Madison Carriage Cove Short Stay Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Rexburg, Idaho.
- Location
- 410 West 1st North, Rexburg, Idaho 83440
- CMS Provider Number
- 135140
- Inspections on file
- 16
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Madison Carriage Cove Short Stay Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that kitchen staff did not follow required food safety standards for storage, labeling, and dating of food items. In the walk-in freezer, an open box of frozen French bread dough and an open bag of frozen chicken breast were not sealed or dated, and a loaf of sliced bread was found on the floor between the wall and shelving. In the walk-in refrigerator, a container of heavy cream was stored past its best-by date. These practices did not comply with FDA Food Code requirements or the facility’s food safety policy for inspecting, properly storing, labeling, dating, and covering food items.
The facility failed to maintain infection prevention and control practices in both food service and insulin administration. During meal service, the kitchen supervisor and dietary staff repeatedly moved between the tray line, storage areas, and resident meal delivery without performing required hand hygiene, and some staff had uncovered ponytails hanging out from under hats instead of using hairnets as required by policy. In a separate incident, a resident with diabetes receiving ordered subcutaneous insulin had the insulin syringe placed directly on the bed surface while the LPN cleaned the injection site, after which the same syringe was used for administration.
The facility did not complete a required PASARR Level I screening before admitting a resident with multiple medical diagnoses, including kidney failure and cancer. Facility policy required all applicants to have a PASARR Level I pre-screening for serious mental disorders or intellectual disabilities prior to admission, but the screening for this resident was not obtained until several days after admission. Record review confirmed the delay, and the ADON stated she had not requested or received the PASARR Level I before admission and only requested it later from the hospital.
A resident with chronic respiratory failure using CPAP and supplemental O2 did not receive respiratory care consistent with CPAP manufacturer guidelines. Surveyors observed the CPAP device turned off while O2 at 2 L/min continued to be bled into the device, and the required in-line pressure valve to prevent O2 backflow was not present. The Administrator acknowledged that the O2 should have been shut off when the CPAP was turned off but was not.
The facility did not maintain daily nurse staffing sheets for the required 18-month period. The DON reported that only staffing records from the time she started in August 2025 were available, and the Administrator could not account for missing staffing sheets from earlier months. This resulted in a lack of accessible historical nurse staffing information for residents, their representatives, and visitors who might request to review staffing levels.
Surveyors identified that controlled medications on one medication cart were not properly tracked when narcotic accountability sheets showed only one nurse signature on a specific date instead of the required two. An LPN and the DON both acknowledged that two nurses should sign the narcotic sheet when accepting or releasing the cart, but this did not occur, affecting all residents receiving controlled medications from that cart.
A resident with diabetes and anxiety had physician orders for Basaglar (insulin glargine) 15 units SQ and insulin lispro per sliding scale. An LPN was observed preparing the glargine insulin pen by dialing it directly to 15 units and administering it without first priming the pen with 2 units, contrary to facility expectations. The LPN later acknowledged that she did not prime the pen on that occasion and only sometimes primed insulin pens before use, while the DON confirmed that insulin pens should be primed with 2 units prior to administering the ordered dose.
Surveyors found that the facility did not follow its own policy for destruction and removal of unused and expired medications. During a medication cart audit, an LPN had a bottle of Gas Relief on the cart that was past its manufacturer expiration date and acknowledged it should have been discarded. In a medication storage room audit, an LPN had two tubes of barrier cream, each bearing prescription labels for residents who had already been discharged, still kept among supplies available for resident use. The DON confirmed that expired and unused medications should have been removed from the cart and storage room but were not.
A resident with multiple diagnoses, including surgical aftercare and septicemia, experienced multiple falls due to inadequate supervision and lack of updated fall interventions. The resident, who had a wound vacuum and Foley catheter, suffered significant injuries, including a hip fracture and brain bleed, after tripping on medical tubing and falling out of bed. The facility failed to update the care plan with new interventions after each incident.
