Bear Lake Memorial Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Montpelier, Idaho.
- Location
- 164 South Fifth Street, Montpelier, Idaho 83254
- CMS Provider Number
- 135070
- Inspections on file
- 14
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Bear Lake Memorial Skilled Nursing Facility during CMS and state inspections, most recent first.
Surveyors found multiple food service deficiencies, including outdated spices, undated cooking oil, and frozen items without use-by or opened dates, as well as opened breakfast biscuits without dates and snack items stored on the floor. Refrigerator temperature logs showed repeated readings above the acceptable range with no documentation that these were reported, despite policy requirements. In the resident snack refrigerator, food containers lacked date labels even though posted instructions required both name and date, and the DNS confirmed this expectation. During a lunch meal, dietary staff handled chicken fried steak with gloved hands while cutting it, then touched a resident’s shoulder and continued plating and cutting food for multiple residents without changing gloves or performing hand hygiene, contrary to proper infection control practices acknowledged by the FSM.
A resident with dementia and diabetes was started on Sertraline 25 mg daily for depression without documented informed consent. Record review showed no psychotropic medication acknowledgement consent for the resident’s current use of Sertraline. During interviews, the LSW confirmed the absence of the consent form, and the MDS RN acknowledged that the resident should have signed a psychotropic medication acknowledgement consent prior to administration but did not.
Surveyors found that the facility did not ensure call lights were within reach for two residents, contrary to its call system policy requiring residents to have a means to summon staff from their bed and other locations. One resident with atrial fibrillation and hypertension was seated in a recliner on one side of the bed while the call light was on a nightstand on the opposite side, out of reach. Another resident with ESRD, diabetes, and a history of repeated falls was seated in a recliner on one side of the bed while the call light was pinned to a curtain on the opposite side, also out of reach. An LPN and the Administrator both acknowledged that call lights should have been within reach and were not in these cases.
The facility failed to maintain a properly functioning room door, resulting in a door that jammed halfway and did not fully open to allow safe entrance or exit. A resident with paranoid schizophrenia and chronic kidney disease reported the door had been in this condition since being assigned to the room, and a surveyor later confirmed the door became stuck when opened. The Administrator stated he was unaware the problem persisted, noting that maintenance had previously attempted to repair the door but the issue had recurred.
Surveyors found that the facility did not revise care plans to reflect current needs and interventions for two residents. One resident with chronic pulmonary edema and a right foot wound experienced multiple falls, including one from a recliner, and used an adaptive shoe and a recliner spacer, but these interventions were not added to the care plan despite documentation of the fall in the medical record. Another resident with paranoid schizophrenia and chronic kidney disease used a low bed position to assist with getting out of bed, but this intervention was not documented in the care plan. An MDS RN acknowledged that these care plans should have been updated and were not.
Surveyors found that staff failed to follow professional standards for bowel care for two residents who went more than 72 hours without a BM. One resident with psychosis and dementia had a 96-hour gap between documented BMs; although Docusate was ordered and given BID, there was no documentation that the physician was notified after 72 hours without a BM, and the MDS RN confirmed staff should have contacted the physician but did not. Another resident with atrial fibrillation and hypertension had an 87-hour gap between BMs, with PRN orders for Milk of Magnesia, Bisacodyl suppository, and Docusate for constipation, yet there was no documentation that any of these PRN bowel medications were administered during that period.
Surveyors found that staff failed to follow facility policy and professional standards for respiratory care. A resident with a history of transient cerebral ischemic attack and chronic kidney disease had a documented SpO2 of 82% on room air with no nursing interventions recorded. In addition, oxygen was observed flowing into PAP devices for two residents with conditions including diabetes, hallucinations, and a lower leg fracture while the PAP devices were turned off and not in use, contrary to the facility’s CPAP/BiPAP policy requiring oxygen to be connected only after the device is on and disconnected before it is turned off.
The facility did not maintain the required minimum of 8 consecutive hours of RN coverage on at least one reviewed day. Review of monthly staffing records showed that on one specific day there were only 4.75 hours of RN coverage. The Administrator confirmed this limited RN coverage, and the DNS was unable to identify any additional RN hours worked that day. This lapse in RN staffing was identified during review of several days of RN coverage and was determined to have the potential to affect all residents.
The facility failed to maintain required historical nurse staffing information for the mandated 18-month period. Daily nurse staffing was documented on a dry erase whiteboard, and the Administrator later provided only monthly staffing schedules that lacked required daily details such as the facility name, scheduled vs actual hours worked, and daily census. The Administrator acknowledged that daily staffing sheets were not maintained because information was kept on the whiteboard, and an MDS RN confirmed that the whiteboard was erased and updated each morning, preventing retention of the required daily staffing records.
Surveyors identified that controlled medications were not properly tracked on two medication carts, as required narcotic accountability sheets were missing one of the two licensed nurse signatures on multiple dates. An LPN and the DNS both confirmed that two nurses were supposed to sign the narcotic sheets when accepting or releasing the carts, but this did not occur as required. This documentation failure involved carts used for residents receiving controlled medications and created the potential for undetected misuse or diversion.
Surveyors found that medication carts were left unlocked and unattended, and expired medications were not removed. One med cart on a hall was observed unlocked while an LPN walked away to a resident room with no other nursing staff present, and the same cart was later seen unlocked in the nursing station area without licensed staff nearby. During an audit of another hall’s med cart with an LPN present, two expired bottles of Milk of Magnesia were discovered, along with white powder debris in a drawer, despite staff statements that carts should be locked when not in use, cleaned monthly, and cleared of expired meds.
