Caldwell Care Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Caldwell, Idaho.
- Location
- 210 Cleveland Boulevard, Caldwell, Idaho 83605
- CMS Provider Number
- 135014
- Inspections on file
- 18
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Caldwell Care Of Cascadia during CMS and state inspections, most recent first.
The facility did not maintain an effective grievance process as required by its own policy, which called for addressing concerns from residents, families, and visitors and making prompt efforts to resolve them. When surveyors requested grievance records for several months, the facility could only produce grievances for a limited recent period and had no records for earlier months. The Administrator confirmed that no grievances were available for the earlier timeframe, and the CRN acknowledged that the grievance process had been identified as needing performance improvement, resulting in a lack of documented access to a functioning grievance system for residents.
Surveyors found that dietary staff prepared and served food while wearing rings and bracelets and performed hand hygiene without removing this jewelry, contrary to FDA Food Code guidance that such items can harbor soil and pathogenic organisms. In addition, kitchen cutting boards were observed to have dark stains embedded in the plastic grain, indicating they were scratched, difficult to clean, and potentially capable of harboring microorganisms. These practices affected all individuals consuming facility-prepared food and created a risk of food contamination and food-borne illness.
The facility failed to hold required quarterly care conferences for multiple residents with dementia, schizoaffective disorder, bipolar disorder, heart failure, dysphagia, and other conditions, documenting only initial or single conferences and no subsequent quarterly meetings in the EHR, as confirmed by leadership. The facility also did not timely revise care plans for two residents when their needs changed: one resident’s fall-related supervision intervention, ordered after a fall, was not added to the care plan until weeks later, and another resident’s toileting status remained documented as largely independent despite an MDS showing complete dependence on staff for toileting, a discrepancy acknowledged by the DON.
Staff failed to follow infection prevention and control practices during blood glucose monitoring and environmental cleaning. An RN performed a blood glucose check and handled insulin pens for a diabetic resident by placing the glucometer and insulin pens directly on the resident's bed surfaces without using a paper towel barrier, contrary to AHCA guidance and facility expectations. In a separate incident, a CNA cleaned a urine spill from a leaking urinary catheter bag in a common area by covering and wiping it with a dry towel while wearing gloves, but did not clean or disinfect the area afterward, despite CDC procedures requiring thorough cleaning and disinfection of body fluid spills.
A resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia, who was assessed as cognitively intact, was moved from one room to another without receiving a proper written explanation for the transfer as required by facility policy. The facility’s room change policy required a written rationale and an opportunity for the resident to see the new location, meet a new roommate, and ask questions. However, the room-to-room transfer form documented only that the POA was notified, with no explanation of why the move was required, and the Social Services Manager later acknowledged the form was not completed correctly. This failure created the potential for psychosocial harm related to the room change.
A resident with schizoaffective disorder, depression, and anxiety had multiple documented episodes of significantly elevated BP over a 90-day period, but nursing staff did not notify the physician as required. Record review showed no evidence of any physician notification regarding these abnormal vital signs, and in an interview the DON confirmed that the physician should have been notified immediately and could not provide documentation that this occurred.
Surveyors found that two residents lived in rooms with unrepaired and visibly patched walls, including exposed broken drywall and numerous white patches over colored paint. Both residents, who had mental health diagnoses and one with COPD, reported that the wall damage and patchwork had been present for an extended period. The facility's own policy required a safe, clean, comfortable, and homelike environment, but the Maintenance Director acknowledged the walls had only been patched and primed and had not yet been painted, and he was unaware of some of the existing wall damage.
The facility failed to accurately identify which resident was the victim and which was the aggressor in a resident-to-resident abuse report submitted to the state. One resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia was documented in the official abuse report as the victim after a bathroom-related altercation in which another resident was reported to have grabbed the resident’s shirt, with no injury found. However, a witness statement indicated that this resident had entered the other resident’s room and was actually the aggressor, and the other resident merely reacted by grabbing the shirt. The Administrator later acknowledged that the report had been completed incorrectly, contrary to facility policy requiring complete and accurate abuse reporting.