The facility failed to properly store, label, and serve food according to professional standards, as observed during an inspection. Unlabeled and undated food items were found in the walk-in refrigerator and freezer, and expired spices were noted in the dry storage area. The CFM acknowledged these issues, which posed a risk of contamination and adverse health outcomes for residents.
A facility failed to assess a resident for the ability to safely self-administer medications, as required by policy. The resident, with multiple diagnoses including metabolic encephalopathy, was using a pain pump with hydromorphone and bupivacaine. Despite care plan and physician orders allowing self-administration, no assessment was conducted, creating potential for adverse effects.
The facility failed to assist residents in formulating advance directives, leading to incomplete or conflicting documentation for three residents. One resident had inconsistent resuscitation status documents, while two others lacked documentation of advance directives or assistance offered by the facility. The CCO acknowledged these deficiencies.
A facility failed to provide necessary health information to a hospital during the transfer of a resident with respiratory failure and hypercapnia. Despite the facility's policy requiring detailed medical information to be sent, the resident's records lacked documentation of such information during two hospital transfers due to changes in condition. This deficiency was confirmed by the ADON.
The facility failed to provide bed hold notices to two residents upon their transfer to the hospital, as required by policy. One resident was transferred twice due to changes in condition, and another was transferred three times due to medical issues, with no documentation of bed hold notices provided. The ADON confirmed the lack of documentation, indicating non-compliance with the facility's policy.
A facility failed to develop and review a baseline care plan with a resident who was admitted with multiple diagnoses, including osteomyelitis and PTSD. The facility's policy required the care plan to be completed and reviewed within 48 hours of admission, but there was no documentation that this was done. The CCO confirmed the oversight.
The facility failed to complete, review, and update comprehensive care plans for residents, leading to potential risks. A resident's care plan was not reviewed within the required timeframe, another's care plan was not updated to reflect a change in medication dosage, and a third resident's care plan was not updated with new fall interventions after multiple falls. These deficiencies were confirmed by facility staff.
The facility failed to ensure proper labeling, dating, and storage of medications. Loose pills were found in a medication cart, and a Tubersol solution vial lacked an opened date. The emergency narcotic kit was not permanently affixed, and a medication cart was left unlocked without a nurse present, contrary to facility policy.
The facility failed to maintain infection control practices during meal service and resident care. A dietary aide did not assist or encourage hand hygiene before meals, and two CNAs did not follow hand hygiene protocols during catheter care for a resident with hemiplegia and kidney failure. Additionally, staff did not wear PPE gowns during a resident transfer, contrary to the care plan requirements.
A facility failed to maintain an effective Antibiotic Stewardship Program, as evidenced by a resident's prescription for erythromycin eye ointment lacking a specified duration or end date. The Infection Preventionist was not notified of the antibiotic order, leading to the oversight. This failure to adhere to the facility's policy and CDC guidelines could result in unnecessary antibiotic use.
The facility failed to follow professional standards of practice for insulin administration for a resident with type 2 diabetes mellitus. The resident had multiple low blood glucose readings, but the hypoglycemic protocol was not followed, and the physician was not notified as required.
The facility failed to ensure expired medications and wound care supplies were not available for administration to residents. Expired items were found in both the south and north side medication storage rooms, including normal saline, Hibiclens, Solosite Hydrogel, Preparation H suppositories, Fiber Good gummies, a Glucagon emergency kit, lubricating gel, Bacitracin, nighttime cold & flu medicine, and nicotine gum. The LPNs present verified the expiration dates and acknowledged the oversight.
