial to moderate assistance with ADLs. Despite these needs and the policy requirements, there was no documented physician order for diabetic nail care in the resident’s record. On multiple observations over several days, the resident’s fingernails were noted to be long, thick, yellow, and dirty, and the resident stated he preferred shorter nails. Initially, the resident reported he was unaware he could ask staff to cut his fingernails, and later stated he had asked staff to cut them. An LPN, when observing the resident’s nails with the surveyor, acknowledged that the thumbnails were long, yellow, dirty, and needed to be soaked and cut, and stated that nurses perform nail care but would need to check the resident’s order to determine how often it should be done. Upon review of the record, the LPN and ADON confirmed there was no order for diabetic nail care for this resident, despite the ADON’s statement that such an order was required and should have been present from admission. This sequence of events shows that the resident did not receive nail care services in accordance with facility policy and his assessed needs.
Lack of Physician Order for Self-Administered Glucose Tablets
Penalty
Summary
The facility failed to ensure a resident had an active physician’s order for a medication the resident was self-administering. A resident who had been readmitted with multiple diagnoses, including type 1 diabetes, partial paralysis of the left side, and ataxia after a stroke, was observed with a bottle of glucose tablets on his desk and stated he took the tablets whenever he felt his blood sugar going low. A physician’s note documented that the physician had seen the resident for low blood sugars and referenced that the resident was taking glucose tablets whenever his blood sugar was in the 60s. However, a review of physician’s orders for the relevant period showed no order for glucose tablets, and the CRN and DON confirmed there were no current physician orders related to glucose tablets. This deficient practice created the potential for adverse outcomes when the resident self-administered a medication not ordered by a physician.
Failure to Follow Wound Care Orders and Delay in Implementing New Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care according to physician orders and acceptable standards of practice for a resident with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease. The resident had a physician order directing staff to cleanse the left heel with wound cleanser, apply normal-saline–moistened gauze, and cover with a dry dressing every shift. During an observation of wound care, an RN removed the soiled dressing, cleansed the wound with wound cleanser and gauze, patted the wound dry, applied skin prep, and applied a clean dry dressing, but did not apply the ordered normal-saline–moistened gauze. The RN later confirmed she performed the wrong treatment, and the ADON confirmed the wound care provided was not consistent with the physician’s order. The deficiency also includes a lapse in implementing new wound treatment orders after discontinuation of a wound vac on the resident’s left heel. The care plan documented the resident was at risk for skin impairment and pressure ulcers, and a physician order directed discontinuation of the wound vac and application of wet-to-dry dressing until further orders were received. A Nursing Progress Note documented discontinuation of prior wound care orders, including those related to the wound vac and associated procedures, but did not document that a new wound treatment was implemented at that time. The Treatment Administration Record showed that a new wound care order for the left heel—cleanse with wound cleanser, apply normal-saline–moistened gauze, and cover with a dry dressing every shift—was not implemented until four days after the wound vac was discontinued. The ADON stated the facility had difficulty communicating with the hospice agency to clarify the wound care order and acknowledged he did not think to obtain a temporary order from the facility’s medical director.
Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy according to physician orders for a resident receiving respiratory care. Facility policy required that oxygen be administered under a physician’s order except in an emergency. The resident was admitted with chronic respiratory failure with hypoxia and congestive heart failure, and the care plan documented that the resident used oxygen per physician order. A physician order dated 3/26/26 specified oxygen at 0–2 LPM via nasal cannula as needed to maintain oxygen saturation at or above 88%, with oxygen saturation checks every shift. The March and April 2026 MAR/TAR showed oxygen saturations ranging from 90–95% and documented that the resident was occasionally receiving 3 LPM of oxygen as needed. On 3/30/26 at 1:00 PM, the resident was observed in bed with the head of the bed elevated, the oxygen concentrator running and set at 2.5 LPM, but the resident was not wearing the nasal cannula and stated he used oxygen at night and when napping. On 4/3/26 at 9:26 AM, the resident was observed lying in bed with oxygen on via nasal cannula, and at 10:43 AM the same day, the DON observed the resident still in bed with oxygen via nasal cannula and identified the concentrator setting as 3 LPM. When the DON reviewed the record at 10:45 AM, she confirmed the physician order was for 0–2 LPM via nasal cannula and acknowledged that the concentrator should have been set between 0–2 LPM, indicating that the resident had been receiving oxygen at a flow rate above the ordered range.
