Bennett Hills Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gooding, Idaho.
- Location
- 1220 Montana Street, Gooding, Idaho 83330
- CMS Provider Number
- 135134
- Inspections on file
- 20
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Bennett Hills Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including dependence on renal dialysis and diabetes, was injured during van transport when their wheelchair fell backwards inside the vehicle. Facility policy required four tie-down mechanisms to be properly secured and locked to the floor fixtures, and staff were expected to operate vehicles safely to prevent injuries. An investigation found that the transport driver did not correctly secure the wheelchair straps or latch the front wheels, causing the straps to come loose and the wheelchair to tip backward, resulting in the resident striking their head and back and reporting neck pain. No mechanical issues were found with the van, and the incident was attributed to improper securement by staff.
The facility failed to maintain a clean, safe, and homelike environment in multiple resident rooms, shower rooms, and common areas. Surveyors observed shower rooms with broken and missing tiles, jagged holes, dark residue in grout, and hair and brown matter in drains. A resident’s dinner tray with food remained on the bed the next morning, and several rooms had wall damage, exposed metal bars near a commode, missing bathroom doors, and vents coated with thick gray buildup. The dining room and hall ceilings had cobwebs and dirty vents, and the kitchen ceiling, pipes, and vents were covered with thick, gray, fuzzy material. Staff, including the Maintenance Supervisor and Administrator, acknowledged that these areas should have been repaired or cleaned and that some surfaces were not included in the cleaning schedule.
The facility failed to meet PASARR requirements for residents with mental health conditions. A resident with schizophrenia remained beyond a 30-day rehabilitation exemption without the facility submitting the required updated MDS, MD orders, social notes, and psych notes to the mental health authority. Another resident with COPD and Bipolar II disorder had a Level I PASARR identifying bipolar disorder, but the facility did not request a Level II PASARR. For a third resident with diabetes and dementia, the Level I and Level II PASARRs documented depression, anxiety, delusional disorder, REM sleep behavior disorder, and use of Haldol and Depakote, yet these diagnoses and medications were not reflected anywhere in the medical record or physician orders. The DON acknowledged that the PASARR information for this resident was incorrect and that the required submissions and Level II request for the other two residents had not been completed.
Two residents did not receive care according to physician orders and professional standards. One resident with a history of fracture and schizophrenia had albuterol and fluticasone inhalers kept at the bedside, which staff reportedly allowed due to delays in reaching the room, despite no physician order or self-administration assessment documented in the record. Another resident with a blood clot and depression was found with ordered Sage boots off and placed on a chair, even though the medical record required bilateral use at all times with refusals documented, and there was no record of refusal on the day observed; both an LPN and the DON acknowledged the boots should have been in use.
Surveyors identified multiple failures in medication storage and control, including unsecured bedside medications and improperly stored controlled drugs. One resident with a history of blood clots and depression had zinc oxide and antifungal cream left at the bedside without an IDT self-administration assessment or a physician order to keep medications at the bedside. Another resident with CHF and diabetes had Biofreeze cream at the bedside, which staff applied, but there was no provider order or care plan for its use, and the ADON reported the family likely supplied it. Additionally, Lorazepam nasal spray, a Schedule IV controlled medication, was found in clear plastic cups on a medication refrigerator shelf instead of in a separately locked, permanently affixed compartment, and a medication cart on one hall was observed left unattended, unlocked, with a drawer open.
A resident with chronic kidney disease and chronic atrial fibrillation was observed lying in bed with the call light plugged into the wall and hanging under the head of the bed, out of reach, and the resident could not independently access it. An RN and the RCN each acknowledged that the call light should have been within the resident’s reach and that it was not, resulting in a failure to reasonably accommodate the resident’s needs and preferences.
A resident with multiple diagnoses, including a right femur fracture and schizophrenia, was not properly identified for PASRR Level II evaluation because the schizophrenia diagnosis was omitted from the Level I PASRR. Review of records showed the Level I PASRR did not list the schizophrenia diagnosis despite its established onset, and the DON acknowledged it should have been documented. As a result, the required referral for further evaluation by the state-designated authority for major mental illness, intellectual disability, or related conditions was not made.
Surveyors identified that the facility did not develop and revise comprehensive care plans in a timely and complete manner for two residents. One resident with COPD and Bipolar II disorder had a current care plan missing interventions for cognition, ADL self-care deficits, fall risk, nutrition, pressure ulcer risk, and pain, and ongoing issues from a prior care plan were not carried forward. Another resident with diabetes and dementia did not have a comprehensive care plan completed and signed within the required timeframe after admission. The DON acknowledged that these care plans were not completed in a timely manner, placing residents at risk of adverse outcomes when care plans were not updated as needs changed.
Two residents with orders for continuous oxygen therapy did not receive respiratory care as prescribed. One resident with a history of fracture and schizophrenia had an order for continuous oxygen at 3 L/min via NC but was repeatedly observed not wearing oxygen, while staff acknowledged he should have been using it as ordered. Another resident with COPD and respiratory failure had an order for continuous oxygen at 4 L/min via NC but was observed on multiple occasions with the concentrator set at 2.5 L/min; staff confirmed the setting did not match the physician’s order.
The facility did not follow its policy requiring two licensed nurses to reconcile and sign for controlled medications at each shift change on one medication cart. During a medication cart audit, surveyors found multiple narcotic audit shift count sheets with only one nurse signature for several shift counts. An LPN and the DON both confirmed that two nurses were required to sign when accepting or releasing the medication cart, but this had not occurred. This lapse in documentation and reconciliation affected controlled medications for residents receiving these drugs.
The facility failed to document the code status in the care plans of six residents, despite physician orders indicating their resuscitation preferences. This omission involved residents with conditions like respiratory failure, diabetes, and dementia, whose care plans did not reflect their full code or DNR statuses, including specific treatment preferences. The DON confirmed the lack of documentation.
The facility did not adhere to its policy of conducting pre-employment background checks for new hires. A nursing assistant was hired without a documented background check, which was only completed six months after the hire date. This oversight had the potential to increase the risk of harm to residents.