Improper Food Storage, Labeling, and Dating in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and dating of food items, contrary to FDA Food Code 2022 and the facility’s own Food Safety Requirements policy. The FDA Food Code requires refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours to be clearly date-marked and used or discarded within seven days at 41°F or less. The facility’s policy required staff to inspect all food upon delivery for safe transport and quality, ensure timely and proper storage, label and date refrigerated foods (including leftovers) so they are used by their use-by date or frozen/discarded, and keep foods covered or in tight containers. During an early morning kitchen tour with the Food Service Manager (FSM), surveyors observed multiple violations. In the walk-in freezer, there was an open box of frozen French bread dough that was not covered, sealed, or dated, and an open bag of frozen chicken breast that was not sealed or dated. Additionally, a loaf of sliced bread in a bag was found lying on the floor between the wall and shelving. In the walk-in refrigerator, surveyors found a container of heavy cream with a best-by date that had already passed. The FSM acknowledged that the bread must have fallen from the shelf, that the French bread and chicken breast should have been sealed and dated, and that the heavy cream had been recently ordered without noticing its expired best-by date.
Infection Control Failures in Dietary Services and Insulin Administration
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices in both the dietary department and during insulin administration. Facility policies required dietary employees to perform hand hygiene before food preparation, when changing tasks, after contact with unsanitary items or body parts, and as often as necessary to prevent cross contamination, as well as to wear hairnets when cooking, preparing, or assembling food. During a meal service observation, the Kitchen Supervisor left the tray line to enter the walk-in refrigerator and dry storage areas and then returned to continue prepping plates without performing hand hygiene. A dietary aide pureed resident food items without performing hand hygiene, and another dietary aide prepped plates, left the kitchen to deliver trays, and returned to prep more plates without washing hands. The Food Service Manager and a dietary aide had their hair pulled back in ponytails under baseball-type hats, with the ponytails hanging out and not restrained by hairnets. The Kitchen Supervisor later stated he was probably not seen washing his hands as much as he should have because one of the handwashing sinks was out of order, and the Food Service Manager stated she believed hairnets were not required if staff wore hats and that handwashing was only needed when hands were visibly dirty and when changing tasks. The deficiency also includes improper infection control practices during insulin administration to a resident with diabetes and anxiety. The resident had physician orders for subcutaneous insulin glargine and insulin lispro per sliding scale. During an observation, an LPN placed a syringe containing insulin glargine on the resident’s bed next to the resident while cleaning the injection site, then picked up the syringe from the bed and administered the insulin. The LPN later acknowledged she should not have placed the insulin syringe on the resident’s bed. The Infection Preventionist stated that the LPN should have placed resident medications on a protective cover on top of the bedside table rather than in the bed.
Failure to Obtain PASARR Level I Screening Prior to Admission
Penalty
Summary
The facility failed to ensure completion of a Pre-admission Screening and Resident Review (PASARR) Level I prior to admitting a resident, as required by its policy and state Medicaid rules. The facility’s policy dated 12/24/25 stated that all applicants would be screened for serious mental disorders or intellectual disabilities through a PASARR Level I pre-screening completed before admission. One resident, identified as Resident #32, was admitted with multiple diagnoses including kidney failure and cancer, but the PASARR Level I, dated 12/16/25, was not received by the facility until four days after the resident’s admission. Record review on 1/28/26 confirmed the PASARR I was not on file at the time of admission, and during an interview, the ADON acknowledged she had not requested or received the PASARR I prior to admission and only realized it was missing on 12/16/25, at which time she requested it from the hospital. This failure created the potential for harm if residents required but did not receive specialized services for mental health while residing in the facility.
