Silverton Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Silverton, Idaho.
- Location
- 405 West Seventh Street, Silverton, Idaho 83867
- CMS Provider Number
- 135058
- Inspections on file
- 18
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Silverton Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
The facility failed to ensure meals were palatable and maintained at appropriate hot and cold temperatures. A resident reported that salads were served warm after being placed on hot plates under plate covers, and another resident refused a meal when a cold salad was observed on a hot plate. Resident council minutes documented ongoing complaints that hot foods were not consistently hot, cold foods were not consistently cold, and some items such as mashed potatoes were watery. Surveyors observed items on the serving line that required reheating and a test tray in which both hot and cold foods and beverages were outside acceptable temperature ranges. The RD and dietary manager acknowledged that salads should be kept on the cold side, that test tray temperatures were out of parameters, and that cold items should not be placed on hot plates or under plate covers.
The facility failed to ensure proper use of beard restraints by dietary staff during food preparation and plating. A staff member with facial hair was observed plating food with a beard guard worn around the neck and then pulling it over the face with gloved hands, without performing hand hygiene, and was later observed plating food without any beard guard. The Dietary Manager confirmed that staff with facial hair are required to wear beard guards and that this staff member had not complied on multiple occasions.
Surveyors found that the facility did not notify the State LTC Ombudsman when four residents were discharged or transferred, despite documenting coordinated discharges and hospital transfers. One resident with dementia and a history of falls was sent to the ED after a fall, another was discharged home after post-surgical recovery, a third with dementia and diabetes was transferred for cellulitis treatment, and a fourth with heart failure and COPD was transferred twice for COPD exacerbations. In each case, records showed coordination with receiving providers but no Ombudsman notification, which the Administrator confirmed had not occurred.
Surveyors found that Schedule II controlled substances were not properly secured during a storage and labeling audit with an LPN. When the LPN unlocked the medication refrigerator, the internal Schedule II compartment was observed to have a black lock that detached from the drawer, leaving the controlled medications accessible instead of stored in a permanently affixed, locked compartment. The LPN acknowledged that the compartment was not appropriately secured and that it should remain locked at all times to ensure the safety of Schedule II medications.
A resident with chronic respiratory failure, diabetes, dementia, and muscle weakness experienced ongoing dizziness, upper body weakness, dysuria, and altered mental status over a period of 1–2 weeks, but nursing did not document timely assessments, vital signs, or completion of a pending UA during this change in condition. Nursing notes later described increased weakness, transfer difficulty, and abnormal movements, with a UA and culture eventually collected and found positive for infection. Vital signs were only recorded on two dates, and there was no documentation of nursing assessment or UA collection during the earlier phase of the resident’s decline. The DON stated that non-STAT medical orders are usually completed within 24 hours and that vitals are typically taken every 30–60 days unless otherwise ordered, and did not explain why the UA was not completed earlier.
A resident with a right humerus fracture and other conditions had an acceptable pain goal of 4/10 and was ordered scheduled acetaminophen and PRN oxycodone, yet documented pain scores repeatedly ranged from 6/10 to 10/10. Therapy notes described persistent shoulder pain that limited participation and episodes of severe pain, and observations showed the resident guarding the affected arm and reporting constant pain without relief since admission. Although the DON believed pain was well managed based on PRN use, there was no documentation that the pain management plan was reassessed or its effectiveness evaluated despite ongoing pain above the resident’s stated goal.
A resident with iron deficiency anemia and a right humerus fracture had a physician order for daily Ferrous Gluconate for supplementation, but the medication was not administered as ordered. During a med pass, a MAC reported the iron supplement was not available, and further review showed the order had been in place for an extended period without doses given. The DON later stated the medication had been obtained but was not moved to the resident’s new med cart after a room change, resulting in ongoing failure to provide the ordered iron therapy.
Two residents’ records were not maintained accurately and completely. For one resident with dementia and a history of falls, an INTERACT hospital transfer form listed vital signs from nearly a week before the actual transfer, which the ADON confirmed did not reflect the resident’s condition at the time of transfer. For another resident with dementia and visual hallucinations, a physician order required per-shift documentation of target behaviors and specific interventions, but behavior monitoring records showed multiple behavior episodes without corresponding documentation of the ordered interventions, and the DON acknowledged that the record did not accurately reflect the interventions used.