Failure to Provide Required Consecutive RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered professional nurse (RN) for at least 8 consecutive hours per day as required. Review of the three-week nursing schedule dated 3/8/26 through 3/28/26 showed that on 3/14/26, 3/15/26, and 3/28/26, the facility did not provide 8 consecutive hours of RN coverage. This deficiency was identified through record review of the posted nursing schedules and confirmed during an interview on 4/2/26 at 9:47 AM, when the Staffing Coordinator stated she was unaware that the required RN hours must be consecutive. The report notes that this failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention, but does not provide specific resident examples or clinical details.
Failure to Prevent Duplicate Medication Orders and Monitor PRN Sedative Side Effects
Penalty
Summary
The facility failed to ensure residents were free from unnecessary drugs by allowing duplicate medication orders and not implementing monitoring for medication side effects. For one resident with diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease, the medical record contained two separate PRN orders for lorazepam oral concentrate 2 mg/mL, each directing administration of 0.5 mL by mouth every 8 hours as needed, one for anxiety and one for terminal agitation. Despite FDA prescribing information indicating the need to monitor for adverse effects such as respiratory depression, cognitive impairment, paradoxical reactions, and dependence or withdrawal symptoms, the resident’s care plan and physician orders did not include any documented monitoring parameters for lorazepam use, including monitoring for sedation, respiratory status, or cognitive changes. The DON confirmed that the record lacked monitoring interventions for lorazepam. Another resident, admitted with multiple diagnoses including diabetes, congestive heart failure, and mild cognitive impairment, had duplicate PRN orders for bisacodyl suppositories. One order directed insertion of a 10 mg bisacodyl suppository rectally as needed for constipation if there were no results within 24 hours from a bisacodyl tablet, and a second order directed insertion of a 10 mg bisacodyl rectal suppository every 24 hours as needed for no bowel movement after the prior bowel protocol regimen. On interview, the CRN acknowledged that the resident had two bisacodyl suppository orders in error. These findings showed the facility did not prevent duplicate medication orders or ensure appropriate monitoring for medication side effects for the residents reviewed.
Expired and Unsecured Medications on Unit and in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to follow its Medication Storage policy requiring all drugs and biologicals to be stored in locked compartments. One resident, readmitted with dysphagia, disease of the esophagus, and a gastrostomy, had a care plan indicating supervision for self-administration of nutrition and an assessment stating he required assistance to store medications in a secure location. Surveyors observed two cups with white powdered residue, including one labeled for a specific administration time, on his nightstand along with six containers of Jevity nutritional supplement. The resident reported that nurses sometimes brought his medications to his room and left them on the nightstand for him to take when he was ready, and that he sometimes went into the hallway early in the morning to obtain his medications for the day, which he then kept on his nightstand. He also stated he self-administered his nutritional supplements and that staff provided him with a case of Jevity to self-administer. The CRN later stated she had not been informed that medications were being left on this resident’s bedside table. The deficiency also includes the presence of expired medications on a medication cart. During inspection of a medication cart on one wing, surveyors found 19 packets of Bacitracin ointment in a clear plastic cup in the bottom drawer, all bearing an expiration date that had passed. When questioned, an LPN confirmed the Bacitracin ointment was expired and stated that expired medications should be disposed of. When asked about the process for checking medication carts for expired medications, the DON reported there was no designated schedule for such checks and indicated that nurses were expected to watch for expired medications during medication pass.
Failure to Maintain Required Hospice Election Documentation
Penalty
Summary
The facility failed to maintain complete hospice records for a resident receiving hospice services, specifically by not having a Hospice Election form on file. SOM Appendix PP requires that when a LTC facility arranges hospice care under a written agreement, a designated interdisciplinary team member with a clinical background must obtain specific hospice documentation, including the hospice election form, physician certifications, plan of care, and related information. The facility’s Hospice Services Facility Agreement, dated 12/2/25, also documented that the facility would arrange hospice services and that the designated facility member would obtain hospice coordination of care information and physician certification, including but not limited to the Hospice Election Form. Resident #18 was admitted with multiple diagnoses including leukemia, dementia, anxiety, and depression and was receiving hospice services. A review of this resident’s medical record and hospice documentation showed that the Hospice Election form was not included in the records maintained at the facility. On 4/2/26 at 11:46 AM, the Clinical Registered Nurse (CRN) confirmed that Resident #18’s Hospice Election form was not on record at the facility prior to requesting a copy from the hospice company that morning. On 4/6/26 at 2:15 PM, the CRN further clarified via email that she did not believe the election form needed to be included in the hospice documentation kept at the facility level.