Failure to Follow CPAP Manufacturer Guidelines for Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with CPAP manufacturer warning guidelines and professional standards of practice for one resident whose respiratory equipment was observed. The CPAP manufacturer’s warnings specified that oxygen supports combustion and should not be used while smoking or near open flame, that when using supplemental oxygen with the CPAP the device must be turned on before the oxygen is turned on and the oxygen must be turned off before the device is turned off to prevent oxygen accumulation in the device, and that a specific pressure valve must be placed in-line between the device and the oxygen source to prevent backflow of oxygen into the device when it is off. The manufacturer’s explanation stated that if oxygen flow is left on while the device is not operating, oxygen may accumulate within the device enclosure, creating a risk of fire, and that failure to use the pressure valve could result in a fire hazard. The resident involved had multiple diagnoses, including a left femur fracture and chronic respiratory failure with hypoxia. On observation in the resident’s room, the CPAP machine was turned off while supplemental oxygen at 2 L/min was still turned on and being bled into the CPAP device, contrary to the manufacturer’s instructions. A subsequent observation with the Administrator confirmed that the resident’s supplemental oxygen continued to be bled into the CPAP while the CPAP was not turned on, and that the required Respironics pressure valve was not installed in the circuit between the device and the oxygen source. The Administrator stated that the oxygen in the resident’s room should have been shut off when the CPAP was turned off and was not.
Failure to Maintain Required Daily Nurse Staffing Records
Penalty
Summary
The facility failed to maintain daily nurse staffing sheets for the required minimum of 18 months. During the survey, the DON reported that she only had access to daily staffing sheets dating back to when she began employment in August 2025. The Administrator stated he was unsure what happened to the daily staffing sheets covering the period from January 2025 through July 2025. This failure affected the facility’s ability to provide historical nurse staffing information for that seven-month period to residents, their representatives, visitors, or others who wished to review the facility’s staffing levels.
Failure to Maintain Dual-Nurse Narcotic Accountability on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications on one of two medication carts reviewed. During an audit of the North Hall medication cart, narcotic accountability sheets dated from 1/1/26 to 1/27/26 were observed with only one licensed nurse signature documented for 1/21/26, instead of the required two signatures. An LPN stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart, and the DON confirmed that two nurses were expected to sign the narcotic accountability sheet at those times. This deficiency involved the process for documenting controlled medication accountability rather than a specific resident, and it affected all residents who received controlled medications in the facility, as the lack of dual signatures meant controlled medications on that cart were not properly tracked for that date.
Failure to Properly Prime Insulin Pen Before Administration
Penalty
Summary
Surveyors identified a deficiency in medication preparation and administration involving insulin for Resident #2. The resident, who had multiple diagnoses including diabetes and anxiety, had physician orders for Basaglar (insulin glargine) 15 units subcutaneously and insulin lispro per sliding scale. On 1/27/26 at 8:27 AM, an LPN was observed removing the glargine insulin pen from the medication cart and dialing it directly to 15 units without first priming the pen with 2 units, as required. At 8:32 AM, the LPN administered the unprimed glargine insulin dose to the resident. At 8:37 AM, the LPN acknowledged she had not primed the insulin pen on that occasion and stated she only sometimes primed the pen before administration. On 1/28/26 at 4:18 PM, the DON confirmed that insulin pens should be primed with 2 units prior to administering the ordered insulin dosage. This failure to consistently prime the insulin pen before dialing and administering the ordered dose resulted in the resident not being ensured freedom from significant medication preparation and administration errors and placed the resident at risk for not receiving the prescribed medication dosage and other adverse outcomes, as stated in the report.
Failure to Remove Expired and Unused Medications From Storage and Use Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of medications, including failure to ensure medications were properly stored, not expired, and appropriately disposed of when unused. The facility’s policy titled “Destruction of Unused Drugs” dated 12/29/25 stated that unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. During a medication cart audit on 1/28/26 at 8:52 AM on the South Hall with an LPN present, surveyors observed one bottle of Gas Relief on the cart with a manufacturer expiration date of 7/25 printed on the bottle, and the LPN acknowledged the bottle should have been discarded and had not been. Later that day at 2:01 PM, during an audit of the North Hall medication storage room with another LPN present, surveyors observed one tube of barrier cream labeled for a resident discharged on 10/3/25 and another tube of barrier cream labeled for a resident discharged on 11/18/25 among available supplies for resident use. At 4:38 PM, the DON stated that expired and unused medications should have been removed from the medication cart and storage room and had not been, confirming the failure to follow the facility’s medication storage and disposal policy. No specific medical histories or current clinical conditions of the residents for whom the labeled barrier creams were prescribed are provided in the report.