A resident with dementia and cognitive communication deficit was verbally abused by a CNA, which was overheard by another CNA. The incident was reported, and the abusive CNA was removed from the situation. This failure to adhere to the facility's abuse prevention policy resulted in a deficiency in protecting the resident from verbal abuse.
A facility failed to document a resident's cancer diagnosis on the comprehensive MDS assessment, despite the resident's care plan indicating a potential psychosocial issue related to the diagnosis. The DON and MDS Resource Nurse confirmed the omission.
The facility failed to post accurate daily nurse staffing information as required, with blank entries found for specific dates. This lapse in maintaining complete staffing records could affect residents, their representatives, and visitors seeking to review staffing levels.
The facility failed to ensure proper labeling, dating, and storage of medications. During audits, loose pills were found in the medication carts of both the East Hall and Skilled Hall. A CMA and an LPN confirmed that the pills should not have been loose and should have been destroyed. The DON stated that the responsibility for destroying the loose pills lay with the nurses or medication aides.
The facility failed to properly store and label food products, with issues such as expired items and lack of date marking, as well as improper meal tray coverage during delivery. These deficiencies could impact all residents by increasing the risk of consuming spoiled or contaminated food.
The facility failed to maintain a safe and clean environment, with overfilled sharps containers and mold-like substances in shower rooms. The DON admitted the absence of policies for housekeeping and sharps containers, acknowledging that showers should have been cleaned after each use and sharps containers changed when full.
The facility failed to ensure the Dietary Manager had the required competencies and certification. The DM, who started in January 2024, did not have prior experience or certification and planned to begin the CDM course in August 2024. The Administrator acknowledged the DM did not meet the necessary requirements, potentially affecting the meal satisfaction of all 52 residents.
The facility failed to monitor dish machine temperatures and sanitizer concentrations, and did not label or date food in the residents' refrigerator, placing 52 residents at risk for foodborne illness. Observations revealed inadequate rinse temperatures, ineffective sanitizing solutions, and unlabeled food items. Staff were unaware of the required procedures.
The facility failed to ensure waste was properly contained, leading to potential pest infestation. Observations revealed a large dumpster with open, bent lids and regular garbage bags mixed with cardboard. Smaller garbage cans were also found with lids open or overflowing. The Maintenance Director and Administrator acknowledged the issue and the need for lid replacement.
The facility failed to ensure a safe, homelike environment, with missing floor tiles, dirty vents, and a hole in the wall observed in two shower rooms and a hallway. The Maintenance Supervisor acknowledged these issues as unsafe and not providing a clean environment.
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential negative outcomes. One resident's care plan lacked details on using a Hoyer lift for transfers, another resident's self-administration of nasal spray was not documented, a third resident's wound care interventions were missing, and a fourth resident's preference to sleep in a recliner was not included.
The facility failed to ensure controlled medications were properly tracked and secured, as evidenced by multiple blank signature lines on narcotic accountability records. An LPN and the DON confirmed that nurses should have signed the narcotic book after counting narcotics with another nurse, but this was not consistently done, creating the potential for undetected misuse and/or diversion of controlled medications.
The facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received an incorrect dose of Heparin instead of a saline flush, while another resident self-administered nasal spray incorrectly and received an insufficient dose of Sertraline. These errors indicate lapses in following prescribed medication regimens and facility policies.
The facility failed to provide residents with nourishing, palatable, well-balanced meals that met their dietary needs and preferences. Several residents reported not receiving the food items or quantities they selected, leading to dissatisfaction and hunger. The Dietary Manager and Registered Dietitian acknowledged the issues, and the Administrator was aware but no corrective actions were mentioned.
The facility failed to provide nutritionally comparable and sufficient alternate meals to residents, leading to dissatisfaction and decreased meal intake. Residents expressed concerns about the limited and repetitive nature of the alternate menu options, which were primarily limited to tuna fish sandwiches or chicken patty sandwiches with chips. The Dietary Manager confirmed the lack of variety, and the Registered Dietitian stated that there should have been planned alternates for vegetables, starch, and protein, which were not provided.
The facility failed to respect and maintain the dignity of residents who required assistance with their meals. Residents needing feeding assistance were consistently served last, leading to extended waiting periods for their meals and beverages. Staff referred to these residents as 'feeders,' a term acknowledged as undignified by the DM, LPN, DON, and Administrator.
A resident reported missing money on two occasions to the Social Services Representative, who admitted to forgetting to fill out a grievance form and failing to investigate the issue. The facility's policy required prompt investigation and response to grievances, which was not followed in this case.
The facility failed to assess a seatbelt used by a resident with congestive heart failure and COPD as a potential restraint. The resident's record lacked documentation of an assessment, and the DON and PT Director confirmed this oversight.
A resident with multiple diagnoses was transferred to the ER without documented evidence that necessary information was provided to the receiving hospital, as required by facility policy. The DON claimed that various documents were sent, but there was no documentation to confirm this.
The facility failed to notify the ombudsman of a resident's transfer to the hospital. The resident, with multiple diagnoses including depression and congestive heart failure, experienced a decline in condition and was sent to the ER. The Social Services Representative was unaware of the requirement to inform the ombudsman.
The facility failed to follow professional nursing standards for three residents, leading to potential risks for wound infection, adverse outcomes from medication refusal, and unmanaged hyperglycemia. An LPN did not label a wound dressing, a resident's repeated refusal of a Nicotine Patch was not properly documented or communicated to the physician, and another resident's high blood glucose levels were not reported as required.
A resident with COPD and other diagnoses did not receive the prescribed 3 liters of oxygen continuously via nasal cannula. Instead, the oxygen concentrator was set at 2 liters, and even when checked, it was found to be set at 2 and a half liters. The DON confirmed the resident required oxygen at the specified concentration.
The facility failed to ensure medications were properly labeled and not expired. During audits, expired Top Care eye drops and Loperamide were found, along with an unlabeled Albuterol Sulfate inhaler. Staff confirmed these medications should have been removed or properly stored.
A facility failed to ensure accurate medical records for a resident with end-stage renal disease, missing documentation for 12 dialysis sessions over two and a half months. Staff interviews confirmed that the resident's refusals to attend dialysis were not recorded in the EMR, violating the facility's policy.