Failure to Maintain Effective QAPI PIP for Systemic Staffing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to implement and sustain a performance improvement plan (PIP) for a systemic staffing concern, despite its QAPI Facility Plan requiring a data‑driven, organized, facility‑wide program to identify and address gaps in systems and ensure adequate staffing. The facility’s own PBJ staffing data for the first quarter of 2026 documented concerns with low weekend staffing. Resident council minutes showed that residents repeatedly reported staffing problems over several months: in November 2025, residents reported the facility was often short staffed on weekends; in December 2025, they reported weekend staffing issues that delayed medication administration until 9:30–10:00 AM, with staffing concerns noted as in progress; and in January 2026, residents were told new staff had been trained and were working regularly, and residents stated short staffing had significantly improved, with the concern noted as resolved. A resident later reported that residents stopped complaining about staffing around December 2025 when the facility had failed to respond to their earlier concerns. Additional findings showed that residents continued to experience staffing‑related issues after the staffing PIP was closed. In March 2026, resident council minutes documented that residents were concerned about not receiving snacks when the facility was short staffed. During a group interview, residents voiced concerns about low weekend staffing and poor staff response time during the night shift, and independent diners reported they could not eat in the independent dining hall when there were not enough staff on weekends. The Administrator confirmed that independent dining had to be closed when staffing was insufficient so residents could dine in the dependent dining hall with available staff. The Administrator reported that a staffing PIP opened in October 2025 was closed in December 2025 when residents stopped complaining, and he did not identify any specific gaps in staffing systems or metrics used to evaluate staffing effectiveness before closing the concern, despite ongoing documented staffing‑related issues.
Failure to Maintain Hand Hygiene and Enhanced Barrier Precautions During Med Pass and Wound Care
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during medication administration and wound care. During a morning medication pass, an LPN prepared and administered medications to two residents without performing hand hygiene upon entering their rooms, despite later stating that hand hygiene is performed before entering and exiting resident rooms. For one resident, the LPN prepared medications, poured water, locked the cart, entered the room, and handed the resident a medication cup and water without performing hand hygiene until exiting the room. For another resident, the LPN similarly prepared medications, entered the room, and administered medications with a spoon and applesauce without performing hand hygiene upon entry, only doing so upon exit. The DON later confirmed that staff should perform hand hygiene upon entering residents' rooms. The deficiency also includes improper infection control practices during wound care for a resident with multiple diagnoses, including palliative care encounter, congestive heart failure, acute kidney disease, chronic wounds, and a history of MDRO to the left heel. The resident’s care plan identified risk for MDRO and physician orders required Enhanced Barrier Precautions every shift, with posted signage directing hand sanitizing before entering and after leaving the room and use of gloves and gowns for high-contact care, including wound care. During observed wound care, an RN entered the room, performed hand hygiene, and applied gloves but did not wear a gown as required. The RN contaminated gloves by adjusting the bed with the same gloves used for wound care, placed the resident’s foot and wound-care supplies on the bed, used scissors taken from a pocket without sanitizing them, touched the bed footboard with gloved hands after donning clean gloves, and reapplied gloves at the end of the procedure without performing hand hygiene. The RN later confirmed that proper PPE, instrument sanitization, and hand hygiene should have been used.
Failure to Educate Residents on Risks and Benefits of Flu and Pneumonia Vaccines
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to educate residents on the risks and benefits of pneumococcal and influenza immunizations as required by facility policy and SOM Appendix PP. The facility’s written policy, last reviewed on 12/22/25, stated that prior to administration of influenza or pneumococcal vaccines, the resident or legal representative would be provided the current CDC Vaccine Information Statement, supplemented with visual or oral explanations, and that a signed consent form and documentation of education and acceptance/refusal would be maintained in the medical record. Record review and staff interview showed that this process was not followed for several residents. For one resident with muscle wasting and osteonecrosis who was readmitted to the facility, the medical record did not contain documentation that he was offered the opportunity to accept or decline the pneumococcal vaccine based on education about risks and benefits, and the Clinical RN confirmed there were no records of such education. For another resident with cancer and coronary artery disease, the record likewise lacked documentation of education or an opportunity to accept or decline the pneumococcal vaccine, which the Clinical RN also confirmed. A third resident with osteoarthritis, protein-calorie malnutrition, and dementia, and/or her representative, had no documented evidence in the record that she was offered the opportunity to accept or decline influenza and pneumococcal vaccines based on staff education regarding risks and benefits, and the Clinical RN again stated there were no records of this education. This lack of documented education and consent occurred for 3 of 5 residents reviewed for current immunizations.