The facility failed to maintain proper infection prevention and control practices, including sanitary PPE storage, wound care setup, and hand hygiene. A resident with a stage 4 pressure ulcer, paraplegia, a suprapubic catheter, and chronic wounds had an Enhanced Barrier Precaution gown stored unwrapped on personal linens instead of in protective packaging as required. In a separate case, the ADON prepared wound care supplies on an unsanitized cart and initially placed them on a toilet surface before moving them to a sanitized bedside table, later acknowledging a barrier should have been used under the supplies. Additionally, a medication aide performed hand hygiene before medication preparation but did not sanitize hands again immediately before donning gloves to administer oral medication and an inhaler to a resident.
A resident with dementia and psychotic disturbances repeatedly physically assaulted three other residents with similar vulnerabilities, while staff failed to consistently monitor, intervene, or document required actions as outlined in care plans and physician orders. This resulted in multiple incidents of abuse and a lack of protection for residents.
Five residents with orders for bowel management did not receive prescribed medications such as MOM, Dulcolax, or Fleet Enema after multiple days without a BM. Despite documented periods of constipation, staff did not administer interventions as ordered, and the DON confirmed that nursing staff should have tracked and provided bowel care medications according to physician instructions.
During kitchen inspections, spoiled onions with visible mold, a toaster with heavy black residue, and coffee cups with brown buildup were found, with staff confirming these items were not in sanitary condition.
A resident with bipolar disorder, dementia, and insomnia was prescribed multiple psychotropic medications, but staff failed to monitor and document side effects as ordered. The resident was repeatedly observed falling asleep during activities and meals, appearing unkempt, and showing signs of over-sedation, yet these observations were not recorded in the MAR. The DON confirmed that staff were not documenting the resident's condition, resulting in inadequate assessment for chemical restraint.
A resident with multiple mental health diagnoses had a PASRR Level II documented in the medical record, but the MDS assessment was incorrectly coded to indicate no PASRR Level II. The MDS Coordinator confirmed the error, which was identified through record review and staff interview.
A resident with dementia and major depressive disorder had a care plan that directed staff to identify triggers for aggressive behavior and use non-pharmacological interventions, but the plan did not specify what those triggers were. The DON confirmed that the resident becomes agitated by overstimulation, but this information was not included in the care plan, leaving staff without necessary guidance.
A resident with muscle weakness, difficulty walking, and a history of falls was assisted to a couch by a CNA. After the transfer, a nurse instructed the CNA to remove the resident's wheelchair from reach. The resident then attempted to self-transfer, lost balance, and fell, sustaining a head injury that required hospital evaluation. Staff statements indicated that removing the wheelchair contributed to the fall.
A resident with obstructive sleep apnea and muscle weakness did not receive prescribed CPAP therapy at bedtime because the machine was nonfunctional and not in use, with the mask found on the floor and the water chamber empty. The resident reported not using the CPAP for a month and instead used oxygen at night. The DON confirmed the CPAP had not worked for two weeks, and although the provider was notified and oxygen was used as an alternative, the order for the CPAP was not placed on hold and the care plan continued to reference its use.
Nursing staff were not adequately educated or competent in identifying and documenting residents' mood, behaviors, and side effects. Despite agendas indicating planned education sessions, there was no evidence that these trainings occurred or that specific content was covered. The DON acknowledged that staff were not consistently recognizing abnormal behaviors, and documentation lacked necessary details.
The facility did not have an RN on-site for 8 consecutive hours on three separate days, as confirmed by staffing records and the Administrator. This failure affected all residents during those days.
The facility failed to maintain accurate documentation in resident records, including inconsistent weight entries for a resident with dysphagia and vitamin D deficiency, and inaccurate recording of CPAP care for another resident with obstructive sleep apnea. Staff signed off on tasks that were not completed, and assessments reflected incorrect information, as confirmed by the DON and an LPN.
The QAPI committee did not take action to resolve systemic problems with inaccurate documentation of resident mood, behaviors, and side effects, despite being aware of the issue. This failure affected all residents in the facility.
During peri-care for a resident, two CNAs sanitized their hands and donned gloves before starting care. One CNA removed soiled gloves and donned new gloves without performing hand hygiene in between, contrary to CDC guidelines. Both CNAs performed hand hygiene only after completing care and removing gloves. Staff interviews confirmed the expectation for hand hygiene between glove changes.