A resident with acute respiratory failure, pneumonia, and COPD experienced worsening respiratory status, did not respond to an albuterol treatment, and required transfer for a higher level of care. Although a transfer/discharge notice and bed-hold agreement were completed, the record lacked documentation that required information was sent to the receiving provider, including practitioner contact details, resident representative contact information, advance directive status, special instructions or precautions for ongoing care, and comprehensive care plan goals. The DON and CRN confirmed that this required transfer documentation was not present in the medical record.
A resident with multiple behavioral health diagnoses, whose primary diagnosis was recurrent major depressive disorder, had an inaccurately completed PASRR Level I that identified dementia/Alzheimer’s disease as the primary diagnosis. Record review and staff interview revealed the discrepancy between the medical record and the PASRR form, and the SW confirmed the PASRR Level I was completed incorrectly.
Surveyors found that staff did not follow professional standards in several clinical practices. A resident with an AV fistula for hemodialysis had multiple blood pressure readings documented on the access arm despite a care plan prohibiting this. Another resident with diabetes received Novolog and Toujeo via insulin pens that an RN failed to prime before dialing to the ordered doses, contrary to manufacturer instructions. A third resident receiving oral potassium chloride had the medication mixed with pudding and was not educated by an LPN about the need to drink a full glass of water afterward, even when the resident declined water.
Multiple residents did not receive ordered or care-planned interventions, including one resident with a fall history who was left sitting on the bed edge and subsequently fell, after which ordered orthostatic BP monitoring was not documented; another resident with muscle weakness and malnutrition who had physician-ordered pressure-relieving boots was repeatedly observed in common areas without the boots on; a resident with psychiatric diagnoses had an elevated BP that was not reassessed or further evaluated; and a resident with cardiac and swallowing issues had an ordered carrot splint for the right hand that was not applied despite observations of tightly fisted hands and fingertip pressure marks on the palm.
A resident with psychiatric conditions and impaired mobility experienced repeated falls from a wheelchair in the dining room after staff left the resident unsupervised. Following an initial fall, the IDT determined the resident should always be supervised in the dining room, but this intervention was not added to the care plan until much later. During this gap, the resident sustained another fall under similar circumstances. The DON confirmed that the supervision intervention was not incorporated into the care plan when it was first identified.
A resident with bipolar disorder, anxiety disorder, and traumatic brain injury was receiving Seroquel 300 mg daily, with a care plan directing staff to monitor and report psychoactive medication side effects. A consulting pharmacist documented that antipsychotic drugs can cause tardive dyskinesia and other movement disorders and recommended completion of an AIMS or DISCUS assessment at least every six months while the resident remained on antipsychotic therapy. The resident’s record showed the last AIMS assessment had been completed more than six months earlier, outside the recommended monitoring interval, and the DON confirmed that the pharmacist’s recommendation had not been implemented and no current AIMS assessment was present in the chart.
Surveyors found that two residents receiving Depakote for conditions including alcohol dependence, borderline personality disorder, Alzheimer’s disease, and suicidal ideations were not monitored for anticonvulsant side effects as required by their person-centered care plans. Although the care plans directed staff to monitor, notify the provider, and document specific symptoms such as over-sedation, agitation, confusion, mental status changes, visual disturbances, gait changes, behavioral changes, and weight changes, the clinical records contained no documentation of such monitoring. The DON confirmed that anticonvulsant monitoring was not present in the records, and the report noted this failure created the potential for harm if side effects were undetected.
Surveyors found that the facility failed to remove expired medications from the medication storage room. During an inspection of the medication room refrigerator with the ADON, five acetaminophen suppositories with a past expiration date were discovered still stored and available for use. The ADON confirmed the suppositories were expired and should not have remained in the refrigerator, creating the potential for adverse effects if administered.