Staff failed to follow infection prevention and control practices during food service and did not maintain current IPCP policies. During meal service, staff continued serving food without removing dirty gloves, performing hand hygiene, and redonning clean gloves, despite a facility policy requiring dietary staff to wash hands before work and when soiled. Separately, the IP and DNS acknowledged that IPCP policies lacked review or revision dates and had not been reviewed annually, and the facility could not provide documentation of required annual policy review, placing all residents at risk for contamination or infections.
The facility failed to maintain a safe and functional environment when a sharps container on one of two medication carts was allowed to become overfilled. Surveyors observed that the sharps container on the South Hall medication cart was filled past the full line and the flip-top lid could not move freely. An LPN acknowledged that the container should have been changed when full but was not, and the Administrator confirmed that sharps containers were expected to be changed when full, which had not occurred.
The facility failed to ensure a physician responded to a pharmacist's recommendations to review the use of prophylactic antibiotics for two residents with a history of UTIs. Both residents were prescribed Cephalexin for extended periods without justification. The pharmacist's recommendations in June 2024 were not addressed, and attempts to contact the prescribing physician were unsuccessful, potentially leading to adverse medication reactions.
The facility failed to ensure appropriate clinical indications for antibiotic use for two residents, leading to potential adverse drug reactions. One resident was prescribed Cephalexin prophylactically for over eight months without meeting UTI criteria, while another continued to receive Cephalexin for over four months despite a negative follow-up UA/CS. The DNS, ICP, and Pharmacist confirmed the inappropriate use of prophylactic antibiotics.
Food Storage, Labeling, Temperature Control, and Hand Hygiene Deficiencies in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, temperature control, and handling of food. During a kitchen tour, they observed outdated spices in dry storage and cooking areas, an undated squeeze bottle of cooking oil in the grilling area, and multiple bags of frozen breaded fish, tater tots, and French fries in the walk-in freezer without use-by or opened dates. In the dry storage area, two opened bags of breakfast biscuits lacked use-by dates, teriyaki sauce was stored past its use-by date, and three boxes of chips were stored directly on the floor. Review of the walk-in refrigerator temperature logs showed multiple recorded temperatures above 40°F on several dates, despite the log stating that temperatures must remain between 35°F and 41°F and that any out-of-range temperatures must be reported to a supervisor and maintenance with notation on the log. No such notations were present, and the Food Service Manager (FSM) acknowledged that outdated and non-dated food items should have been addressed and that elevated refrigerator temperatures should have been reported but were not. Surveyors also observed deficiencies in labeling of resident food items and in hand hygiene and glove use during meal service. In the resident snack refrigerator, two small containers of food were found, one labeled with a resident’s name but neither labeled with a date, despite a posted sign instructing that all items placed in the refrigerator must be labeled with a name and date. The Director of Nursing Services (DNS) confirmed that all items in the resident refrigerator should be dated but were not. During a lunch meal observation, dietary staff plated chicken fried steak by holding the meat on the plate with a gloved hand while cutting it into bite-size pieces with a pizza cutter, then delivered the plate to a resident, rubbed the resident’s shoulder, and returned to plating and cutting food for multiple residents without changing gloves or performing hand hygiene. The FSM later stated that after touching the resident’s shoulder, the staff member should have removed gloves, washed hands, and donned new gloves before continuing to serve food, but this did not occur.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to initiating a psychotropic medication for one resident. The resident was admitted with multiple diagnoses, including dementia and diabetes. On 1/21/26, a physician ordered Sertraline 25 mg once daily for depression. Record review showed there was no psychotropic medication acknowledgement consent on file for this resident’s current use of Sertraline. On 2/18/26 at 3:16 PM, the LSW confirmed there was no psychotropic medication acknowledgement consent for the resident, and at 3:18 PM, the MDS RN stated the resident should have signed a psychotropic medication acknowledgement consent prior to administration of Sertraline but had not. This lack of documented informed consent before starting the psychotropic medication constituted the identified deficiency.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
Surveyors determined the facility failed to ensure residents’ call lights were within reach, as required by the facility’s undated “Call System, Residents” policy, which states each resident must be provided a means to call staff directly for assistance from the bed, toileting/bathing areas, and from the floor. Resident #35, admitted with diagnoses including atrial fibrillation and high blood pressure, was observed on 2/17/26 at 10:27 AM sitting in a recliner placed on the left side of her bed while her call light was lying on the nightstand on the right side of the bed, out of her reach. At 10:30 AM, LPN #1 confirmed the call light should have been within Resident #35’s reach and was not. Resident #30, admitted with diagnoses including end stage renal disease, diabetes, and repeated falls, was observed on 2/17/26 at 1:25 PM sitting in a recliner on the right side of his bed while his call light was pinned to the room curtain on the left side of the bed, also out of his reach. At 1:42 PM, LPN #1 acknowledged that Resident #30’s call light should have been within reach and was not, and at 2:52 PM the Administrator likewise stated that resident call lights should be within residents’ reach and had not been in these instances. These findings, based on policy review, observation, record review, and staff interview, showed that for 2 of 12 residents reviewed for residents’ rights, the facility did not reasonably accommodate residents’ needs and preferences by ensuring their call lights were accessible.