Failure to Maintain Proper Food Temperatures and Palatability
Penalty
Summary
The deficiency involves the facility’s failure to provide food that was palatable and maintained at residents’ preferred and appropriate temperatures for all residents receiving facility-prepared meals. One resident reported that cold salads were served warm because they were placed on the hot food plate under a plate cover, and stated she preferred her salads cold and did not know why they were not served with cold beverages. Another resident refused a lunch tray when the surveyor observed that the cold salad had been placed on the hot food plate under the plate cover, while a cold fruit bowl and juice were placed next to the hot plate. Resident council minutes over several months documented repeated concerns that some foods expected to be hot were not served hot, some foods expected to be cold were not served cold, and that certain items such as mashed potatoes were watery. On a later observation of the serving line, two items (pureed chili macaroni and regular-diet green peas) required reheating before plating, and dietary staff stated the food had been on the serving line for 30 minutes and should not have lost temperature so quickly. A test tray taken from a hall tray cart showed hot items (chili macaroni casserole, peas, toast) and cold items (cantaloupe, apple juice, milk, salad) all outside appropriate temperature parameters. The registered dietitian acknowledged that small cold salads should be kept on the cold side and not placed on the hot plate, and agreed that the test tray temperatures were out of range. The dietary manager stated he did not know why the steam table was not maintaining proper temperatures and acknowledged that cold food items should not be placed on hot plates or under plate covers.
Failure to Ensure Proper Use of Beard Restraints in Food Preparation Area
Penalty
Summary
The facility failed to maintain a clean and sanitary food preparation environment when dietary staff with facial hair did not consistently use beard restraints in accordance with the FDA Food Code. On 1/5/26 at 11:49 AM, one staff member was observed plating residents’ food while wearing a beard guard around his neck rather than over his facial hair; upon making eye contact with the surveyor, he pulled the beard guard up over his chin and mouth with his gloved hands and continued plating food, without performing hand hygiene. On 1/6/26 at 11:58 AM, the same staff member was again observed plating residents’ food without wearing any beard guard. On 1/8/26 at 11:54 AM, the Dietary Manager stated that all staff with facial hair were required to wear beard guards and confirmed that this staff member had not been wearing one on 1/5/26 and 1/6/26 and had shaved his facial hair before work on 1/7/26. This deficient practice was cited under the requirement to procure, store, prepare, distribute, and serve food in accordance with professional standards and the FDA Food Code, which requires food employees to wear effective hair and beard restraints to prevent hair from contacting exposed food, clean equipment, utensils, and linens.
Failure to Notify State LTC Ombudsman of Resident Discharges and Transfers
Penalty
Summary
The facility failed to ensure the discharge process included required notification to the Office of the State LTC Ombudsman for four residents whose discharges or transfers were reviewed. For a resident with muscle weakness, dementia, and a history of falls who was transferred to the emergency department after a fall, the record showed a coordinated discharge with the receiving facility but lacked documentation that the Ombudsman was notified. Another resident admitted for post-surgical care and treatment of multiple abscesses was discharged home after meeting goals and no longer requiring skilled nursing care; her record documented a coordinated discharge but did not include any indication that the Ombudsman was informed. A resident with dementia, diabetes, and neuropathy was transferred to the emergency department for cellulitis of the right lower leg, and the record reflected coordination with the receiving hospital but no documentation of Ombudsman notification. Another resident with heart failure and COPD required transfers to the emergency department on two separate occasions for COPD exacerbations; in both instances, the records documented coordination with the receiving hospital but did not show that the Ombudsman was notified of either transfer. During an interview, the Administrator confirmed that the facility did not inform the Office of the State LTC Ombudsman of these residents' discharges.
Improperly Secured Schedule II Medications in Medication Refrigerator
Penalty
Summary
Surveyors identified a deficiency in the storage of Schedule II controlled substances when conducting a storage and labeling audit with LPN #1. During the audit, LPN #1 unlocked the medication refrigerator in the medication room, revealing a Schedule II drug compartment inside the refrigerator that was secured with a black lock attached to a drawer. Upon further inspection, the black lock detached from the drawer, leaving all Schedule II medications inside the compartment accessible rather than securely stored in a permanently affixed, locked compartment. LPN #1 confirmed that the compartment was not appropriately secured and stated that, to ensure the safety of Schedule II medications, the compartment should remain locked at all times. The report notes that this failure to ensure Schedule II controlled substances were stored in a permanently affixed, secured compartment created the potential for drug diversion and misappropriation.