Failure to Document COVID-19 Vaccine Education and Offer for Residents
Penalty
Summary
Surveyors found that the facility failed to follow its COVID-19 Vaccination policy requiring documentation in the medical record of education on risks, benefits, and potential side effects of the COVID-19 vaccine, as well as documentation of each dose administered or the reason for non-receipt (medical contraindication or refusal). Record review for two residents showed no documentation that they were offered the opportunity to accept or decline the COVID-19 vaccine, nor that any vaccine-related education was provided. One resident was readmitted with multiple diagnoses including muscle wasting and osteonecrosis, and another was admitted with multiple diagnoses including osteoarthritis, protein-calorie malnutrition, and dementia, yet neither record contained any entries regarding COVID-19 vaccine education or offer. In staff interview, the Clinical Resource Nurse confirmed there were no records on file related to educating or offering the COVID-19 vaccine for these residents. This deficient practice created the potential for harm when residents were not offered education related to the risks and benefits of receiving the COVID-19 vaccination.
Failure to Prevent Resident Neglect During Transfers and Incontinence Care
Penalty
Summary
The facility failed to protect residents from neglect, as evidenced by three separate incidents involving residents with significant medical needs. One resident, who had a history of cerebral infarction, hemiplegia, and major depressive disorder, required two-person transfers using a mechanical lift according to her care plan. Despite this, a staff member attempted to transfer her alone, resulting in the sling detaching and the resident falling, which caused a comminuted fracture and significant pain. Another resident, with non-dominant sided hemiplegia and dysphagia following a stroke, filed a grievance stating that incontinence care was not provided when a specific CNA was on duty. Review of camera footage confirmed that the CNA only attended to the resident once during an overnight shift, substantiating the resident's claim of neglect. The resident was subsequently assessed, and no evidence of physical or psychosocial harm was found following the incident. A third resident, diagnosed with severe vascular dementia, chronic kidney disease, and diabetes, was found soiled at the end of a shift, indicating that incontinence care had not been provided. Facility investigation and camera footage revealed that the same CNA had extended absences from the floor and provided minimal care to residents during the shift. The investigation confirmed that the CNA failed to perform required care for this resident, though no physical or psychosocial harm was identified upon assessment.
Failure to Timely Report Allegations of Neglect
Penalty
Summary
The facility failed to ensure timely reporting of allegations of neglect to the State Agency for two residents. For one resident with a history of cerebral infarction, hemiplegia, and major depressive disorder, an incident occurred during a transfer with a full mechanical lift when the sling detached, resulting in a fall and a comminuted fracture of the left arm. The incident was not reported to the State Agency until after the injury was confirmed by X-ray, which was outside the regulated reporting timeframe. The investigation later confirmed neglect due to a staff member deviating from the resident's plan of care by attempting the transfer alone. In another case, a resident with hemiplegia and dysphagia following a stroke made an allegation of neglect, which was documented in the facility's grievance log. However, this allegation was not reported to the State Agency as a separate incident and was instead included in another investigation without associating the resident's name. The administrator acknowledged that the allegation should have been reported when it was received.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the security and inaccessibility of medications to unauthorized staff and residents, as observed with one of the three medication carts. On January 6, 2025, at 10:25 AM, a medication cart located on the 200 hall was found unlocked and unattended by staff. RN #1, who was responsible for the cart, returned at 10:33 AM and acknowledged that she should have locked the cart when she stepped away. The Director of Nursing confirmed that RN #1 did not adhere to the facility's protocol for securing the medication cart before leaving it unattended. This oversight created a potential risk for harm if unauthorized individuals accessed the medications.
Inadequate CMA Competency in Insulin Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) possessed the necessary competencies for medication administration, specifically for insulin. This deficiency was identified for all four CMAs reviewed. The facility's policies stated that CMAs are prohibited from administering medications via parenteral routes and from calculating medication dosages. However, CMA #1 was observed calculating insulin dosages and administering subcutaneous insulin injections to two residents, despite the facility's skills check-off sheets lacking documentation of competency in insulin administration. The facility's Administrator confirmed the absence of specific CMA competency training for insulin dosage calculation and subcutaneous injection.
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.
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