Room Door Not Properly Functioning, Limiting Safe Entrance and Exit
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment by not maintaining a resident room door in proper working condition, resulting in a door that did not open correctly or fully to allow entrance or exit. Resident #23, who had been admitted with multiple diagnoses including paranoid schizophrenia and chronic kidney disease, reported that the door to his assigned room had been jammed since he was placed in that room. On 2/17/26 at 10:45 AM, a surveyor observed that the door to room [ROOM NUMBER] became jammed when opened only about halfway. On 2/18/26 at 1:15 PM, the Administrator stated he was unaware that the door to room [ROOM NUMBER] remained stuck, explaining that maintenance had previously attempted to repair the door and that the same issue must have recurred. This deficient practice was identified for 1 of 6 resident room doors observed and created the potential for diminished quality of life and psychosocial distress for residents when their room doors do not open correctly or fully to allow entrance or exit of the room.
Failure to Revise Care Plans to Reflect Current Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans to reflect residents’ current needs and interventions following changes in condition or care. For one resident with chronic pulmonary edema and an open right foot wound, the resident reported having fallen multiple times, with the most recent fall occurring when he slid off his recliner onto the floor. The medical record contained a progress note documenting the fall, and the resident stated the facility had provided him with a different recliner. However, review of the resident’s care plan showed no documented interventions related to the recent fall, no inclusion of the need for a spacer with the recliner, and no documented interventions related to the resident’s right adaptive shoe use. The MDS RN confirmed the care plan should have been revised to include these needs and had not been. A second resident, with diagnoses including paranoid schizophrenia and chronic kidney disease, was observed with his bed positioned very low to the ground, and he stated this made it easier for him to get out of bed. Review of this resident’s care plan showed that the use of a low bed position was not documented as an intervention. The MDS RN stated that the low bed position should have been included in the care plan and was not. The survey findings concluded that the facility did not ensure care plans were revised to reflect current needs and interventions for these residents, placing them at risk for adverse outcomes if care and services were not provided due to outdated care plans.
Failure to Follow Bowel Care Standards and Notify Physician After Prolonged Absence of Bowel Movements
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for bowel care by not contacting physicians when residents had no bowel movement (BM) for more than 72 hours. One resident with psychosis and dementia had a documented BM on 1/26/26 at 21:59 and not again until 1/30/26 at 21:53, a 96-hour interval. This resident had a physician’s order dated 10/1/25 for Docusate 100 mg orally twice daily for constipation, and the MAR showed it was administered twice daily throughout January 2026. However, there was no documentation in the medical record that the physician was contacted between 1/26/26 and 1/30/26 regarding the absence of a BM for over 72 hours. The MDS RN stated that nursing staff should have contacted the physician after 72 hours without a BM and had not done so. Another resident with atrial fibrillation and high blood pressure had a documented BM on 2/8/26 at 00:29 and not again until 2/12/26 at 15:05, an 87-hour interval. This resident had PRN orders for Milk of Magnesia 30 ml once daily by mouth for constipation, Bisacodyl 10 mg suppository rectally once daily if needed if Milk of Magnesia was not effective, and Docusate 100 mg orally twice daily as needed for constipation. Review of this resident’s medical record on 2/17/26 at 4:03 PM showed no documented administrations of any of the ordered bowel care medications between 2/8/26 and 2/12/26. These findings show that ordered bowel care interventions and physician notification parameters were not implemented or documented as required for two residents.
Failure to Follow Oxygen and PAP Device Protocols and Address Low SpO2
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services consistent with professional standards of practice and its own CPAP/BiPAP Support Level III policy. The policy directed staff to connect supplemental oxygen only after the CPAP machine was turned on and to disconnect oxygen before turning the CPAP machine off, and to adjust the flow rate as prescribed. For one resident with a history including transient cerebral ischemic attack and chronic kidney disease, the medical record showed an SpO2 of 82% on room air on a documented date, with no nursing interventions related to this low oxygen saturation recorded in the nursing notes. The MDS RN later stated that this low SpO2 level should have been addressed by nursing staff but was not. For two other residents with multiple diagnoses, including diabetes, hallucinations, and a lower right leg fracture, surveyors observed oxygen being bled into their PAP devices while the PAP devices were not turned on or in use. One resident’s oxygen was observed at 3 LPM and the other’s at 2 LPM under these conditions. In both cases, the MDS RN stated that the oxygen should have been turned off before the PAP device was turned off when the residents were done using the PAP devices, but this was not done. These observations and record reviews showed that staff did not follow the facility’s policy and professional standards for safe use of oxygen with PAP devices and did not document appropriate nursing response to a significantly low SpO2 reading.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, as required. During review of monthly scheduled staffing sheets from January 2025 through January 2026, surveyors identified that on 4/11/25 the facility did not have 8 consecutive hours of RN coverage. The Administrator confirmed that on that date the facility only had 4.75 hours of RN coverage. The DNS later stated she could not find any additional RN hours worked on 4/11/25 beyond the 4.75 hours already reported. This deficiency was based on record review of the facility’s monthly scheduled staffing sheets and staff interviews with the Administrator and DNS, and it was determined that this lapse in RN coverage occurred on 1 of 3 days reviewed for RN coverage, with the potential to affect all residents residing at the facility.