Failure to Assess and Timely Complete UA for Resident With Ongoing Weakness and Mental Status Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the resident’s goals and preferences when a resident experienced a change in condition. The resident was admitted with multiple diagnoses including chronic respiratory failure, diabetes, dementia, depression, and muscle weakness. On 12/26, a doctor/nursing communication note documented ongoing dizziness and upper body weakness, with a provider indicating a follow-up would be scheduled. On 12/30, a physician’s history and physical note indicated a pending urinalysis related to dysuria and altered mental status. On 1/4, nursing documented increased weakness and difficulty with transfers and notified physical therapy for an evaluation. On 1/6, nursing documented the resident had a “tick,” dropping arms and head, and staff were directed to collect a urine specimen after the resident was found soiled, although she was usually continent. On 1/7, nursing documented that a UA and culture were collected and sent to a local laboratory, and later that day the lab faxed positive UA results indicating infection. The resident’s record did not include documentation of nursing assessment, vital signs, or UA collection related to her change in mental status and weakness between 12/30 and 1/6, despite these ongoing symptoms. Vital signs were only documented on 1/6 and 1/8. On 1/8, the resident’s POA called the facility expressing concern that the resident “isn’t right” and requested transfer to the ER, and the resident was transferred via non-emergent services. Hospital records from that day documented the resident was seen for weakness and dizziness lasting 1–2 weeks and was admitted with findings including weakness, expressive aphasia, stroke-like symptoms, acute kidney injury on chronic kidney insufficiency, hyperkalemia, and UTI. The DON stated that staff usually complete medical orders within 24 hours if a STAT order is not placed and did not provide a response when asked why the UA had not been completed around 12/30, and also stated that vitals are typically taken only every 30–60 days unless ordered otherwise.
Failure to Reassess and Effectively Manage Ongoing Pain
Penalty
Summary
The facility failed to provide effective pain management for a resident admitted with a right humerus fracture, head injury, and iron deficiency anemia. At admission, the care conference established goals to get the resident’s pain under control and to work with therapy, and a pain evaluation set the resident’s acceptable pain level at 4/10. Medication orders included scheduled Tylenol Extra Strength 500 mg, two tablets three times daily, and PRN oxycodone 5 mg every eight hours for severe pain. The MAR showed 17 administrations of oxycodone over the review period, with documented pain scores ranging from 6/10 to 10/10, all above the resident’s stated acceptable pain level. Physical therapy notes during the same period documented ongoing shoulder pain that created barriers to participation, with one entry describing the resident as very upset with 10/10 pain and emotional about wanting to improve mobility to return home. Another therapy note recorded increased pain while the resident was lying in bed and a request to nursing to administer pain medication. Observations found the resident guarding her right shoulder and reporting she was always in pain and could not recall a time since admission when her pain had been under control, and later stating she was in pain all the time during a medication pass. The DON stated she believed the resident’s pain was well managed based on PRN effectiveness, but upon review of the record did not identify documentation of reassessment or evaluation of the overall pain management plan despite repeated reports of pain levels above the resident’s acceptable goal.
Failure to Provide Ordered Iron Supplement Due to Medication Unavailability and Cart Transfer Error
Penalty
Summary
The facility failed to ensure a resident received a routinely ordered medication when a prescribed iron supplement was not available or administered as ordered. A resident admitted with multiple diagnoses, including a right humerus fracture and iron deficiency anemia, had a physician order for Ferrous Gluconate 324 mg by mouth once daily for supplementation. During a medication pass observation on 1/7/26 at 9:08 AM, the medication aide (MAC #1) preparing the resident’s medications reported that the Ferrous Gluconate was not available in the facility. At 9:10 AM, MAC #1 stated that the physician’s order had been in place since 12/24/25, but the medication had not been administered because it had not been available. On 1/8/26 at 12:38 PM, the DON reported that the facility had obtained the Ferrous Gluconate on 1/1/26, but after the resident was moved to a different room, the medication was not transferred to the new medication cart for nursing staff to administer, resulting in continued missed doses despite the medication being on site.