The facility failed to follow its Antibiotic Stewardship Policy and McGeer’s Criteria when initiating antibiotic therapy for a suspected UTI in a resident with multiple diagnoses, including adult failure to thrive and a need for assistance with personal care. The resident’s care plan directed monitoring for specific urinary and systemic symptoms, and the resident was later noted to be increasingly lethargic with decreased muscle function. A provider ordered lab tests, including a urinalysis with culture and sensitivity, along with cefdinir for a UTI diagnosis, and the antibiotic was started before culture and sensitivity results were available. The urine culture and sensitivity were completed several days after antibiotic initiation, and the DON later confirmed the resident did not meet McGeer’s criteria for antibiotic treatment for UTI.
The facility failed to ensure resident rights were honored when past survey results and plans of correction were not readily accessible. A binder labeled “State Survey Results” was placed in a corridor pocket folder but was blocked by a stuffed chair with stacked equipment, two vital signs towers, and an extra-large padded specialized wheelchair, preventing easy access. During a Resident Council discussion, residents reported they were unaware of the facility’s responsibility to make the past three years of survey results available, did not know they had the right to review them, and did not know where the survey results were posted. The Administrator confirmed that the survey results were inaccessible due to being blocked by stored equipment.
The facility did not have an RN on duty for 8 consecutive hours on one of the reviewed days, with an LPN covering the RN duties instead. This staffing lapse created the potential for unmet nursing needs, affecting all residents.
The facility failed to properly store and label food items, as outdated yogurts and an ice cream container were found in storage past their use-by dates. The CDM acknowledged these items should have been removed according to the facility's policy and the Idaho Food Code.
The facility failed to provide proper respiratory care for residents requiring oxygen therapy, with incomplete physician orders and improper oxygen administration. A resident with panic disorder and dementia was found without his oxygen nasal cannula, while another resident with hemiplegia had an incomplete oxygen order. Additionally, a resident with acute respiratory failure was observed with a portable oxygen unit set at zero liters per minute, despite a physician's order for 2 liters per minute.
A resident with multiple diagnoses, including schizoaffective disorder and COPD, was transferred from a single-bed room to a four-bed room without receiving the required written notice. A CRN confirmed the absence of documentation indicating prior notification of the room change.
The facility did not maintain a safe and homelike environment in one of its shower rooms, where peeling paint was observed. A CNA noted the issue had been present for months, but no maintenance work order was found. The Maintenance Director was unaware of the problem, which affected the quality of life for residents using the shower room.
A resident with dementia exhibited aggressive behavior towards another resident with hemiplegia and end-stage renal disease, including placing them in a chokehold and pushing their wheelchair. The facility failed to prevent these incidents, placing all residents at risk of abuse.
A facility failed to provide a bed-hold notice to a resident with multiple diagnoses, including schizoaffective disorder and COPD, upon transfer to the hospital for worsening respiratory symptoms. The resident's record lacked documentation of the notice, and the DON confirmed this omission during an interview.
The facility failed to refer two residents with major mental illnesses for PASARR level 2 evaluations as required. One resident with bipolar disease and another with schizophrenia did not have the necessary evaluations completed, despite policy requirements and instructions from PASARR level 1 screenings.
The facility failed to complete timely PASARR screenings for two residents with mental disorders. One resident with bipolar disease had no PASARR Level 1 completed, while another with schizophrenia had the screening done 36 days post-admission. This non-compliance could affect the provision of necessary mental health services.
A facility failed to update a care plan for a resident with Parkinson's and bipolar disorder, who required 30-minute checks after a fall. Despite documentation in the care plan and interdisciplinary notes, the medical record lacked evidence of these checks being performed. The DON later acknowledged the oversight.
A facility failed to follow standard practices during a resident transfer and did not adhere to a care plan for monitoring weight loss. A CNA used a resident's belt loop instead of a gait belt, violating safety policy. Another resident experienced significant weight loss without the required notification to the MD, risking potential harm.
A resident with panic disorder and dementia was found without access to a call light, which was placed across the room, contrary to his care plan. The resident reported yelling for help due to pain but was not heard. A CNA admitted to forgetting to provide the call light, and the DON confirmed the requirement for staff to ensure call light access.
A resident with a history of stroke and diabetes reported nearly falling in the east shower room due to missing anti-slip pads. Observations confirmed the absence of non-slip strips, which had been missing for about two months. Despite a work order being submitted, the strips were not replaced until later.