The facility failed to maintain proper infection control practices, including improper handling of an oxygen cannula, lack of hand hygiene before meals, and failure to use required PPE during wound care. These actions placed residents at risk for cross-contamination and infection.
The facility failed to ensure that a resident who consented to the pneumococcal vaccine received it. The resident had multiple diagnoses and had previously received the PPSV23 vaccine. Despite consenting to receive the PCV20 vaccine, there was no documentation of its administration in her record, as confirmed by the DON.
Resident Injury Due to Improper Wheelchair Securement During Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and that adequate supervision and safety measures were provided during transportation. The facility’s Transportation Policy/Procedure required staff to insert the four tie-down mechanisms to the floor fixtures and ensure they were secured and locked in. The Fleet Safety Program manual stated that employees are expected to operate vehicles safely to prevent accidents that may result in injuries and property loss. Resident #8, who had multiple diagnoses including dependence on renal dialysis and diabetes, was being transported back from dialysis when the incident occurred. According to the facility’s investigation, on 12/27/25 at 8:12 AM, the resident fell backwards in his wheelchair while in the facility van, striking his head and back on the back door of the van and reporting neck pain afterward. The facility’s investigation determined that the straps had not been connected correctly to the resident’s wheelchair and had come loose during transport, causing the wheelchair to fall backwards. The van was inspected by the Maintenance Supervisor on the same day, and no mechanical issues or concerns were found. The Administrator stated that the driver did not latch the front wheels of the resident’s wheelchair as required, and the facility substantiated that the failure to properly secure the wheelchair before transport resulted in injury to the resident.
Failure to Maintain Clean, Safe, and Homelike Environment Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Safe, Homelike Environment policy dated October 2007. Surveyors observed multiple shower rooms with cleanliness and maintenance issues, including black hair and dark residue in shower drains, broken and missing tiles with jagged-edged holes, cracks in tiles, dark residue in grout, and small round holes in shower stall walls. In one resident room, a prior night’s dinner tray with dishes and a full bowl of vegetables was left sitting on the resident’s bed the following morning. Additional observations included missing floor tiles and dark black residue debris between shower floor tiles in another shower room, and a shower drain with brown formed matter and dark strands of hair in a different hall’s shower room. Surveyors also observed disrepair and unclean conditions in resident rooms and common areas. One bathroom had two metal bars sticking out of the wall near the commode, a bathroom door with a missing 3 x 2 inch piece of wood by the hinges, and a vent with a thick gray substance. Another room had a hole on the outside of the bathroom door, and a separate room had two large holes in the wall and no bathroom door; the resident in that room stated the holes and lack of bathroom door had been present since moving in. In the dining room, vents and ceiling areas had thick gray substances and long cobwebs, and vents on the east hall ceiling also had a gray substance. In the kitchen, the ceiling, pipes, and vents were observed with a thick, gray, fuzzy substance. The Maintenance Supervisor and Administrator acknowledged that tiles, vents, doors, and other areas should have been repaired or cleaned and that certain areas were not included in existing cleaning schedules.
Failure to Complete and Reconcile PASARR Evaluations for Residents With Mental Health Conditions
Penalty
Summary
The deficiency involves the facility’s failure to comply with PASARR requirements for residents with possible mental disorders or intellectual disabilities. One resident with a diagnosis of schizophrenia was admitted under a Level II PASRR that granted a 30-day rehabilitation exemption and directed staff that, if the resident remained beyond 30 days, the facility must submit the most current MDS, MD orders, social notes, and psychiatric notes to the state mental health authority (BLTC). Record review showed no documentation that any additional information was submitted after the 30-day exemption expired. Another resident with chronic obstructive pulmonary disease and Bipolar II disorder had a Level I PASRR that identified bipolar disorder, but the facility did not request the required Level II PASRR. A third resident, admitted with diagnoses including diabetes and dementia, had a Level I PASRR that documented depressive and anxiety disorders, delusional disorder, REM sleep behavior disorder, and the use of Haldol and Depakote for mental health treatment. Based on this information, a Level II PASRR was requested and completed, reiterating these mental health diagnoses and medications. However, the resident’s medical record did not list depressive and anxiety disorders, delusional disorder, or REM sleep behavior disorder as diagnoses, and the physician orders for current and discontinued medications did not document Haldol or Valproic Acid/Depakote as prescribed for the resident. The DON later stated that the Level I PASRR information for this resident was incorrect and should have been corrected but was not, and also acknowledged that additional information should have been submitted for the resident with schizophrenia and that a Level II PASRR should have been requested for the resident with bipolar disorder.
Failure to Follow Physician Orders and Professional Standards for Medication and Pressure Prevention Devices
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and professional standards for two residents. For one resident with a history of right femur fracture and schizophrenia, surveyors observed albuterol and fluticasone inhalers on the bedside table. The resident reported that nurses had given the inhalers to him and allowed him to keep them in his room because staff sometimes could not get to his room quickly enough. Review of the medical record showed no physician order for any inhaler medication and no documentation that a self-administration assessment had been completed for the inhaler. The DON later confirmed that the resident should not have had the inhaler in the room because there was no order for it. For another resident with diagnoses including acute embolism and thrombosis of the left popliteal vein and depression, surveyors observed that the resident’s Sage boots, ordered for pressure prevention, were lying in a chair next to the bed rather than being worn. An LPN stated that the resident should have been wearing the Sage boots but was not. The medical record contained a physician order for Sage boots to be applied to both feet at all times with refusals to be documented, but there was no documentation of any refusal for the day of the observation. The DON also stated that the resident should have been wearing the Sage boots but had not been.
