Life Care Center of Idaho Falls: Wrong DNR Order - ID
The resident, identified in inspection records only as Resident 5, had chronic kidney disease and diabetes. Her code status was DNR. It was documented in her physician's orders. It was documented in her POST form, the Physician Orders for Scope of Treatment that travels with a patient and governs exactly these moments. It was documented in her care plan. Three separate places, the same instruction: do not resuscitate.
None of it mattered when LPN 1 entered the room.
A certified nursing assistant found Resident 5 unresponsive. Nursing staff were called. They assessed her and correctly determined she was a DNR. That part went right. Then LPN 1 arrived, holding a POST document, and announced that Resident 5 was a full code. CPR began.
The POST document LPN 1 was holding belonged to a different resident entirely.
Staff called 911. When the ambulance crew arrived, someone had sorted out the confusion — the inspection report does not say who, or how, or how long it took — and facility staff told the paramedics that Resident 5 was in fact a DNR. CPR was stopped. Time of death was called at 3:30 PM.
The facility's own investigation confirmed what happened. The admissions nurse and RN 1 told inspectors on September 2, 2025, that Resident 5 had been a DNR and that CPR should not have been started on her. The inspection report notes the statement was made at 2:05 PM that afternoon.
What the report does not explain is how a licensed practical nurse came to be holding another resident's POST document at the moment she entered a dying woman's room, or why she acted on it without checking the chart, the care plan, or the orders already in the room's system. It does not say whether LPN 1 knew the document she was holding had a different name on it, or whether she looked.
The violation was cited under the federal regulation requiring nursing homes to honor residents' self-determination, including their right to formulate an advance directive. CMS classified the harm level as minimal, a designation that reflects the regulatory framework's assessment of the deficiency's category, not a judgment that what happened to Resident 5 was minor. Inspectors noted the deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed.
The word "potential" is doing significant work in that sentence. Resident 5's wishes were not followed. CPR was performed on a woman who had specifically, formally, and repeatedly documented that she did not want CPR. She died during the incident. The harm was not potential.
A DNR order is among the most fundamental expressions of autonomy available to a nursing home resident. For people with serious chronic illnesses, the decision to forgo resuscitation is often made carefully, in consultation with physicians and family, and reflects considered judgment about what a person wants the end of their life to look like. Cardiopulmonary resuscitation is physically violent. Chest compressions break ribs. For a resident with chronic kidney disease and diabetes, the likelihood of meaningful recovery from a cardiac event is low. The DNR order exists precisely because the resident, or someone legally authorized to speak for her, decided that the violence of resuscitation was not what she wanted.
Life Care Center of Idaho Falls had that instruction in three places in her file. The system failed anyway.
The inspection report covers only a single resident, which is the nature of a complaint investigation rather than a full facility survey. Inspectors reviewed the records of one resident for code status compliance and found a violation in that one case. That does not mean the problem is isolated to one incident. It means inspectors looked at one case and found it.
The facility is located at 2725 East 17th Street in Idaho Falls. It is part of the Life Care Centers of America chain, one of the largest nursing home operators in the country. The inspection was conducted September 2, 2025, and was triggered by a complaint.
What the record shows is a specific, traceable chain of events. A CNA found a resident unresponsive. Nurses responded and correctly identified her code status. Then a different nurse arrived with the wrong paperwork and overrode the correct assessment. Nobody in the room stopped her. Nobody said, wait, let's check the chart. CPR started.
The ambulance crew arrived and the error was caught. Death was called.
There is no indication in the inspection report of what disciplinary action, if any, was taken against LPN 1. There is no indication of what changes, if any, were made to how the facility stores or accesses POST documents. The report states that the facility's plan of correction can be obtained by contacting the nursing home or the state survey agency, which is standard language that does not describe what the plan contains.
For nursing home residents and their families, a DNR order represents a promise. The resident signs the form, the physician signs the form, the facility acknowledges the form, and the understanding is that when the moment comes, the instruction will be followed. Life Care Center of Idaho Falls broke that promise for Resident 5.
She had chronic kidney disease and diabetes. She had been admitted, discharged, and readmitted. She had a POST form that said do not resuscitate. She had a physician's order that said do not resuscitate. She had a care plan that said do not resuscitate.
She was found unresponsive. A nurse walked in with the wrong piece of paper. And for however many minutes passed between the start of CPR and the arrival of the ambulance crew, her body was subjected to the intervention she had taken legal steps to refuse.
The inspection report does not name her. It does not say whether she had family present, or whether anyone who loved her witnessed what happened. It does not say what she looked like, or how long she had lived at the facility, or what she had wanted her final moments to be.
It says time of death was called at 3:30 PM, and that CPR should not have been started on her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Idaho Falls from 2025-09-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
Life Care Center of Idaho Falls in Idaho Falls, ID was cited for violations during a health inspection on September 2, 2025.
The resident, identified in inspection records only as Resident 5, had chronic kidney disease and diabetes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.