Failure to Maintain and Implement an Effective Grievance Process
Penalty
Summary
The facility failed to ensure a grievance process was available for residents as required by its own Grievance Process policy, which stated that the grievance program addresses concerns of residents, family members, and visitors and that the facility should make prompt efforts to resolve grievances. During the survey, when the SA requested copies of grievances covering the period from September 2025 through March 2026, the facility was only able to provide grievances from January 2026 through March 2026 and had no additional grievances available for the earlier months. In an interview, the Administrator, with the CRN present, confirmed there were no grievances available prior to January 2026 and the CRN acknowledged that the facility had identified its grievance process as needing a performance improvement plan. This lack of an available and functioning grievance process created the potential for psychosocial harm if residents’ concerns were not identified and addressed in a timely manner. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency centered on the facility-wide failure to maintain and implement an effective grievance process over the specified time period.
Improper Jewelry Use and Unsanitary Cutting Boards During Food Preparation
Penalty
Summary
Surveyors identified a deficiency in food service practices related to staff wearing jewelry during food preparation and service. On the morning of 3/4/26, one dietary staff member and one dietary trainee were observed preparing and serving food while wearing rings, and the trainee was also wearing bracelets on both wrists. Hand hygiene was performed while the jewelry remained in place. According to the FDA Food Code, items of jewelry such as rings, bracelets, and watches may collect soil, be difficult to clean, and act as reservoirs for pathogenic organisms transmissible through food. The Dietary Manager stated that jewelry should not be worn while preparing or serving food and that if jewelry was permanent, gloves should be worn to cover it. A second deficiency involved the condition and cleanliness of cutting boards used in the kitchen. On the afternoon of 3/5/26, surveyors observed that the plastic cutting boards in the kitchen had dark-colored stains within the grains of the plastic. The FDA Food Code states that cutting surfaces that become scratched and scored may be difficult to clean and sanitize, allowing pathogenic microorganisms transmissible through food to accumulate and be transferred to foods prepared on those surfaces. The Culinary Manager stated that cutting boards should be replaced when they are not able to get clean or have stains removed. These deficiencies had the potential to affect the 59 residents who consumed food prepared by the facility and placed them at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.
Failure to Hold Quarterly Care Conferences and Timely Revise Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to conduct required quarterly care conferences and to timely revise care plans based on residents’ changing needs. Facility policy dated 9/3/25 required that care plans be created, reviewed, and revised by an interdisciplinary team (IDT) with resident and/or representative involvement, and that updates occur as needed based on residents’ response to interventions and changes in condition. Record review showed that multiple residents with complex medical and psychiatric diagnoses had only an initial or single quarterly care conference documented, with no evidence of subsequent quarterly conferences in the electronic health record. The Administrator and Clinical Resource Nurse confirmed that if a care conference was not documented in the electronic health record, it was not completed. For one resident with dementia, depression, anxiety, muscle weakness, and difficulty walking, a quarterly care conference was documented in July 2025, but there was no documentation of additional quarterly conferences around October 2025 or January 2026. Another resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia had a care conference in August 2025, with no further quarterly conferences documented for November 2025 or March 2026. A resident with paranoid schizophrenia, depression, anxiety, and difficulty walking had a care conference in June 2025, but there were no records of required quarterly conferences for September and December 2025, nor documentation that a March 2026 conference was scheduled. Additional residents with schizoaffective disorder, depression, anxiety, dementia, bipolar disorder, heart failure, dysphagia, and sleep apnea similarly lacked documentation of required quarterly care conferences after an initial or single documented meeting. The facility also failed to revise care plans in a timely manner for two residents when their care needs changed. One resident with paranoid schizophrenia, depression, anxiety, and difficulty walking had a fall care plan dated August 2023 that included various fall-prevention interventions and directed quarterly re-evaluation and revision with changes in condition or after a fall. A fall investigation on December 1, 2025 documented that the resident fell while unattended in the dining room, and the IDT directed that the resident be supervised at all times while in the dining room; however, this new supervision intervention was not added to the care plan until January 27, 2026. Another resident with major depressive disorder, anxiety disorder, and alcohol dependence had a care plan revised in April 2022 indicating independence with toileting and one-person assistance for occasional nighttime incontinence, but a later quarterly MDS documented that the resident was dependent on staff for all toileting needs. The DON confirmed the resident was dependent in toileting and that the care plan should have been revised to reflect the current care needs.