Failure to Implement Fall Interventions Leads to Resident Harm
Penalty
Summary
The facility failed to ensure adequate supervision and implement necessary interventions to prevent falls for a resident, resulting in harm. The resident, who had multiple diagnoses including surgical aftercare and septicemia, returned from the hospital with a wound vacuum and a Foley catheter. On one occasion, the resident was found on the floor after apparently tripping on the tubing of the wound vacuum or Foley catheter while attempting to get out of bed. This incident led to a right hip fracture, subdural hematoma, and UTI. Despite the fall, the resident's care plan was not updated with new fall interventions. Subsequent incidents occurred where the resident rolled out of bed and sustained an abrasion, and later was found disoriented and confused on the floor with a skin tear and bruising. The resident was again transferred to the hospital with a traumatic subarachnoid hemorrhage and UTI. The Director of Nursing acknowledged that new fall interventions were not implemented after these incidents, and the care plan was not updated accordingly, highlighting a failure in the facility's responsibility to provide adequate supervision and prevent accidents.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food storage, labeling, and serving standards as outlined in the Idaho Food Code and the facility's own Food Safety Requirements policy. During an inspection, several deficiencies were observed in the kitchen area, including unlabeled and undated containers of tomato juice, lemonade, shredded cheese, and lunch meat in the walk-in refrigerator. Additionally, a bag of ham was improperly stored on top of an open bag of lettuce, and a tray of sliced tomato, onion, and pickles was undated. In the walk-in freezer, a large bag of cubed carrots was found open to the air and not sealed correctly. Expired onion and garlic powder were also found in the dry food storage area. Further observations revealed a bag of lettuce in the refrigerator that was not sealed correctly, and in the grill area, a liquid butter alternative container and a squirt bottle were not dated or labeled. The Certified Food Manager (CFM) acknowledged these issues, stating that the opened, non-dated food items should have been dated and sealed correctly, and the bag of meat should not have been stored on top of the lettuce. These practices placed residents at risk for potential contamination and adverse health outcomes, including food-borne illnesses.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for their ability to safely self-administer medications, as required by their policy. This deficiency was identified during a review of Resident #13, who was admitted with multiple diagnoses including metabolic encephalopathy, pneumonia, and a UTI. The facility's policy, dated 12/16/24, mandates that an interdisciplinary team assess and determine if self-administration of medication is clinically appropriate for a resident, with results recorded on the Medication Self-Administration Safety Evaluation. However, Resident #13 did not have such an assessment completed. Resident #13's care plan and physician orders included instructions for the use of a pain pump with hydromorphone and bupivacaine for pain management, allowing the resident to self-administer doses under certain conditions. Despite these instructions, the Chief Clinical Officer (CCO) confirmed that no assessment had been conducted to determine if Resident #13 was safe to self-administer medication. This oversight created the potential for adverse effects if the resident self-administered medications inappropriately.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advance directive. This deficiency was identified for three residents whose records were reviewed. Resident #7's medical record contained conflicting documents regarding their resuscitation status, with some documents indicating a full code status and others indicating a Do Not Resuscitate (DNR) status. This inconsistency was acknowledged by the facility's chief clinical officer, who stated that the documents were confusing and needed clarification. For Residents #185 and #186, the facility did not document whether they had advance directives, whether the facility offered assistance in formulating one, or if the residents declined to formulate an advance directive. The care plan conference documents for these residents were incomplete, with sections regarding advance directives left blank. The chief clinical officer confirmed that the advance directives should have been completed for these residents, indicating a lapse in the facility's adherence to its policy on supporting residents' rights to formulate advance directives.