Improper Storage and Control of Medications, Including Controlled Drugs
Penalty
Summary
Surveyors found that the facility failed to ensure medications were properly stored, labeled, and controlled in accordance with facility policy and the State Operations Manual. One resident with a history of acute embolism and thrombosis of the left popliteal vein and depression had a tube of zinc oxide on the overbed table and a tube of antifungal cream on the bedside table. The resident stated staff had left the tubes of medicine in the room and that he could not apply the cream independently. Review of his medical record showed no IDT assessment for self-administration of medications and no physician order to leave medication at the bedside, and the RCN confirmed the resident should not have had these medications at the bedside. Another resident with congestive heart failure and diabetes had a tube of Biofreeze topical pain reliever on the bedside table, reported that staff applied it to her left knee, and record review showed no order for the Biofreeze. The ADON stated this resident did not have an order or care plan for the Biofreeze and that the family must have brought it in. Surveyors also observed failures in the secure storage of controlled medications and general medication security. Two clear plastic cups, each containing a bottle of Lorazepam nasal spray, a Schedule IV controlled medication, were found stored on a medication refrigerator shelf without being in a separately locked, permanently affixed compartment, contrary to facility policy and the State Operations Manual. The DON acknowledged that the Lorazepam had not been stored in an affixed box as required. Additionally, the north hall medication cart was observed left unattended, unlocked, with one medication drawer pulled open, and the DON stated the cart should not have been left unlocked with a drawer open and unattended.
Call Light Not Kept Within Reach of Resident
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure a resident’s call light was within reach. The resident, who had been admitted with multiple diagnoses including chronic kidney disease and chronic atrial fibrillation, was observed on 4/29/26 at 7:51 AM lying in bed with the call light plugged into the wall and hanging down the wall under the head of the bed, out of the resident’s reach. The resident was unable to independently reach the call light. At 7:53 AM the same day, an RN confirmed that the call light should have been within the resident’s reach and acknowledged that it was not. Later that afternoon at 3:48 PM, the RCN also stated that residents’ call lights should be within reach and confirmed that in this instance it had not been.
Failure to Document Schizophrenia Diagnosis on PASRR and Refer for Level II Evaluation
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program by not ensuring a resident with a major mental illness was properly identified and referred for further evaluation. Record review showed that one resident, who had multiple diagnoses including a right femur fracture and schizophrenia, had a Level I PASRR dated 3/23/26 that did not document the schizophrenia diagnosis, which had an onset date of 3/21/22. Staff interview on 4/30/26 at 8:45 AM with the DON confirmed that the schizophrenia diagnosis should have been documented on the Level I PASRR but was not, and the resident was therefore not referred for a Level II PASRR evaluation as required for individuals with major mental illness, intellectual disability, or related conditions. This deficient practice was identified for 1 of 3 residents reviewed for Level II PASARR evaluations and was cited as having the potential to cause harm if the resident’s specialized services for mental health needs were not evaluated by the appropriate state-designated authority.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
Surveyors found that the facility failed to ensure residents' care plans were developed and revised to reflect current needs and interventions, as required. For one resident with COPD and Bipolar II disorder, the current care plan dated 3/25/26 to 6/23/26 was missing interventions for multiple identified problem areas, including risk for impaired cognitive function/dementia or impaired thought processes, ADL self-care performance deficit, risk for falls, nutritional problems or potential nutritional problems, pressure ulcer or potential for pressure ulcer development, and acute/chronic pain. Record review showed that this resident's prior care plan, dated 6/3/24 to 4/5/26, had all issues either resolved or cancelled, and ongoing issues were not carried forward into the newest care plan. Surveyors also determined that another resident with diabetes and dementia did not have a timely comprehensive care plan. This resident was admitted on a specified date, but the care plan was not initially started until 2/11/26 and was not signed off until 2/19/26, which was 15 days after admission, exceeding the required timeframe for completion. During an interview on 4/30/26 at 8:42 AM, the DON acknowledged that the care plans for both residents should have been completed in a timely manner and had not been. The report states that this failure placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being developed or revised as residents' needs changed.
Failure to Follow Physician Orders for Continuous Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services as ordered by physicians for two residents who required continuous oxygen therapy. One resident with a history of right femur fracture and schizophrenia had a physician’s order dated 3/23/26 for continuous oxygen at 3 L/min via nasal cannula every shift. On 4/27/26 at 11:25 AM, the resident’s oxygen concentrator was observed turned on and set at 4 L/min, but the resident was not using the oxygen and stated he only used it at night or when he felt he needed it during the day. On 4/29/26 at 6:58 AM, the same resident was again observed sitting in his wheelchair without wearing oxygen during a medication pass. At 7:03 AM, an LPN asked the resident why he was not wearing his oxygen, and the resident replied that he had not needed it. At 7:04 AM, the LPN stated the resident should have been using his oxygen but had not been, and the DON also stated on 4/29/26 at 4:39 PM that the resident should be using oxygen at 3 L/min as ordered and was not. Another resident, admitted with diagnoses including COPD and respiratory failure, had a physician’s order dated 3/25/26 for continuous oxygen at 4 L/min via nasal cannula every shift. On 4/27/26 at 10:28 AM and again on 4/28/26 at 2:27 PM, this resident was observed wearing a nasal cannula while the oxygen concentrator was set at 2.5 L/min instead of the ordered 4 L/min. On 4/28/26 at 2:31 PM, review of the medical record confirmed the 4 L/min continuous oxygen order. At 2:49 PM, a CNA stated the resident’s oxygen had been set to 2.5 L/min and should have been set at 4 L/min via nasal cannula, and at 3:03 PM, the RCN confirmed the oxygen had not been set at 4 L/min as ordered and should have been.
Failure to Complete Required Dual-Nurse Controlled Medication Shift Counts
Penalty
Summary
The facility failed to ensure controlled medications were consistently tracked and secured in accordance with its own policy, which required a reconciliation or physical inventory of all controlled medications by two licensed nurses at each shift change, documented on an audit record. During an audit of the East Hall medication cart on 4/29/26 at 7:59 AM, surveyors reviewed Narcotic Audit Shift Count sheets with start dates of 2/14/26 and 4/1/26 and found missing second nurse signatures for the 0600 and 1800 counts on 2/15/26 and the 0630 count on 4/6/26. An LPN confirmed that two nurses should have signed the Narcotic Audit Shift Count sheets but had not done so. The DON also stated that two nurses were required to sign the Narcotic Audit Count sheets when accepting or releasing the medication cart and acknowledged that this had not occurred. This failure was identified for 1 of 2 medication carts reviewed and was determined to create the potential for undetected misuse and/or diversion of controlled medications affecting all residents receiving controlled medications. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to the process and documentation of controlled medication counts on the East Hall medication cart.