Failure to Follow Infection Control Practices During Glucose Monitoring and Urine Spill Cleanup
Penalty
Summary
The deficiency involves failure to implement proper infection prevention and control practices during medication administration. A resident with multiple diagnoses including diabetes and asthma was observed during a blood glucose check and insulin administration. An RN entered the resident's room with a glucometer (with test strip inserted), two insulin pens, a lancet, and alcohol wipes, and placed the glucometer and insulin pens directly on the foot of the resident's bed. After performing hand hygiene and donning gloves, the RN then moved the glucometer to a position above the pillow where the resident's arm was resting to check the blood glucose level, again without using any barrier. The RN did not place a clean, dry paper towel or other barrier under the glucometer or insulin pens on either surface, despite guidance from the American Health Care Association that such equipment should be placed on a paper towel before being set on a resident's table or medication cart. The DON later stated that insulin pens and glucometers should be placed on top of a paper towel before placing them on any surface in residents' rooms. The deficiency also includes improper cleaning of a urine spill in a common area. A CNA was observed assisting another CNA with a urine spill from a leaking urinary catheter collection bag in a wing common area. The CNA placed a dry white towel over a small puddle of urine, donned gloves, wiped up the urine with the towel, and then left the area without further cleaning or disinfection. CDC environmental cleaning procedures for spills of blood or body fluids specify wearing appropriate PPE, confining and wiping up the spill with absorbent material to be disposed of as infectious waste, then thoroughly cleaning with neutral detergent and warm water, disinfecting with a facility-approved intermediate-level disinfectant, and sending reusable supplies for reprocessing. When later asked about the process for cleaning soiled areas, the CNA stated the process was to wear gloves, wipe up the soiled area, and use alcohol or disinfectant wipes, and acknowledged that no disinfectant was used on the urine spill and that the area should have been sanitized and housekeeping notified.
Failure to Provide Proper Written Notice and Explanation Before Room Change
Penalty
Summary
The facility failed to honor a resident’s right to receive written notice and explanation before a room change when staff moved Resident #13 to a new room without properly completing the required written notification. The facility’s “Resident Room Changes & Roommate Rights” policy, revised 8/31/25, required that when a resident is moved at the request of facility staff, the resident, family, and/or representative must receive a written explanation of why the move is required and be given an opportunity to see the new location, meet the new roommate, and ask questions. Resident #13, who had multiple diagnoses including schizoaffective disorder, insomnia, anxiety, depression, and dementia, and was documented as cognitively intact on a quarterly MDS assessment, was re-admitted to the facility and later transferred from one room to another. The “Notice of Room-to-Room Transfer” form for this move, signed 11/13/25, listed only “POA Notified” as the rationale for the transfer, with no further written explanation of the reason for the move. During interview, the Social Services Manager acknowledged that the notification of room change was not filled out correctly and should have identified in writing why the resident was moving rooms. This deficient practice created the potential for psychosocial harm if Resident #13 was not provided an opportunity to see the new location, meet a new roommate, or have questions answered related to the move.
Failure to Notify Physician of Repeated Elevated Blood Pressures
Penalty
Summary
Resident rights related to timely physician and family notification were not honored when abnormal clinical findings were not reported. One resident with multiple diagnoses including schizoaffective disorder, depression, and anxiety had four documented episodes of elevated blood pressure over a 90-day period, with readings of 171/104, 164/98, 171/99, and 173/104. Record review showed no documentation that the physician was notified of any of these elevated blood pressure readings. During an interview on 3/6/26 at 9:20 AM, the DON stated that nurses should have notified the physician immediately of the elevated blood pressures and was unable to provide any documentation that such notification occurred. This failure to notify the physician of abnormal vital signs was identified for 1 of 16 residents reviewed for physician notification and was determined by surveyors to have placed the resident at risk for harm.