Failure to Provide Pertinent Health Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that pertinent health information was provided to the receiving hospital during the transfer of a resident. The facility's Transfer and Discharge policy requires that specific information, such as contact information of the resident's practitioner, resident representative information, advance directives, and all necessary medical details, be provided to the receiving provider. However, for Resident #14, who was transferred to the hospital on two occasions due to changes in condition, there was no documentation in the medical record indicating that this information was sent to the hospital. Resident #14, who had multiple diagnoses including respiratory failure and hypercapnia, was initially admitted to the facility and later readmitted. On two separate occasions, the resident was transferred to the hospital due to a change in condition, specifically weakness and lethargy. Despite the facility's policy, the medical records did not contain documentation of the pertinent medical information that should have been provided to the hospital, as confirmed by the Assistant Director of Nursing (ADON). This lack of documentation could potentially result in adverse outcomes if the resident was not treated in a timely manner due to missing information.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives upon transfer to the hospital, as required by their policy. This deficiency was identified for two residents who were reviewed for transfers. The facility's policy, dated 12/2/24, mandates that written information regarding bed hold policies be provided prior to transferring a resident to the hospital. However, for Resident #14, who was transferred to the hospital on two occasions due to changes in condition, there was no documentation of a bed hold notice being provided. Similarly, Resident #24, who was transferred to the hospital on three separate occasions due to medical issues, also did not have documentation of a bed hold notice being provided. The absence of bed hold notices for these residents was confirmed through staff interviews. The Assistant Director of Nursing (ADON) acknowledged the lack of documentation for both residents, indicating that the facility did not adhere to its policy. This oversight created the potential for harm, as residents were not informed of their right to return to their former bed or room within a specified time frame, as outlined in the facility's policy.
Failure to Implement Baseline Care Plan
Penalty
Summary
The facility failed to develop, review with the resident, and implement a baseline care plan for one of the residents whose care plans were reviewed. This deficiency was identified for a resident who was admitted and later readmitted with multiple diagnoses, including osteomyelitis of the vertebra, sacral and sacrococcygeal region, chronic post-traumatic stress disorder, and nutritional deficiency. The facility's policy required that the baseline care plan be completed within 48 hours of admission, reviewed with the resident or their representative, and a copy provided to them. However, there was no documentation in the resident's medical record indicating that the baseline care plan had been reviewed with or given to the resident or their representative. The Chief Clinical Officer confirmed that the baseline care plan should have been completed and shared with the resident but was not.
Failure to Update and Review Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were completed, reviewed, and updated for residents, as required. For Resident #7, there was no documentation that the comprehensive care plan had been reviewed with the resident or their representative within 21 days of admission, as confirmed by the Chief Clinical Officer (CCO). Resident #13's care plan was not revised to reflect an updated physician order that increased the dosage of hydromorphone and bupivacaine, which was a deviation from the documented care plan dated 9/24/24. Resident #24 experienced multiple falls resulting in serious injuries, including a right hip fracture and a traumatic subarachnoid hemorrhage. Despite these incidents, the care plan was not updated with new fall interventions after each fall, as acknowledged by the Director of Nursing (DON). These deficiencies in care planning placed residents at risk of adverse outcomes due to the lack of timely updates and reviews of their care plans in response to changes in their conditions.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of medications, as observed during an inspection of the south side medication cart and medication room. In the medication cart, two small white pills and one oval white pill were found loose in the second drawer, with the RN present unable to identify them. The ADON later confirmed that the medication carts are cleaned weekly, and the pills should not have been loose. Additionally, a Tubersol solution vial in the medication refrigerator lacked an opened date, which was confirmed by the RN and acknowledged by the ADON as a failure to follow proper dating procedures. Further inspection revealed that the emergency narcotic kit in the medication storage refrigerator was not permanently affixed, contrary to the facility's policy for storing Schedule II controlled medications. The ADON admitted to being unaware of the requirement for the narcotic box to be permanently affixed. Additionally, the south medication cart was found unlocked with no nurse present, which was acknowledged by RN #2, who stated the cart should have been locked. The DON confirmed that nursing staff are required to lock medication carts when not in attendance.