Failure to Document Code Status in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for six residents, which placed them at risk of negative outcomes. The care plans did not include critical information regarding the residents' code status, which is essential for ensuring appropriate medical interventions. This deficiency was identified through observation, record review, and staff interviews, revealing that the care plans lacked documentation of the residents' resuscitation preferences as per their physician orders. Specifically, the care plans for residents with various medical conditions, such as respiratory failure, hypertension, sacral spina bifida with hydrocephalus, diabetes, chronic obstructive pulmonary disease, heart failure, dementia, pneumonia, and multiple sclerosis, did not reflect their documented code statuses. These statuses ranged from full code to DNR with specific treatment preferences, such as the use of IV fluids, antibiotics, and the refusal of feeding tubes and blood products. The Director of Nursing acknowledged the omission of this critical information in the care plans.
Failure to Conduct Pre-Employment Background Check
Penalty
Summary
The facility failed to implement its policy for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. This deficiency was identified during a review of personnel files, where it was found that a nursing assistant (NA #1) was hired without a documented pre-employment background check. The facility's policy, revised in December 2023, required such checks to be completed prior to hiring. However, NA #1 was hired on June 13, 2024, and the background check was only completed on December 6, 2024, six months after the hire date. The Administrator confirmed the absence of a completed background check at the time of hire, which had the potential to place residents at increased risk for physical and/or psychosocial harm.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving verbal abuse. A certified nursing assistant (CNA) overheard another CNA verbally abusing a resident who had been admitted with diagnoses including dementia and cognitive communication deficit. The incident was reported, and the abusive CNA was instructed to leave the resident's room. The facility's policy on abuse prevention and prohibition was not adhered to, resulting in a deficiency in safeguarding the resident from verbal abuse.
Failure to Document Cancer Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to document a resident's diagnosed medical condition on the comprehensive Minimum Data Set (MDS) assessment, which is required by the State Operations Manual and the Resident Assessment Instrument (RAI). This deficiency was identified for one resident whose MDS assessments were reviewed. The resident, who was admitted with multiple diagnoses including renal failure, diabetes, and hyponatremia, had a care plan updated to reflect a potential psychosocial well-being problem related to a recent cancer diagnosis. However, the comprehensive MDS assessment did not document the cancer diagnosis. The Director of Nursing (DON) and MDS Resource Nurse acknowledged that the MDS should have included this diagnosis.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted daily for each shift, as required by the State Operation Manual, Appendix PP. This manual mandates that facilities post specific information daily, including the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, as well as the resident census. During a review conducted on March 20, 2025, it was found that the posted nurse staff hours for October 18, 2024, and January 9, 2025, were blank. The Administrator acknowledged that all posted nursing hours should have been completed, indicating a lapse in maintaining accurate and complete staffing records. This deficiency had the potential to affect all residents residing in the facility, as well as their representatives, visitors, and others who might want to review the facility's staffing levels.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications available for residents were labeled, dated, and stored appropriately. During an audit of the East Hall medication cart, conducted with a Certified Medication Aide (CMA) present, it was observed that there were three loose pills in the bottom of the third drawer: one oval-shaped white tablet, one small round white tablet, and one large oblong white tablet. The CMA acknowledged that the pills should not have been loose in the medication cart. Similarly, an audit of the Skilled Hall medication cart, conducted with a Licensed Practical Nurse (LPN) present, revealed two small, round white pills loose in the bottom of the third drawer. The LPN confirmed that the pills should not have been loose and should have been destroyed. The Director of Nursing (DON) later stated that the nurses or medication aides should have destroyed the loose pills.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to properly store, label, and manage food products in accordance with the Idaho Food Code, which could potentially impact all residents. Observations revealed several issues: dry pasta with an open date of 10/9/24 was not disposed of by 3/9/25, barley with a use-by date of 12/24 was still present, and Ragu pasta sauce with a use-by date of 3/13/25 was not discarded. Additionally, three #10 size cans of pineapple tidbits and beans lacked a received date. A soy sauce bottle provided to a resident had no use-by date, and a container of salsa in the resident refrigerator was found with a white fuzzy substance growing inside, indicating spoilage. Furthermore, during meal delivery, it was observed that CNA #1 delivered meal trays to residents' rooms without covers on the bread or dessert, which is against the facility's protocol. The DS confirmed that food should be covered when transported down the hall. These lapses in food handling and storage practices placed residents at risk of consuming spoiled or contaminated food, potentially leading to adverse health outcomes.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, which had the potential to impact all residents by placing them at risk for injury and infections. During observations, it was noted that sharps containers in multiple locations were overfilled, with used razors protruding from the openings. Additionally, a fuzzy black mold-like substance was observed on shower tiles and near ceiling vents in the shower rooms. Interviews revealed that the facility lacked policies for housekeeping, cleaning, showers, or sharps containers. The Director of Nursing acknowledged that showers should have been cleaned after each use and sharps containers should have been changed when full, but these actions were not taken.
Dietary Manager Lacks Required Competencies and Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) had the required competencies and skills for the position. The job description for the DM required a minimum of two years' experience in a supervisory capacity in a hospital, skilled nursing care facility, or other related medical facility. Additionally, the DM was required to be a Certified Dietary Manager (CDM), Certified Food Service Manager, or have a similar national certification. The current DM, who started in January 2024, did not have prior experience as a DM and was not certified. She planned to begin the CDM course in August 2024, which would take six to eight months to complete, meaning she would not be fully qualified until more than a year after starting her position. The Registered Dietitian (RD) confirmed that the DM was signed up for the CDM course but would not be fully qualified until its completion. The Administrator acknowledged that the DM did not meet the educational, experience, or certification requirements for the position. The DM missed the January 2024 CDM course due to being in a trial period for the position. This deficiency had the potential to affect the meal and food satisfaction of all 52 residents receiving food from the kitchen.