Failure to Maintain Homelike Room Environment Due to Unrepaired and Unpainted Walls
Penalty
Summary
Surveyors determined that the facility failed to honor residents' rights to a safe, clean, comfortable, and homelike environment when room walls were left unrepaired and with visible patchwork. The facility's Homelike Environment policy, revised 9/17/25, states that the facility supports residents' rights to such an environment to promote dignity, independence, and quality of life. During observations on 3/2/26, Resident #13's room was found to have a jagged vertical damaged line on the wall from floor to ceiling exposing broken drywall, along with other areas of the walls covered with white patches on top of colored paint. Resident #13, who had been re-admitted with schizoaffective disorder, insomnia, anxiety, depression, and dementia, stated that the white patches and damaged wall had been present since she relocated to the room in November 2025. On the same date, Resident #53's room was observed to have various white patches on painted walls, both small and large, throughout the room. Resident #53, who had been admitted with schizophrenia and COPD, stated that the white patches had been on the walls for as long as she could remember. On 3/5/26, the Maintenance Director reported that the walls in both residents' rooms had been patched and primed and were ready to be painted, but they had not yet been painted. He also stated he was unaware that Resident #13's room had any damaged walls that still needed to be fixed. These observations and statements showed that the facility did not ensure timely repair and consistent painting of residents' room walls, resulting in an environment that did not meet the homelike standard described in the facility's policy.
Inaccurate Identification of Victim and Aggressor in Abuse Report
Penalty
Summary
The facility failed to accurately report which resident was the victim and which was the aggressor in an abuse investigation submitted to the Idaho BFS LTC Reporting System. The facility’s Abuse – Reporting & Response: No Crime Suspected policy required that reports include sufficient detail to describe the nature of the alleged violation and that new or revised information be included in follow-up submissions to ensure completeness and accuracy. An abuse report dated 11/13/25 identified Resident #13 as the victim in a resident-to-resident interaction, documenting that another resident was heard banging on a restroom door while Resident #13 was using it, that Resident #13 exited the bathroom on the other resident’s side and began yelling, and that the other resident reacted by grabbing Resident #13’s shirt without making physical contact. The report further documented that Resident #13 complained of a hurt arm, which was assessed with no injury found, and that Resident #13 was moved to a new room the same day because the facility believed she should not share a bathroom with the other resident for their safety. Resident #13 had been re-admitted to the facility with multiple diagnoses, including schizoaffective disorder, insomnia, anxiety, depression, and dementia. A witness statement dated 11/13/25, however, documented that Resident #13 was the aggressor, entering the other resident’s room and yelling at her, and that the other resident reacted by grabbing Resident #13’s shirt. Despite this conflicting information, the abuse investigation submitted to the state continued to identify Resident #13 as the victim. During an interview on 3/5/26 at 10:21 AM, the Administrator stated he had filled out the report incorrectly and acknowledged that Resident #13 was actually the aggressor, not the victim as documented on the investigation report.
Missing Required Transfer Documentation for Acutely Ill Resident
Penalty
Summary
The facility failed to ensure that required transfer and discharge documentation was included in a resident’s medical record to support communication of essential information to the receiving healthcare provider. A resident admitted with acute respiratory failure, pneumonia, and COPD had a care plan initiated that identified altered respiratory status and directed staff to monitor and report signs of compromised airway. A progress note later documented that the resident was not responding to an albuterol breathing treatment and had declining oxygen saturation requiring a higher level of care, and a Notice of Transfer or Discharge and a bed-hold agreement were completed for an immediate transfer due to urgent medical needs. However, the resident’s record did not contain documentation that the following required information was sent to the receiving provider at the time of transfer: contact information for the practitioner responsible for the resident’s care, resident representative contact information, advance directive information, all special instructions or precautions for ongoing care as appropriate, and comprehensive care plan goals. On review, the DON and CRN confirmed that the required transfer and discharge documentation was missing from the resident’s record.