Inaccurate Transfer Documentation and Incomplete Behavior Intervention Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with muscle weakness, dementia, and a history of falls, the record documented an unwitnessed fall on 12/9/25 at 5:50 PM and included an INTERACT Hospital Transfer Form dated the same day. However, the vital signs recorded on that transfer form were dated 12/3/25, six days prior to the transfer, and therefore did not reflect the resident’s condition at the time of transfer. On 1/7/26, the ADON confirmed that the INTERACT Hospital Transfer Form contained inaccurate information because the vital signs were not current at the time of transfer. For another resident with muscle weakness, visual hallucinations, and dementia, a physician order dated 12/1/25 directed staff to document the number of episodes per shift of specific target behaviors, including exit seeking, hallucinations, delusional statements, and sexually inappropriate comments, and to implement and document specified interventions such as 1:1 conversation, providing activities of choice, assisting the resident to a quiet and calm location with a snack and alternate activities, and reapproaching at a different time. Review of this resident’s behavior monitoring records from 10/1/25 to 12/31/25 showed multiple documented behavior episodes on listed dates without corresponding documentation of the ordered interventions. When the surveyor requested documentation of interventions for those episodes, no additional documentation was provided. On 1/8/26, the DON stated that while the record accurately reflected the behaviors, it did not accurately reflect the interventions used at the time the behaviors occurred.
Infection Control Lapses in PPE Storage, Wound Care Setup, and Hand Hygiene
Penalty
Summary
The deficiency involves failures in infection prevention and control practices related to PPE storage, wound care supply handling, and hand hygiene. One resident with a stage 4 pressure ulcer, paraplegia, a suprapubic catheter, and chronic wounds had an Enhanced Barrier Precaution (EBP) gown stored unwrapped on top of personal linens in the closet, contrary to the care plan that required EBP, including gown and gloves, to reduce MDRO transmission during high-contact care. The Infection Preventionist later stated gowns are to be stored in their original plastic wrapping in the upper area of the resident’s closet and that this resident’s EBP gown should have been stored in a plastic bag. In a separate observation, the ADON prepared wound care supplies on top of a wound cart without sanitizing the cart surface and then placed the supplies on the back of a toilet in a resident’s room before moving them to a sanitized bedside table, later acknowledging a barrier should have been used between the wound care items and the surfaces. In another incident, a medication aide sanitized her hands before preparing medications, then carried the medications and water to a resident’s room, placed them on the bedside table, and applied gloves without performing hand hygiene immediately prior to glove application. The medication aide confirmed she should have performed hand hygiene before donning gloves.
Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents where one resident with dementia and psychotic disturbances physically assaulted three other residents. The facility's abuse policy requires that residents remain free from abuse, neglect, and corporal punishment, but records show that this was not upheld. In each case, the aggressor resident initiated physical altercations, including kicking and slapping, against other residents who had diagnoses such as dementia, muscle weakness, and major depressive disorder. These incidents were reported and investigated, with the aggressor consistently identified as the source of abuse. Despite care plans and physician orders directing staff to monitor the aggressive resident closely, document behaviors, and intervene as necessary, there were repeated failures to implement or document appropriate interventions. Behavior monitoring records indicated multiple episodes of physical aggression without corresponding interventions, and in some cases, incidents of aggression were not documented in the resident's record at all. Staff interviews confirmed that interventions were either not carried out or not documented, and that staff missed opportunities to intervene when the resident became agitated. The lack of consistent monitoring, failure to implement or document required interventions, and inadequate response to escalating behaviors directly contributed to the ongoing risk and occurrence of resident-to-resident abuse. The facility's inaction and insufficient documentation allowed the aggressive behaviors to persist, resulting in repeated physical altercations and a failure to ensure a safe environment for all residents involved.
Failure to Administer Bowel Care Medications per Physician Orders
Penalty
Summary
The facility failed to follow professional standards of practice for bowel and bladder care for five residents with physician orders for bowel management. Each resident had specific orders for the administration of medications such as Milk of Magnesia, Dulcolax suppositories, and Fleet Enemas to be given if a bowel movement did not occur within a specified timeframe. Despite documented periods of three or more days without a bowel movement, the medication administration records showed that these residents did not receive the prescribed interventions. For example, one resident with dementia and poor decision-making ability did not have a bowel movement for four days and was not given any bowel care medications as ordered. Another resident, who was cognitively intact, experienced constipation for up to six days and reported having to request bowel medications from nursing staff, rather than being proactively offered them according to the physician's orders. The Director of Nursing (DON) confirmed upon review that nursing staff should have tracked bowel movements and administered medications as ordered when residents had not had a bowel movement within the specified period. Similar deficiencies were observed for the other residents reviewed, including those with impaired decision-making and those requiring cues or supervision. In each case, the residents' bowel movement records indicated extended periods without a bowel movement, and the corresponding medication administration records showed that the prescribed bowel care interventions were not provided. Staff interviews and record reviews confirmed that the facility did not adhere to the physician's orders for bowel management for these residents.