Failure to Maintain Required Historical Nurse Staffing Information
Penalty
Summary
The facility failed to maintain required nurse staffing information for 18 months after posting, as mandated. On 2/17/26 at 9:40 AM, surveyors observed the daily nurse staffing documented only on a dry erase whiteboard. Later that day at 4:10 PM, the Administrator provided monthly staffing scheduling sheets for the past 13 months, but these did not contain the required daily staffing details such as the facility name, scheduled versus actual hours worked, and the daily census. On 2/18/26 at 10:10 AM, the Administrator acknowledged the facility had not maintained 18 months of daily staffing sheets because the information was recorded on the dry erase whiteboard and not preserved. On 2/18/26 at 3:35 PM, the MDS RN confirmed that the daily whiteboard information was erased and replaced with new information each morning, resulting in the loss of historical daily staffing data. This failure had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who might wish to review the facility’s staffing levels, because the required historical daily staffing information was not retained as required.
Failure to Maintain Required Narcotic Accountability Signatures on Medication Carts
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications on both the South Hall and North Hall medication carts. During a medication cart audit on the South Hall, the narcotic accountability sheet covering 2/1/26 to 2/18/26 was missing one of the required licensed nurse signatures on four separate dates (2/2/26, 2/4/26, 2/8/26, and 2/17/26). During a similar audit on the North Hall, the narcotic accountability sheet for the same date range was missing one licensed nurse signature on 2/16/26. An LPN stated that two nurses were supposed to sign the narcotic accountability sheet when they accepted or released the medication cart, but this had not occurred on the identified dates. The DNS also confirmed that two nurses should have signed the narcotic accountability sheet when accepting or releasing the cart and acknowledged that this had not been done. The report states this failure created the potential for undetected misuse and/or diversion of controlled medications and could affect all residents receiving controlled medications in the facility. No specific residents, medical histories, or conditions were identified in the report; the deficiency was related to the facility’s process for narcotic accountability and documentation on the medication carts used for residents receiving controlled medications.
Unlocked Med Carts and Expired Medications Found During Audit
Penalty
Summary
The deficiency involves failure to ensure medications were secured in locked medication carts and that expired medications were removed from use. On entry to the facility, the North Hall medication cart was observed unlocked and unattended while an LPN walked away down the hall to a resident room, with no other nursing staff present around the cart. Later, the same medication cart in the nursing station area was again observed unlocked with no licensed nursing staff present, and the surveyor waited 10 minutes before encountering a CNA and requesting to speak with the MDS RN. The MDS RN stated that medication carts were to be locked when not in use and when no nursing staff were present, but this had not occurred. During an audit of the South Hall medication cart with an LPN present, two bottles of Milk of Magnesia were found with a manufacturer-printed expiration date of 10/25, and the LPN acknowledged these should have been discarded but had not been. The same audit revealed white, fine powder debris along the length of the back edge of the third drawer of the medication cart. The LPN stated that medication carts were cleaned monthly and should not have had debris in the drawers. The MDS RN also stated that expired medications should have been removed from the medication cart, but this had not been done.
Failure to Follow Hand Hygiene and Maintain Current IPCP Policies
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices during food service and in the management of infection control policies. Based on observation, staff did not remove soiled gloves, perform hand hygiene, and don clean gloves before continuing to serve food to residents, contrary to the facility’s undated Hand Washing policy that required dietary staff to wash hands before starting work and when hands were soiled. This practice had the potential to contaminate served food items and make residents ill. In addition, the facility failed to ensure current infection control standards of practice were implemented by not conducting at least an annual review of Infection Prevention and Control Program (IPCP) policies and procedures. During an interview, the Infection Preventionist (IP) presented IPCP policies that had no review or revision dates, and the facility could not provide documentation that these policies had been reviewed annually. The IP acknowledged that the IPCP policies had not been reviewed or revised annually and stated there were many such policies. The Director of Nursing Services (DNS) also confirmed that the IPCP policies had not been reviewed annually and that they should have been, placing all residents at risk for contamination or infections.
Overfilled Sharps Container on Medication Cart
Penalty
Summary
The facility failed to maintain a safe and functional environment when a sharps container on one of two medication carts was allowed to become overfilled. On two separate observations, the sharps container on the South Hall medication cart was noted to be filled past the indicated full line, and the flip-top lid was not freely movable. During an interview, a licensed practical nurse acknowledged that the sharps container should have been changed when it was full but had not been. In a separate interview, the Administrator also confirmed that the sharps containers were expected to be changed when full and that this had not occurred. This deficiency involved the medication cart area and sharps disposal system used by staff, with no specific residents identified in the report. The failure was noted by surveyors on multiple days and confirmed by both nursing and administrative staff as not meeting the facility’s own expectations for timely replacement of full sharps containers.
Failure to Address Pharmacist's Recommendations on Prophylactic Antibiotics
Penalty
Summary
The facility failed to ensure that the physician responded to the pharmacist's recommendations regarding the use of prophylactic antibiotics for two residents, R3 and R4, who were being reviewed for unnecessary medications. Both residents had a history of urinary tract infections (UTIs) and were prescribed Cephalexin, an antibiotic, for UTI prophylaxis. R3 had been taking the antibiotic for over eight months, while R4 had been on it for over four months. The pharmacist's monthly drug regimen review in June 2024 recommended that the physician review the necessity of these prophylactic antibiotics, but there was no evidence of a response from the physician. The Director of Nursing Services confirmed that the physician did not respond to the pharmacist's recommendations made in June 2024. Attempts to reach the prescribing physician were unsuccessful. This lack of response and action from the physician had the potential for both residents to experience adverse medication reactions due to the continued use of antibiotics without proper justification.