Infection Control Deficiencies in Meal Service and Resident Care
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as observed during meal service and resident care activities. During breakfast service, a dietary aide did not assist or encourage residents to perform hand hygiene before meals, despite the facility's policy requiring such actions. This oversight was acknowledged by the dietary aide, who admitted to not offering hand hygiene assistance to the residents. In another instance, two CNAs provided catheter care to a resident with multiple diagnoses, including hemiplegia and kidney failure, without adhering to proper hand hygiene protocols. The CNAs failed to perform hand hygiene between glove changes and placed soiled linens on the floor, contrary to the facility's policies. Additionally, the CNAs did not change the resident's bed linens despite visible contamination. Furthermore, during a transfer using a Hoyer lift, the CNAs and an occupational therapist did not wear PPE gowns as required by the resident's care plan for high-contact activities, which was later confirmed as a lapse by the staff involved.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (IPCP) that included a functional Antibiotic Stewardship Program. This deficiency was identified during a review of the medical records of a resident who was prescribed erythromycin eye ointment. The prescription lacked a specified duration or end date for use, which is a requirement under the facility's Antibiotic Stewardship Program policy. The policy mandates that all antibiotic prescriptions specify the dose, duration, and indications for use, and the McGeer Criteria may be used to determine whether to treat an infection with antibiotics. The issue was further compounded by the Infection Preventionist (IP) not being notified of the antibiotic order through the electronic medical records system, which is the usual protocol. As a result, the lack of a duration date for the erythromycin prescription was not identified and addressed. This oversight had the potential to lead to the unnecessary use of antibiotics, as the facility's policy and CDC guidelines emphasize the importance of monitoring antibiotic use to ensure compliance with prescribing policies.
Failure to Follow Hypoglycemic Protocol for Insulin Administration
Penalty
Summary
The facility failed to follow professional standards of practice for insulin administration for a resident with type 2 diabetes mellitus. The resident had multiple low blood glucose readings on three separate occasions, but the hypoglycemic protocol was not followed. Specifically, the resident's blood glucose levels were recorded as 58 mg/dL, 52 mg/dL, and 67 mg/dL on different days, but there was no documentation of follow-up blood glucose checks or notification of the resident's physician as required by the facility's hypoglycemia management policy. During an interview with the Director of Nursing (DON) and the Clinical Resource Nurse (CRN), it was confirmed that the resident's physician was not notified, and the hypoglycemic protocol was not adhered to on the specified dates. This failure to follow the protocol created the potential for harm to the resident, as adverse outcomes from low blood sugar were not properly managed according to the established guidelines.
Expired Medications and Supplies Found in Storage Rooms
Penalty
Summary
The facility failed to ensure expired medications and wound care supplies were not available for administration to residents. During an inspection of the south side medication storage room, several expired items were found, including five bottles of normal saline, one bottle of Hibiclens, two tubes of Solosite Hydrogel, and one box of Preparation H suppositories. The LPN present verified the expiration dates and acknowledged that these items should not have been available for use. The DON stated that nurses were responsible for checking the dates of medications and wound care supplies before use and disposing of expired supplies. In the north side medication storage room, additional expired items were discovered, including 30 bottles of Hibiclens, Fiber Good gummies, another box of Preparation H suppositories, a Glucagon emergency kit, a tray of lubricating gel, a tray of Bacitracin, a bottle of nighttime cold & flu medicine, and a box of nicotine gum. The LPN present was unsure whose responsibility it was to check for expired medications and mentioned that the pharmacy randomly checked the medication room and carts for expired items. The facility's failure to remove expired medications and wound care supplies from the storage rooms was evident.
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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