Unsanitary Food Storage and Drinkware Maintenance
Penalty
Summary
The facility failed to store and maintain food and drinkware in a safe and sanitary manner, as observed during kitchen inspections. In the dry goods pantry, a large box of yellow onions was found with a green fuzzy substance on multiple onions, indicating spoilage. Additionally, a bread toaster on the kitchen counter was noted to have a thick layer of black encrusted particles, and several purple coffee cups stored in a clean cabinet were found with a layer of brown substance inside. These conditions were confirmed by staff interviews, with both the Dietitian and Kitchen Aid acknowledging the unsanitary state of the items.
Failure to Monitor and Document Effects of Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor and document the effects of psychotropic medications for a resident with multiple diagnoses, including bipolar disorder, dementia, and insomnia. Physician orders required staff to monitor for side effects such as over-sedation, lethargy, mental status changes, and changes in mobility. Despite these orders, there was no documentation in the resident's Medication Administration Record (MAR) regarding sedation or lethargy, even though the resident was observed multiple times falling asleep during activities, at meals, and while standing in her doorway. The resident also appeared unkempt and disheveled, with staff noting that her condition was not being documented. Observations included the resident falling asleep at a table during activities, at lunch after only a few bites, and while leaning on her doorway. The resident's care plan directed staff to monitor and report changes in cognitive function, but these changes were not documented. The Director of Nursing confirmed that staff were not documenting the resident's condition, making it unclear if medication adjustments were needed. This lack of monitoring and documentation resulted in the resident not being adequately assessed for potential chemical restraint or unnecessary medication use.
Inaccurate MDS Assessment Coding for PASRR Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for residents, as evidenced by the incorrect coding of a resident's PASRR (Preadmission Screening and Resident Review) status. Specifically, a resident with diagnoses including post-traumatic stress disorder, stimulant abuse, and panic disorder was found to have a PASRR Level II documented in the electronic medical record, but the annual MDS assessment incorrectly indicated that the resident did not have a PASRR Level II. This error was confirmed by the MDS Coordinator, who acknowledged that the assessment should have been coded to reflect the PASRR Level II status. This deficiency was identified through review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, and it was noted that such inaccuracies in assessment information could impact the monitoring and care of residents.
Care Plan Lacked Documentation of Behavioral Triggers
Penalty
Summary
The facility failed to ensure that care plans were revised according to residents' needs, as evidenced by the case of one resident with dementia and major depressive disorder. The resident's care plan, last revised on 11/14/24, instructed staff to investigate and identify potential triggers for aggressive behaviors and to use non-pharmacological interventions, as well as to keep the resident within line of sight due to aggressive tendencies. However, the care plan did not document specific triggers that led to the resident's aggression toward others. During an interview, the DON confirmed that the resident becomes agitated by overstimulation from loud sounds or excessive activity, and that the care plan did not include this information, leaving staff without guidance on identifying triggers for the resident's aggressive behaviors.
Failure to Provide Adequate Supervision Resulting in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with a history of muscle weakness, difficulty walking, and previous falls. The resident's care plan directed staff to keep personal items and assistive devices within reach. On the date of the incident, a CNA assisted the resident in transferring to a couch in the common area. After the transfer, the CNA placed the resident's wheelchair nearby, but a nurse instructed the CNA to remove the wheelchair and place it behind the couch to prevent the resident from attempting to self-transfer. Following the removal of the wheelchair, the resident attempted to self-transfer, lost balance, and fell, resulting in a head injury. The incident and accident report documented that the resident was 5-7 feet away from a transfer area at the time of the fall. Statements from two CNAs indicated that the removal of the wheelchair contributed to the fall. The resident sustained a goose egg on the right side of the head and was sent to the hospital for further evaluation.