Inappropriate Antibiotic Use for Two Residents
Penalty
Summary
The facility failed to ensure appropriate clinical indications for the use of antibiotics for two residents, leading to potential adverse drug reactions. Resident 3 was admitted with a history of UTIs and was prescribed Cephalexin prophylactically without meeting the criteria for a UTI. Despite having no symptoms or signs of a UTI, the resident continued to receive the antibiotic for over eight months. The Director of Nursing Services (DNS) and the Infection Control Preventionist (ICP) confirmed that the resident did not meet the criteria for a UTI and that the antibiotic was prescribed without justification. Resident 4, also with a history of UTIs, was initially treated with Omnicef for a UTI based on a UA result. However, the treatment was changed to Cipro after consultation with the physician. A follow-up UA/CS showed no UTI, yet the resident continued to receive Cephalexin prophylactically for over four months without any signs or symptoms of a UTI. The DNS, ICP, and Pharmacist confirmed that the use of prophylactic antibiotics was not recommended and that the criteria for prescribing them were not met. The report highlights the facility's failure to adhere to its own policy and CDC guidelines on antibiotic stewardship, which emphasize the importance of appropriate antibiotic use to prevent resistance and adverse reactions. The facility's actions resulted in the unnecessary administration of antibiotics to both residents, despite the absence of clinical indications for their use.
Latest citations in Idaho
A resident admitted with a diagnosis of PTSD and severe cognitive deficits had an admission MDS and an Interim History and Physical documenting PTSD, but the Idaho PASRR Level I form incorrectly indicated no major mental illness, even though PTSD is listed on the form as a major mental illness. The SSD stated he reviewed hospital records and the chart but missed the PTSD diagnosis and did not mark it on the PASARR, contrary to facility expectations and policy requiring accurate pre-admission screening for serious mental disorders and appropriate follow-up evaluation when a Level I screen is positive.
A resident with COPD and dementia, receiving scheduled nebulizer treatments, was found on multiple occasions to have a nebulizer mask stored on top of the machine rather than in a sanitary manner. A CNA and a nurse aide in training confirmed the mask’s placement, and an LPN reported that masks were routinely cleaned, dried, and then stored on top of the machine. The DON later acknowledged that masks should be washed, dried, and placed on a clean surface, and facility policy required oxygen and respiratory supplies to be stored in a plastic bag when not in use.
Staff failed to consistently implement and follow Enhanced Barrier Precautions (EBP) during wound care for two residents. For a resident with an indwelling urinary catheter and an EBP order, an RN and a CNA removed their gowns after catheter care and performed a heel and toe dressing change wearing only gloves, despite a door sign requiring gown and gloves for wound care and other high-contact care. For another resident with multiple open leg wounds and active wound care orders, an RN and a nurse aide performed dressing changes with gloves only, without gowns, and there was no EBP signage or order in place. Interviews with nursing staff, the IP, and the DON revealed inconsistent understanding and application of the facility’s EBP policy, which requires gown and gloves for high-contact care activities, including wound care and device care, for residents with chronic wounds or indwelling devices.
A resident with diabetes, chronic kidney disease, and a history of breast cancer had previously received PPSV23 and PCV13 at the appropriate age, but review of the EMR and vaccine consent form showed the pneumococcal section was marked as "not needed" and no additional pneumococcal vaccine was offered. The ADON/IP acknowledged that, according to CDC guidelines, the resident was not fully vaccinated and should have been offered PCV20, and the DON stated her expectation that vaccine status be reviewed on admission and tracked to ensure residents are fully vaccinated.
Two residents who experienced emergent hospital transfers for issues including abnormal critical labs, uncontrollable pain, and SOB with low O2 saturation were not provided with required written bed-hold policies and transfer notices. One resident had severely impaired cognition, and another was cognitively intact and later died at the hospital. Progress notes documented the transfers and that contacts or family were notified, but there was no documentation that written notices addressing bed-hold, appeal rights, or ombudsman information were given, despite facility policies requiring such written information at admission and again at or shortly after transfer. The Administrator confirmed that bed-hold notices were not sent for these residents.
Two residents who required staff assistance with ADLs did not receive showers and hair washing as care-planned and expected. One resident with dementia and cervical spine conditions was observed with flaky skin and greasy hair, and the family’s shower calendar showed only four showers in a month despite an expectation of three per week, with no refusals documented in the record or care plan. Another cognitively intact resident with quadriplegia and spinal stenosis reported rarely receiving scheduled showers, and was observed with long, greasy hair, again with no refusals documented. The DON and Administrator acknowledged CNAs believed they could not provide baths without a dedicated bath team and historically had no room assignments, despite facility policy requiring provision and documentation of ADL care and refusals.
Surveyors found multiple expired medications, including various insulin products, Trulicity injection pens, and a large bottle of Gabapentin solution, stored in a medication room refrigerator and still available for use. The MDS coordinator confirmed the drugs were expired. The DON reported that no one had been specifically assigned to check the refrigerator for expired medications, while an LPN stated she only reviewed medication carts and did not check refrigerated stock. Facility policies required checking expiration/beyond-use dates before administration, dating multi-dose containers when opened, discarding them within specified time frames, and returning or destroying outdated medications, but these procedures were not followed for the medications in the refrigerator.