Failure to Monitor Dish Machine and Sanitizer Concentrations
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of the dish machine, sanitizing solutions, and labeling of food in the residents' refrigerator. During an initial tour of the kitchen, it was observed that the dish machine's rinse temperatures did not meet the manufacturer's minimum requirement of 120 degrees Fahrenheit, with recorded temperatures ranging from 36 to 90 degrees Fahrenheit. Additionally, the chemical sanitizer concentration was not measured or recorded, and the sanitizer solution for kitchen surfaces was found to be ineffective, as indicated by a test strip that did not change color. The refrigerator at the nursing station contained unlabeled and undated food items, including partially consumed McDonald's shakes and open containers of french fries and refried beans, which were not stored in closed containers to prevent contamination. During a follow-up kitchen observation, it was noted that the sanitizer solution for pot washing and kitchen surfaces was inadequately mixed, with concentrations close to zero parts per million (PPM). The cook verified the low concentration and adjusted the solution to the required level of 200 PPM. The commercial dishwasher's rinse temperature was again found to be below the required 120 degrees Fahrenheit, and the dish machine log consistently lacked records of sanitizer levels. The Dietary Manager (DM) and Maintenance Director were unaware of the need to monitor and record the sanitizer concentration and rinse temperatures, respectively. The Registered Dietitian (RD) confirmed that the rinse temperatures were too low and that the sanitizer concentration should have been monitored. The deficiencies observed placed the 52 residents receiving meals from the kitchen at risk for foodborne illness. The facility's failure to adhere to proper sanitation procedures, including monitoring dish machine temperatures and sanitizer concentrations, as well as ensuring food in the residents' refrigerator was labeled and dated, contributed to the potential health risks. Staff interviews revealed a lack of awareness and adherence to the required procedures, further exacerbating the issue.
Improper Waste Containment Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to ensure that waste was properly contained with lids or otherwise covered, creating the potential for insect and pest infestation. During an observation, a large dumpster with two plastic lids was found with both lids open, exposing the contents. There were no staff in the vicinity actively disposing of garbage. Additionally, several smaller garbage cans were observed, one of which had its lid open and was empty. The DM stated that the large dumpster was designated for cardboard, but it contained four bags of regular garbage on top of the cardboard boxes. The DM acknowledged that the garbage cans might have been full, leading to the regular garbage bags being placed in the large dumpster. The lids remained open when leaving the area. In a subsequent observation, one of the two lids of the large dumpster was open, exposing the contents again. The lids were bent, preventing a complete seal even if closed. The garbage bags observed earlier remained in the dumpster with the cardboard. The DM confirmed that the large dumpster was emptied weekly, and the smaller garbage cans were serviced daily from Monday to Thursday. The DM stated that staff should have distributed the garbage evenly among the smaller cans to prevent overflow and ensure the lids could be closed. The Maintenance Director and the Administrator both acknowledged the issue with the damaged lids and the need for replacement to prevent pest access.
Failure to Provide Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure residents were provided with a safe, homelike environment. This was observed in two of the three shower rooms in the facility. Specifically, the skilled hall shower room had 8 missing floor tiles, a dry, light gray substance in the air vent slats, and a black substance around the vent on the ceiling. Additionally, the skilled hall hallway outside a room had a hole in the wall approximately 4 inches by 2 inches. The east hall shower room had a white, fuzzy film on the ceiling vent. The Maintenance Supervisor acknowledged that the missing tiles in the shower room were unsafe and that the room should not be used for showering residents. He also stated that the hole in the wall and the dirty ceiling vents did not provide a clean, homelike environment.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for four residents, leading to potential negative outcomes. Resident #17, who was dependent on staff for transfers due to an amputation and spina bifida, did not have her care plan updated to include the use of a Hoyer lift for transfers. This omission was confirmed by the DON, who acknowledged that the care plan should have specified the type of lift, the number of staff needed, and the type and size of the transfer sling. Similarly, Resident #24, who was cognitively intact and had a physician's order to self-administer Fluticasone Furoate nasal spray, did not have this self-administration documented in her care plan. An LPN was also unaware if this was care planned, despite the resident regularly self-administering the medication. Resident #31, who required specific wound care for a subdural hemorrhage and diabetes, did not have these wound care interventions documented in the care plan, as confirmed by the DON. Lastly, Resident #198, who preferred to sleep in a recliner due to spina bifida and kidney disease, did not have this preference documented in his care plan, even though he was observed sleeping in the recliner and had been educated on the importance of sleeping in bed due to his wounds. The DON confirmed that this preference should have been included in the care plan.
Failure to Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure controlled medications were properly tracked and secured, as evidenced by multiple blank signature lines on narcotic accountability records. During a medication cart audit, it was observed that the narcotic accountability record for one medication cart had missing signatures for several days. Specifically, from 4/28/24 to 5/8/24, 7 out of 34 days lacked signatures from licensed nurses for each shift, and from 5/9/24 to 5/15/24, 8 out of 20 days had missing signatures. This indicates that the required reconciliation of controlled medications by two licensed nurses at each shift change was not consistently performed or documented, as per the facility's policy revised in December 2023. An LPN confirmed that nurses should have signed the narcotic book after counting narcotics with another nurse. The Director of Nursing (DON) also stated that the reconciliation sheets are located at the back of the narcotic book and should be signed by both the off-duty and on-duty nurses during each shift change, even if the shift is split between nurses. The failure to adhere to this protocol created the potential for undetected misuse and/or diversion of controlled medications, affecting all residents who received such medications in the facility.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, as evidenced by a 6.67% error rate observed during the survey. Resident #17, who has multiple diagnoses including amputation and spina bifida, was supposed to receive a normal saline flush solution intravenously as per the SASH protocol. However, LPN #3 administered 5 ml of Heparin 100 mg/ml instead. The Director of Nursing (DON) and a Registered Nurse (RN) were unsure about the correct dose of Heparin and had to consult the pharmacy for clarification, indicating a lack of adherence to the facility's medication administration policy and protocol knowledge among staff members. Resident #24, diagnosed with heart failure and chronic obstructive pulmonary disease (COPD), was observed self-administering Fluticasone Furoate nasal spray incorrectly by using only 1 spray in each nostril instead of the prescribed 2 sprays. Additionally, LPN #3 administered only 150 mg of Sertraline HCl instead of the prescribed 200 mg. The LPN acknowledged the errors, confirming that the resident should have received the correct dosages as per the physician's orders. These medication administration errors highlight significant lapses in following prescribed medication regimens and the facility's policies, putting residents at risk of not receiving their proper medication or dosage.