Failure to Provide Prescribed Respiratory Care Due to Nonfunctional CPAP Machine
Penalty
Summary
The facility failed to provide necessary respiratory services for a resident with obstructive sleep apnea and muscle weakness. The resident had a physician's order for the use of a CPAP machine at bedtime, but the machine was observed to be nonfunctional and not in use, with the mask found on the floor and the water chamber empty. The resident reported not using the CPAP machine for a month due to it not working and instead used an oxygen cannula at night. The DON confirmed the CPAP machine had not worked for two weeks and that the provider was notified, resulting in the resident being placed on oxygen at night. However, the order for the CPAP machine was not placed on hold, and the care plan continued to reference its use, leading to a failure in following the prescribed respiratory care regimen.
Failure to Ensure Staff Competency in Identifying and Documenting Mood, Behaviors, and Side Effects
Penalty
Summary
The facility failed to ensure that nursing staff, including nurses and nurse aides, were properly educated and competent in identifying and documenting residents' mood, behaviors, and side effects. During a record review with the DON, it was revealed that concerns had been identified regarding incomplete or inaccurate documentation of these areas. Although agendas from several staff education sessions listed topics such as notifying nurses of behaviors and documenting behaviors and side effects, no proof of actual education or specific content covered was provided. The DON confirmed that staff were not consistently identifying abnormal behaviors, and the documentation reviewed did not reflect specific mood, behavior, or side effect information.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on-site for 8 consecutive hours each day, as required, for 3 out of 21 days reviewed. Specifically, on three identified dates, the facility did not provide the mandated RN coverage, as confirmed by a review of nursing staff hours and an interview with the Administrator. This deficiency was identified through record review and staff interview, and it affected all residents in the facility during the days in question. No specific residents or their medical conditions were mentioned in the report, and the deficiency was based on staffing records and administrative confirmation.
Inaccurate Documentation in Resident Medical Records and CPAP Care
Penalty
Summary
The facility failed to ensure that resident records contained accurate documentation for two residents. For one resident with multiple diagnoses including dysphagia and vitamin D deficiency, the medical record showed inconsistent and inaccurate weight entries over several months. A weight recorded on 5/13/25 was later crossed out as inaccurate, but this incorrect value was still used in both the Quarterly Nutritional Assessment and the Quarterly MDS assessment. The Director of Nursing confirmed that these assessments reflected the inaccurate weight. For another resident with obstructive sleep apnea, the care plan and physician orders required daily cleaning of the CPAP mask and weekly replacement of tubing. The Medication Administration Record (MAR) indicated that staff signed off on completing these tasks, but review showed that the order to assist with CPAP placement was not signed off as completed on multiple dates. An LPN stated she did not clean the CPAP machine, despite her credentials indicating otherwise, and the DON reported that the CPAP machine had not worked for two weeks, with no explanation for the inaccurate MAR documentation.
QAPI Committee Failed to Address Documentation Inaccuracies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) committee took effective action to identify and resolve systemic problems related to resident mood, behaviors, and side effects, as evidenced by inaccurate documentation of residents' current conditions. The QAPI plan required the committee to meet regularly, coordinate and evaluate QAPI activities, develop and implement corrective actions for identified deficiencies, and review and analyze data, including that from drug regimen reviews. Despite the Director of Nursing providing ongoing education to nursing staff on these topics, and the administrator acknowledging that the QAPI committee had identified documentation inaccuracies, the committee did not implement a Performance Improvement Plan (PIP) to address the issue. This deficiency affected all 49 residents in the facility.
Failure to Perform Hand Hygiene Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as observed during direct resident care. On one occasion, two CNAs entered a resident's room to provide peri-care. Both staff members sanitized their hands and donned gloves before beginning care. During the process, one CNA removed her soiled gloves, reached into her shirt pocket for a new pair, paused, and then obtained gloves from a box in the resident's bathroom. She donned the new gloves without performing hand hygiene between glove changes. The care was completed, and both CNAs performed hand hygiene only after removing their gloves and before leaving the room. Staff interview confirmed that hand hygiene should have been performed after removing dirty gloves and before donning new gloves, in accordance with CDC guidelines. The DON also stated that the expectation for direct care staff is to wash their hands between glove changes. The failure to follow these infection control protocols was observed and acknowledged by staff, indicating a lapse in adherence to established hand hygiene practices.
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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