Surveyors found that the facility did not maintain sanitary conditions in the walk-in freezer and ice machine area. Ice buildup on freezer lines was encroaching on a box of burritos, and an ice scoop holder attached to the ice machine contained standing water with two scoops resting in it and no visible drainage. The Dietary Manager acknowledged the recurring ice buildup and reported that the standing water issue had not previously been raised. These practices did not follow the facility’s policies for food safety, storage, and ice machine preventative maintenance and had the potential to affect 46 residents who consumed food from the kitchen.
A resident with dementia, malnutrition, anemia, CKD3, and other comorbidities was care planned as at risk for nutritional decline and dehydration, with weekly weights and RD review ordered. An RD later documented poor PO intake averaging about 31%, fluid intake around 612 ml with meals, and no routine supplements in place, and recommended starting 2 oz Med Pass BID between meals with nursing to document consumption. No Med Pass order was entered into the EMR, and the resident did not receive the supplement, while experiencing a 10‑lb (6.8%) weight loss over several months. Interviews showed the RD typically communicated recommendations via email and NAR meetings, but NAR meetings had not been held consistently and no email or other system ensured the recommendation was received or implemented; requested policies on RD recommendations/supplement orders and weight loss were not provided.
A resident with multiple cardiopulmonary diagnoses received continuous O2 at 1.5 LPM via nasal cannula without a physician order or corresponding MAR documentation, despite the care plan and MDS indicating a need for and receipt of oxygen therapy. Surveyors observed the resident on oxygen on several occasions, initially without humidification and later with humidification. An LPN and the DON both confirmed at the bedside that the resident had been on oxygen since admission without a provider order, and that no monitoring was documented, contrary to facility policy requiring verification of a provider order before initiating or changing oxygen therapy.
Failure to Update PASARR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to ensure that a PASARR Level I screen was accurately completed and updated to reflect a major mental illness diagnosis for one resident. The resident’s admission MDS, with an ARD of 03/30/26, showed a diagnosis of Post-Traumatic Stress Disorder (PTSD) and a BIMS score of 3/15, indicating severe cognitive deficits. An Interim History and Physical dated 03/25/26 also documented PTSD as a diagnosis. However, the Idaho PASRR Level I form dated 03/19/26 indicated “No” under the section asking whether the individual had any major mental illnesses, despite PTSD being listed on the form as a qualifying major mental illness and despite the resident having that diagnosis. The Social Services Director reported that he reviewed hospital records and the resident’s chart to ensure that diagnoses on the admitting PASARR matched the resident’s conditions, and he confirmed the resident was admitted with PTSD. He acknowledged that he missed the PTSD diagnosis and that it should have been marked on the PASARR. During an interview, the DON and Administrator stated the expectation that all PASARRs be correct and that, if not correct at admission, a new PASARR should be submitted. The facility’s PASRR policy specified that potential admissions are to be screened for serious mental disorders or intellectual disabilities prior to admission and that a positive Level I screen requires a Level II evaluation by the state-designated authority prior to admission unless otherwise authorized.
Improper Storage of Nebulizer Mask and Respiratory Supplies
Penalty
Summary
Surveyors identified a deficiency in the sanitary storage of respiratory equipment for one resident receiving respiratory care. The resident was admitted with COPD and unspecified dementia and had care plan focuses for terminal prognosis due to COPD and shortness of breath, with interventions including administration of inhalers and nebulized medications as ordered. Physician orders included scheduled ipratropium-albuterol nebulizer treatments twice daily for COPD. During multiple observations in the resident’s shared room, the nebulizer mask was seen lying on top of the nebulizer machine rather than being stored in a sanitary manner. Staff interviews confirmed the observed storage practice. A CNA and a nurse aide in training each verified that the nebulizer mask was lying on top of the machine at the times of observation. An LPN stated that masks were cleaned after use, dried, and then stored on top of the machine, and acknowledged this could be an infection control issue. During a later observation, the LPN again confirmed the mask was on top of the machine. In an interview, the DON, with the Administrator present, stated the mask should be washed, dried, and placed on a clean surface and acknowledged it could be an infection control issue, and the facility’s written policy specified that oxygen and respiratory supplies were to be stored in a plastic bag when not in use.
Failure to Implement and Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use and implementation of Enhanced Barrier Precautions (EBP) during wound care. One resident with an indwelling urinary catheter had an active order and care plan for EBP, and a door sign specifying that gown and gloves were required for high-contact resident care activities, including wound care and device care. During an observation, an RN and a CNA entered this resident’s room, performed hand hygiene, donned gown and gloves, and completed catheter care in accordance with the posted EBP instructions. However, after completing catheter care, the RN instructed the CNA that they could remove their gowns because EBP was “only for the catheter,” and both staff removed their gowns and gloves, performed hand hygiene, and then donned only clean gloves to perform a dressing change on the resident’s right heel and pinky toe, despite the door sign indicating gown and gloves were required for wound care. A second resident had multiple open wounds on both lower extremities that required cleansing, application of collagen with wound gel and alginate, and coverage with border gauze dressings. Progress notes documented that these wounds originated as skin tears and were slowly healing, and active wound care orders were in place. During an observation of wound care for this resident, an RN and a nurse aide performed hand hygiene and donned gloves but did not wear gowns. There was no EBP sign or PPE set up outside the room, and there was no order for EBP in the electronic medical record, even though the resident had open wounds requiring dressing changes. In interviews, the RN stated that EBP was required for chronic wounds such as pressure, venous, and arterial wounds, and that EBP for the first resident applied only to catheter care. The CNA reported that she relied on the door sign and believed she only needed to gown for catheter care, brief care, or toileting, and not for transferring if she was not in contact with the catheter. The Infection Preventionist explained that EBP was used for chronic wounds and indwelling devices and stated that staff would only need to gown when providing care to the Foley catheter, while the DON stated that EBP was for residents with devices or dressing changes to prevent MDROs and that staff should wear gown and gloves even when not providing direct catheter care. The facility’s written EBP policy specified that EBP applies to residents with chronic wounds and/or indwelling medical devices and that PPE for EBP is necessary when performing high-contact care activities, including wound care and medical device care, which was not consistently followed in the observed wound care encounters.