Failure to Provide Nourishing and Palatable Meals
Penalty
Summary
The facility failed to ensure residents were provided with nourishing, palatable, well-balanced meals that met their daily special dietary needs and specific preferences as documented on the residents' meal tickets. This issue was identified for five residents who reported not receiving the food items they selected or the quantities they requested. For instance, one resident consistently ordered three chicken sandwiches but received only two chicken patties on a bun, and another resident requested three fried eggs but was served only two. Additionally, residents reported missing items on their trays, such as zucchini and oranges, which were either not available or not provided despite being requested. The facility's policy stated that menus should be developed to meet the nutritional needs and preferences of residents, but this was not consistently followed. Resident Council meeting minutes documented ongoing concerns about missing food items and unfulfilled meal preferences. During interviews, residents expressed dissatisfaction with the meals served, indicating that they often did not receive the food they selected or the quantities they needed to feel satisfied. One resident, who was a large man, reported hoarding food because he did not receive enough to eat, while another diabetic resident was served fruit cocktail in heavy syrup instead of the fresh fruit she requested. The Dietary Manager (DM) and Registered Dietitian (RD) acknowledged the issues, stating that dietary staff did not always serve everything residents requested on their meal tickets. The DM admitted to routinely serving less food to certain residents based on her judgment of their dietary needs, rather than following the residents' selections. The RD confirmed that residents should be served what they selected and that their preferences should be accommodated. The Administrator was aware of the situation and verified that some residents might be hungry if served regular-sized portions, but no corrective actions were mentioned in the report.
Failure to Provide Sufficient Alternate Meals
Penalty
Summary
The facility failed to provide nutritionally comparable and sufficient alternate meals to residents, as observed through multiple instances and resident interviews. The facility's Food and Nutrition Menus policy required that menu alternatives aligned with individual needs and preferences should be available if the primary menu or immediate selections for a particular meal were not to the resident's liking. However, the Week Two spring/summer cycle menu and its daily menu extensions did not include planned alternative food items. Resident Council meeting minutes from 7/14/23 to 3/13/24 documented ongoing concerns about the limited and repetitive nature of the alternate menu options. Residents expressed dissatisfaction with the lack of variety and the repetitive nature of the alternate meals, which were primarily limited to tuna fish sandwiches or chicken patty sandwiches with chips. Specific resident interviews revealed that residents were often served the same limited alternatives, leading to dissatisfaction and decreased meal intake. For example, one resident was served a chicken patty on a bun instead of a casserole, which she did not like, and another resident could not get a peanut butter and jelly sandwich because it was not on the alternate menu. The Dietary Manager (DM) confirmed that the alternate menu for lunch and dinner every day for the current six-month cycle menu was either a tuna fish sandwich or a chicken patty sandwich with chips, with no alternatives for vegetables, starch, fruit, or dessert. The Registered Dietitian (RD) stated that there should have been planned alternates on the menu daily for lunch and dinner, including alternates for vegetable and starch exchanges in addition to the entree/protein, which were not provided.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to respect and maintain the dignity of residents who required assistance with their meals. Observations during breakfast and lunch revealed that residents seated at horseshoe-shaped tables, who needed feeding assistance, were consistently served last. These residents were brought to the dining room first but had to wait extended periods for their meals and beverages, while other residents in the main dining area were served promptly. This practice led to residents at the horseshoe tables sitting unassisted, not drinking their beverages, and some dozing off or with their eyes closed. Staff interviews confirmed that the residents at the horseshoe tables were referred to as 'feeders,' a term acknowledged by the Dietary Manager (DM), Licensed Practical Nurse (LPN), Director of Nursing (DON), and the Administrator as undignified. The DM and LPN stated that the residents at the horseshoe tables were served last so that staff could be available to assist them without interruption. However, this resulted in these residents waiting significantly longer for their meals and beverages compared to other residents in the dining room. One resident at the horseshoe table, who could be interviewed, expressed that she was improving and could eat with less assistance but still had to wait long periods for her meals. The DON and Registered Dietitian (RD) acknowledged that referring to residents as 'feeders' was a dignity issue and that residents needing assistance should not be brought to the dining room first if they were going to be fed last. The Administrator confirmed that the terminology used was not dignified and that residents needing assistance should not have to wait as long as they had.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure grievances were responded to and investigated, and prompt corrective action was taken to resolve them. This was evident in the case of a resident who reported missing money on two occasions. The resident, who was moderately cognitively intact and had multiple diagnoses including aftercare following surgical amputation of both legs below the knee, reported the missing money to the Social Services Representative. However, the Social Services Representative admitted to forgetting to fill out a grievance form and failing to investigate the issue. The facility's Grievances policy and procedure, revised December 2023, required the Grievance Official to evaluate and investigate concerns and take immediate action to resolve them. The policy also mandated that the Grievance Official or designee respond to the individual expressing the concern within three working days. In this case, the Social Services Representative did not follow the policy, leading to the resident's grievances being unaddressed and unresolved.
Failure to Assess Seatbelt as Potential Restraint
Penalty
Summary
The facility failed to ensure that a seatbelt used for a resident was assessed as a potential restraint. This was identified for one resident who was observed sitting in her electric wheelchair with a seatbelt fastened. The facility's policy defined a physical restraint as any device that the resident cannot remove easily and restricts freedom of movement. The policy also required an accurate and thorough assessment by the IDT before applying any restraints. However, the resident's record did not include documentation of such an assessment for the seatbelt. The resident in question had multiple diagnoses, including congestive heart failure and chronic obstructive pulmonary disease. Despite these conditions, there was no documentation that the seatbelt was assessed as a potential restraint. The DON and PT Director reviewed the resident's record and confirmed the absence of such documentation. They also stated that the seatbelt came with the wheelchair and no assessment was completed regarding its use. When asked if the seatbelt should have been assessed as a potential restraint, the DON and PT Director did not provide an answer.
