Karcher Post Acute
Karcher Post Acute in Nampa, ID — inspection on November 7, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
shot up crooked towards the ceiling and she began to start blinking rapidly and trying to respond. I said that I was getting the nurse and that something was not right. I ran to get the nurse.The incident report included the records from Resident #50's hospitalization.
The emergency department physician documented patient with history of advanced dementia, comes from skilled nursing facility with possible convulsions.The hospital records documented a diagnosis of displaced left femoral neck fracture (break in the bone that connects the hip to the thigh where the fractured segment is moved out of position).The hospital records documented a reported episode of possible convulsion and no corroborating evidence of seizure event following computed tomography (CT) scan (a medical imaging procedure that uses X-rays and computer technology to create detailed, cross-sectional images of the inside of the body) of her head with no acute findings.On 11/7/25 at 1:13 PM, CNA #8 stated he provided a written statement to the facility of his observation during the incident on 7/12/25 with Resident #50. CNA #8 stated the DON said his statement was unacceptable and shredded his original statement. CNA #8 reported, the DON typed up a second statement minimizing the severity of the situation and made him sign it, and the second statement is the one in the investigation report. CNA #8 provided a copy of his original statement dated 7/12/25.
The original statement documented Numerous times for the morning of my work shift I was asked what the staff were supposed to do if [Resident #50] refused care. I stated we are to leave her alone and reapproach at another time.
While the day went on, this resident had refused about 5-6 different times, when lunch was approaching around noonish- [LPN #10] stated it was neglect and abuse to leave her [soiled] so [RNA #1] and I were going to try to reapproach her.
When we got to her room, the resident was already requesting to be left alone when [RNA #1] pulled her up from a laying position to sitting.
When [RNA #1] did that, [Resident #50] started to fight against [RNA #1] and was swinging at her. I asked if I could help and maybe change her just in bed and [RNA #1] said she was wet and had to get up. [RNA #1] was focused on getting her out of bed and she did not put shoes on [Resident #50].
When she sat her in the wheelchair, her head shot up, crooked toward the ceiling and she began to stutter and blink rapidly, still trying to respond. I said, I'm going to get the nurse, something isn't right.On 11/7/25, at 1:25 PM, CNA #8 stated, Resident #50 had been approached multiple times that morning and continuously refused to get out of bed and LPN #20 had directed him to let her rest. CNA #8 stated RNA #1 was trying to get her out of bed for restorative activities and he reminded her of their training the month prior, that Resident #50 should not be transferred if she is refusing or combative to avoid injury. CNA #8 stated he observed RNA #1 picking up Resident #50 under her arms, without footwear on, while she was yelling and striking RNA #1. CNA #8 reported he was shocked RNA #1 was picking up the resident, and brought the wheelchair closer to try to keep her safe.
CNA #8 stated, RNA #1 firmly placed Resident #50 into her wheelchair and he heard two snapping or cracking sounds. He stated, Resident #50 immediately threw her head back and began making full body jerking movements and yelling ow, 911 repeatedly through a garbled voice.On 11/7/25 at 1:48 PM, LPN #20 stated, I instructed the CNAs to leave [Resident #50] in bed if she wanted to rest, and [RNA #1] did not listen.On 11/7/25 at 3:14 PM, the DON stated the 2 CNAs involved did not report Resident #50 was transferred unsafely.
The DON was asked, did the CNA's follow the care plan for transferring?, she responded, yes, because [Resident #50] would always refuse and become combative no matter what you were approaching her with.On 11/7/25 at 3:44 PM, the Administrator stated he was not employed at the facility at the time of the incident. He added, it seemed like they were in a tough spot and there is a fine line between neglecting someone by leaving them soiled or abusing them by transferring them when they're refusing.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/07/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Karcher Post Acute
1127 Caldwell Boulevard Nampa, ID 83651
SUMMARY STATEMENT OF DEFICIENCIES
facility's Medication Error Report, dated 10/27/25, documented a medication error occurred on 10/27/25 when the day nurse failed to administer the morning dose of Lyrica 150 mg to Resident #6.On 11/7/25 at 12:47 AM, the DON confirmed on 10/20, 10/24, and 10/27, medication errors occurred involving Resident #6's Lyrica.4. Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including osteomyelitis (a bacterial infection of the bone), diabetes, and kidney failure.Resident #7's physician's orders, dated 10/9/25, documented, daptomycin (an antibiotic) intravenous solution reconstituted, 1250 mg intravenously in the morning every other day for infection related to osteomyelitis.The facility's Medication Error Report documented a medication error occurred on 10/19/25 when nurse administered ceftriaxone (an antibiotic) 1 gm intravenously instead of the ordered daptomycin.On 11/7/25 at 12:54 PM, the DON confirmed the nurse administered Resident #7 the wrong IV antibiotic on 10/19/25. 5. Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cerebral palsy (CP is caused by abnormal brain development or damage to the developing brain that affects a person's ability to control their muscles) and dysphasia (inability to use or understand language).Resident #8's physician's orders, dated 8/21/25, documented to give an enteral feed four times a day for nutritional needs, Vital AF 1.2 calorie nutrition formula - 250 ml, bolus feeds (a method of delivering nutrition directly into the stomach through a gastrostomy (G-tube) feeding tube using a large syringe and gravity.
The bolus method involves infusing a set amount of formula, similar to a single meal, over a short period of time).The facility's Medication Error Report documented a medication error occurred on 10/13/25 when Resident #8 was not administered his enteral feeding as ordered.On 11/7/25 at 12:56 PM, the DON confirmed Resident #8 was not administered his ordered tube feeding on the evening of 10/13/25 in error. 6. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD is a disease that causes airflow blockage and breathing related problems), diabetes, and opioid dependence.Resident #9's physician's order, dated 7/9/25, documented fentanyl transdermal patch 25 mcg/hour, apply one patch every 3 days for pain.
The facility's Medication Error Report documented a medication error occurred on 9/10/25 when Resident #9 was administered Fentanyl 37.5 mcg/hour transdermal patch.
The mistake was reported on the evening of 9/11/25 when it was noted the narcotic count was not correct.On 11/7/25 at 1:00 PM the DON confirmed Resident #9 was administered the wrong dose of Fentanyl on 9/10/25 and it was not discovered until 9/11/25. 7. Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including stroke and insomnia (a sleep disorder characterized by persistent difficulty falling or staying asleep).Resident #10's physician's order dated 7/18/25, was for zolpidem tartrate (Ambien) 10 mg, give 1 tablet by mouth at bedtime for insomnia.The facility's Medication Error Report documented a medication error occurred on 8/7/25 when Resident #10 was administered 20 mg of Ambien rather than the 10 mg ordered.On 11/7/25 at 1:02 PM the DON confirmed Resident #10 was administered double the ordered dose of Ambien on 8/7/25. 8. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses including respiratory failure, heart failure, and end of life care.Resident #11's physician's order, dated 7/18/25, documented an order for alprazolam (Xanax) 1 mg tablet, give 1 mg by mouth at bedtime for anxiety.Resident #11's physicians orders did not include an order for tramadol 50mg.The facility's Medication Error Report documented a medication error occurred on 7/22/25 when Resident #11 was administered another resident's tramadol 50 mg instead of the ordered Xanax.On 11/7/25 at 1:05 PM, the DON confirmed Resident #11 was administered another resident's tramadol by mistake.
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