Failure to Offer Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its pneumococcal vaccination policy for one resident. The resident was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and a history of malignant neoplasm of the breast, and was over the age threshold referenced in CDC guidance. Record review showed the resident had previously received PPSV23 on 06/07/04 and PCV13 (Prevnar 13) on 11/04/14, both administered when the resident was older than the specified age. The resident’s Informed Consent Form for vaccines, dated 09/17/25, had the pneumococcal section marked as “not needed,” despite documentation of prior PPSV23 and PCV13 doses. During interviews, the ADON/Infection Preventionist stated she tracks resident vaccine records on a spreadsheet and confirmed that, based on CDC recommendations, the resident was not fully vaccinated and should have been offered PCV20. She also stated she did not know why “not needed” was written on the consent form. The DON stated her expectation was that residents’ vaccine status would be reviewed on admission, tracked when due, and that the IP nurse would review pneumonia vaccine status to determine if residents were fully vaccinated and offer the vaccine if not. Review of the facility’s pneumococcal vaccination policy and the CDC Adult Immunization Schedule showed that, for adults who previously received both PCV13 and PPSV23 with PPSV23 given at age 65 or older, one dose of PCV20 or PCV21 should be considered at least five years after the last pneumococcal vaccine dose, indicating the resident met criteria to be offered an additional pneumococcal vaccine dose.
Failure to Provide Required Bed-Hold and Transfer Notices for Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold policies and transfer notices to two residents and/or their resident representatives when the residents were emergently transferred to the hospital. One resident had severely impaired cognition with a BIMS score of 3/15 and was transferred to the hospital due to abnormal critical lab results, then later returned to the facility. Documentation showed that the facility called the contact on file and a POA returned the call, but there was no documentation that a written transfer notice or bed-hold information was provided. The facility’s own policy required that written transfer/discharge notices include the reason for transfer, effective date, receiving location, a statement of the right to appeal, and contact information for the state LTC ombudsman and protection and advocacy agencies, as well as sending a copy to the ombudsman. A second resident, who had intact cognition with a BIMS score of 15/15, was transferred to the hospital on one occasion for uncontrollable pain and returned to the facility, and on another occasion for SOB, tremors in both arms, and oxygen saturation below 88%, after which the resident expired at the hospital. Progress notes documented the transfers and that the family was notified, but there was no documentation that written transfer notices or bed-hold policies were provided at either transfer. The facility’s bed-hold policy required that all residents or their representatives, regardless of payor source, receive written information about facility and state bed-hold policies twice: in advance of transfer (e.g., in the admission packet) and again at the time of transfer, or within 24 hours for emergency transfers. During an interview, the Administrator confirmed that bed-hold notices had not been sent for these two residents.
Failure to Provide Required Showering and Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide required assistance with showering and personal hygiene for two residents who were dependent on staff for ADLs. One resident was observed with flaky skin and greasy hair, and the resident’s family member reported the resident was supposed to receive three showers or baths per week but was “lucky to get one.” The family maintained a calendar showing the resident received only four showers in the month of April. The resident’s admission record showed diagnoses including traumatic spondylolisthesis of the cervical spine, unspecified dementia, and cervical spinal stenosis. The quarterly MDS documented moderate cognitive impairment with a BIMS score of 10 and a need for substantial/maximal assistance with showering/bathing, with no documentation of care refusals. The resident’s care plan identified an ADL self-care performance deficit related to impaired balance, limited mobility, limited ROM, and neck pain, and contained no documentation of rejection of care or a pattern of negative responses. A second resident was observed with waist-length hair that appeared greasy at the crown and in need of washing. This resident stated she was supposed to receive three showers or baths per week but was “lucky” to get one, and reported staff told her they were short-staffed and that there was no bath team. Her admission record listed diagnoses including quadriplegia at C5–C7, bipolar disorder, and spinal stenosis. Her quarterly MDS documented that she was cognitively intact with a BIMS score of 15 and required partial/moderate assistance for showering/bathing, with no documentation of refusing care. Her care plan identified an ADL self-care performance deficit related to incomplete quadriplegia and did not document any concerns with rejection of care for ADLs, including showering. The DON and Administrator acknowledged that CNAs believed they were short-staffed without a bath team and were unaccustomed to providing baths and grooming when the bath team was unavailable, and that previously there had been no CNA room assignments, resulting in a lack of accountability for residents’ care. The facility’s ADL policy required that residents unable to perform ADLs independently receive services necessary to maintain grooming and personal hygiene and that refusals be documented in the clinical record.