Failure to Provide Necessary Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that necessary information was provided to the receiving hospital during the transfer of a resident. The facility's policy required that specific information, including contact information of the resident's practitioner, advance directives, special instructions, comprehensive care plan goals, and other necessary documentation, be communicated to the receiving healthcare institution. However, for the resident in question, there was no documentation in the medical record indicating that this information was provided to the hospital during the transfer. The resident, who had multiple diagnoses including depression, congestive heart failure, and dysphagia, experienced a decline in condition and was sent to the ER. Although the Director of Nursing (DON) stated that various documents were sent with the resident, there was no documentation to confirm this. This lack of documentation could potentially lead to delays in treatment and care for the resident at the receiving hospital.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure transfer notices were provided to the ombudsman for a resident transferred to the hospital. Resident #9, who had multiple diagnoses including depression, congestive heart failure, and dysphagia, was admitted to the facility on an unspecified date. On 3/10/24, the resident was reported to be in pain with a high pulse rate, and the physician and resident's representative were notified. The following day, the resident's condition declined further, and the representative requested an ER visit, which was approved by the provider. The resident was sent to the ER, but there was no documentation that the ombudsman was informed of the transfer. The Social Services Representative later confirmed that she was unaware of the requirement to notify the ombudsman of such transfers.
Failure to Follow Professional Nursing Standards
Penalty
Summary
The facility failed to follow professional standards of nursing practice for three residents, leading to potential risks for wound infection, adverse outcomes from medication refusal, and unmanaged hyperglycemia. Resident #31 had a wound dressing that was not labeled with the date, time, or initials, contrary to the Lippincott Nursing Procedures textbook guidelines. This oversight was observed when an LPN changed the dressing without labeling it, and the LPN later acknowledged the mistake. Resident #37, who was moderately cognitively intact and had a physician's order for a Nicotine Patch, refused the patch 29 times out of 41 opportunities. The facility's policy required that the physician be notified of such refusals, but there was no documentation that this was done. The DON admitted that while the provider was verbally informed, no follow-up was made to obtain further orders regarding the refusals. Resident #43, who had diabetes, had blood glucose levels greater than 400 mg/dl on two occasions. The physician's order required that the provider be notified of such high readings, but there was no documentation that this was done. The Nurse Practitioner and DON confirmed that the physician should have been notified and that the resident's condition and the notification should have been documented in the progress notes or a Change of Condition assessment.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #16 received oxygen therapy as per the physician's orders. Resident #16, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), multiple rib fractures, and pneumonia, had a physician's order dated 4/5/24 to receive 3 liters of oxygen continuously via nasal cannula. However, the nurses' daily skilled notes from 5/9/24 to 5/15/24 documented that the resident's oxygen was administered at 2 liters instead of the prescribed 3 liters. Observations on multiple occasions confirmed that the oxygen concentrator was set at 2 liters, and even when checked by LPN #1, it was found to be set at 2 and a half liters, not the prescribed 3 liters. Resident #16, who was severely cognitively impaired, expressed concerns about his health and mentioned that he did not feel good on 5/16/24. Despite his condition and the physician's clear orders, the staff failed to administer the correct oxygen concentration. The Director of Nursing (DON) confirmed that the resident required oxygen for his COPD diagnosis and acknowledged that the nurses should have administered the oxygen at the concentration specified in the physician's orders.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure medications available for residents were properly labeled and had not expired. During a medication cart audit of the Skilled Hall medication cart, a bottle of Top Care eye drops with an expiration date of 3/2024 was found. An RN confirmed the eye drops were expired and should have been removed. In a separate audit of the East Hall medication cart, a package of Loperamide with an expiration date of 2/23/23 and an unlabeled Albuterol Sulfate inhaler were found. An LPN identified the inhaler as belonging to a resident based on a sharpie mark but acknowledged it should have been stored in its original box. The DON stated that discontinued and expired medications should be removed from the medication carts promptly.
Failure to Document Dialysis Refusals
Penalty
Summary
The facility failed to ensure that the medical record of a resident with end-stage renal disease, who was dependent on renal dialysis, was accurate and complete. Specifically, the resident had a physician order for hemodialysis three times a week, but the Dialysis Flow Sheets showed that 12 sessions were missing over a period of two and a half months. The missing dates were not documented in the resident's Progress Notes, Medication Administration Records (MARs), or Treatment Administration Records (TARs). This lack of documentation meant that the healthcare provider was unaware of the extent of the resident's non-compliance with dialysis treatments. Interviews with staff revealed that the resident refused dialysis at least once a week, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the refusals should have been documented in the Electronic Medical Record (EMR). However, the refusals were not recorded, which was verified by the DON and ADON. This failure to document the resident's refusals to attend dialysis sessions was a violation of the facility's policy on the content of medical records, which requires prompt and appropriate entries by all healthcare professionals involved in the resident's care.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, which had the potential to impact all 52 residents. One incident involved an LPN who picked up a resident's oxygen cannula from the floor and placed it back in the resident's nose without cleaning it. Another incident involved CNAs who did not offer hand hygiene to residents before serving their meals and placed dirty trays on a cart with clean trays. Additionally, an LPN provided wound care to a resident without wearing the required gown, despite the resident being on Enhanced Barrier precautions due to wounds and a physician's order requiring PPE for high-contact care activities. Resident #3, who had multiple diagnoses including acute pancreatitis and respiratory failure, was subjected to improper handling of their oxygen cannula. During lunch tray delivery, residents were not offered hand hygiene, and dirty trays were mixed with clean ones. Resident #31, with diagnoses including subdural hemorrhage and diabetes, was not provided with the required Enhanced Barrier precautions during wound care, as the LPN failed to wear a gown. These actions and inactions directly violated the facility's infection control policies and placed residents at risk for cross-contamination and infection.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents who were offered and consented to the pneumococcal vaccine received the vaccine. This was evidenced by the case of a resident who had multiple diagnoses, including amputation of her left leg above the knee and spina bifida. The resident's record showed that she had received the PPSV23 vaccine previously and had consented to receive the PCV20 vaccine according to CDC recommendations. However, there was no documentation in her record indicating that the PCV20 vaccine was administered to her. The Director of Nursing (DON) reviewed the resident's record and confirmed the absence of documentation for the administration of the PCV20 vaccine. This failure to administer the vaccine as per the resident's consent and CDC guidelines created the potential for increased risk of pneumococcal pneumonia and severe illness or death among residents.
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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