Expired Medications Not Removed From Medication Room Refrigerator
Penalty
Summary
Surveyors identified a failure to properly manage and discard expired medications stored in a medication room refrigerator. During an observation of the medication storage room refrigerator with the Minimum Data Set Coordinator, multiple expired medications were found, including one Lispro insulin vial and one Lantus insulin vial, both with expiration dates of 01/23/26 and no open dates on the vials. An Apidra Solostar insulin pen with an expiration date of 02/04/26, a Trulicity 3 mg/0.5 ml injection pen carton with two pens remaining and an expiration date of 01/16/26 with no open date on the carton, and a 500 ml bottle of Gabapentin solution with 450 ml remaining and an expiration date of 10/02/23 with no open date on the bottle were also present. These medications remained stored in the refrigerator and available for use despite being outdated. During interviews, the MDS Coordinator confirmed that the medications in the storage refrigerator were expired and stated that an LPN was responsible for monitoring medication expiration dates for medications stored there. The DON reported that she did not think anyone had been assigned to check the medication storage refrigerator for expired medications and acknowledged that expired medications should have been destroyed by staff or returned to the pharmacy. The LPN later stated that she reviewed all medication carts for expired medications but did not check the medications stored in the refrigerator. Review of facility policies showed requirements that expiration or beyond-use dates be checked prior to administration, that multi-dose containers be dated when opened and discarded within 28 days unless otherwise specified, and that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, which were not followed in this instance.
Unsanitary Walk-In Freezer and Ice Scoop Storage Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in food storage and ice handling areas. During an initial kitchen tour, the walk-in freezer was found to have ice buildup on the freezer lines that extended far enough to encroach on the upper stacked box of burritos. The Dietary Manager acknowledged during interview that this ice buildup had occurred before. At the end of the tour, inspection of the ice machine revealed an ice scoop holder mounted on the side of the machine containing two ice scoops, with approximately 20 milliliters of standing water in the bottom of the holder and the scoops in direct contact with the water, and no visible way for the water to drain. The Dietary Manager stated that no one had ever mentioned the standing water in the scoop holder before. These conditions were inconsistent with the facility’s written policies on food safety and storage and on ice machine preventative maintenance, which require that food and supplies be stored and handled to ensure safety and sanitation and that exterior surfaces, including the catch basin, be wiped down with a clean cloth and food-safe sanitizer. The deficiency had the potential to affect 46 residents who consumed food from the kitchen.
Failure to Implement RD Supplement Recommendation for Resident With Weight Loss
Penalty
Summary
The facility failed to implement a registered dietician’s (RD) recommendation to address gradual weight loss for one resident. The resident was admitted with dementia with behavioral disturbance, malnutrition, anemia, osteoporosis, B vitamin deficiency, history of alcohol abuse, peripheral vascular disease, hypertension, and stage 3 chronic kidney disease. Her care plan identified her as at risk for nutritional decline and dehydration or potential fluid deficit, with approaches including weekly weights, completion of a Mini Nutritional Assessment, provision of meals per physician diet order with intake documentation, and RD review as indicated. A quarterly MDS showed severely impaired cognition, risk for pressure ulcers, receipt of a therapeutic diet, and a need for set-up or clean-up assistance with eating. On a nutritional review, the RD documented that the resident’s average intake was about 31%, average fluid intake with meals was about 612 ml, and that there were no routine supplements in place, although the RD felt she would benefit from additional support. The RD recommended initiating 2 oz Med Pass BID between meals and directed nursing to document the amount consumed. However, there was no corresponding Med Pass order in the EMR, and the resident did not receive the supplement. The resident experienced a 10‑lb (6.8%) weight loss over four months, with a low of 128.4 lbs. Interviews revealed that the RD expected recommendations to be implemented within 48 hours and typically communicated them via email to nursing and through Nutrition At Risk (NAR) meetings, but there had been no consistent NAR meetings and no email or other system in place to ensure the RD’s recommendation for Med Pass was communicated and implemented. Requested policies on RD recommendations/supplement orders and weight loss were not provided before survey exit.
Oxygen Therapy Administered Without Physician Order or Documentation
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician’s order, in accordance with professional standards of practice and facility policy, before administering oxygen to a resident. The resident was admitted with diagnoses including pulmonary hypertension, malignant neoplasm of the cardia and lower third of the esophagus, abnormal lung findings, and chronic systolic congestive heart failure. The resident’s care plan documented a potential for altered respiratory status and the need for oxygen therapy via nasal cannula, and the admission MDS indicated the resident received oxygen while in the facility. However, review of the electronic medical record, including the Order Recap Report, MAR, and progress notes for the relevant period, revealed no physician order for oxygen and no documentation that oxygen was being administered or monitored. Surveyor observations on multiple dates showed the resident receiving oxygen via nasal cannula at 1.5 LPM, initially without humidification and later with humidification. During interviews at the bedside, an LPN confirmed the resident was receiving oxygen at 1.5 LPM, acknowledged there was no physician’s order for oxygen, and stated the resident had been on oxygen since admission, with no MAR documentation of monitoring. The DON also confirmed the resident was receiving oxygen at 1.5 LPM without a corresponding physician’s order and stated that an order should have been obtained before oxygen was administered. Review of the facility’s “Oxygen Administration, Safety, Storage & Maintenance” policy showed that staff were required to verify a provider order prior to initiating or changing oxygen therapy, which was not followed in this case.
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