Inaccurate PASRR Level I Primary Diagnosis Documentation
Penalty
Summary
The facility failed to ensure that a resident’s Preadmission Screening and Resident Review (PASRR) accurately reflected the resident’s primary diagnosis, resulting in an incorrect PASRR Level I determination. The resident was admitted with multiple diagnoses, including major depressive disorder, anxiety disorder, and alcohol dependence, and record review showed the primary diagnosis was recurrent major depressive disorder. However, the PASRR Level I, dated 9/9/25, documented “Yes” in Box 12, indicating the individual had a primary diagnosis of dementia or Alzheimer’s disease. During an interview on 3/5/26 at 4:45 PM, the Social Worker confirmed that this PASRR Level I had been inaccurately completed. This inaccuracy was identified through record review and staff interview, which showed a discrepancy between the documented primary diagnosis in the medical record and the diagnosis selected on the PASRR Level I form.
Failure to Follow Professional Standards in BP Monitoring and Medication Administration
Penalty
Summary
The deficiency involves failures to follow accepted professional standards of clinical practice during care and medication administration for multiple residents. For a resident with end stage renal disease and an AV fistula in the left forearm for hemodialysis, the care plan specified that blood pressures should not be taken on the left arm. Despite this, the resident’s vital sign records showed 18 blood pressure readings documented as taken on the left arm over a 90‑day period. The DON later confirmed the record showed blood pressures taken on the left arm and suggested the person measuring the blood pressure may have documented incorrectly, while also stating there had been no adverse outcomes and that the resident was aware blood pressures should not be taken on that arm. Additional deficiencies were identified in insulin administration and oral medication administration. For a resident with diabetes, physician orders required Novolog (insulin aspart) three times daily and Toujeo (insulin glargine) twice daily. During observation, an RN sanitized and re‑needled both insulin pens, dialed each pen directly to the ordered dose, and administered the injections without priming either pen, contrary to the manufacturers’ Instructions for Use that require priming to ensure proper dosing. For another resident with heart failure, dysphagia, and sleep apnea who was ordered potassium chloride 20 mEq twice daily, an LPN dissolved the potassium chloride in a small amount of water, mixed it with pudding, and administered it. When the resident declined water afterward, the LPN did not provide education about the importance of drinking a full glass of water after taking potassium chloride, despite reference material indicating it should be taken with food or just after a meal and followed with a full glass of water to reduce stomach irritation.
Failure to Implement Care Plan Interventions and Physician Orders for Multiple Residents
Penalty
Summary
The deficiency involves failures to implement resident-centered care plan interventions and physician-ordered treatments for multiple residents. One resident with a history of falls and a need for assistance with personal care was care planned for one-person assistance with ambulation and transfers and for staff to monitor her position in bed and in her wheelchair for safety. While a CNA was assisting with dressing, the resident was left sitting on the edge of the bed while the CNA stepped away to the closet, during which time the resident stood and fell forward, striking her face on the floor. Following this fall, the interdisciplinary team determined that orthostatic blood pressures should be monitored, but the facility was unable to provide any documentation that orthostatic blood pressures were obtained. Another resident with muscle weakness, dementia, and protein-calorie malnutrition had a care plan and physician order directing that pressure-relieving boots be applied bilaterally when in bed and in a wheelchair, but he was repeatedly observed in common areas without the boots, which were seen on his bedside nightstand. An LPN stated the resident only wore the boots in bed, and the DON confirmed the resident should have had the boots on at all times. Additional deficiencies included failure to reassess an elevated blood pressure and to implement a physician-ordered splint. A resident with schizoaffective disorder, depression, and anxiety had a documented blood pressure of 171/104, with no record of a reassessment of the blood pressure or assessment for related symptoms on that date. The DON stated that nurses should have notified the provider and reassessed the resident but could not provide documentation that this occurred. Another resident with heart failure, dysphagia, and sleep apnea had a physician’s order for a carrot splint to the right hand with monitoring for skin alteration twice daily. Despite this order, the resident was observed multiple times with both hands closed in fists and no carrot splint applied. When staff assisted in opening the right hand, pressure marks from the fingertips were noted on the palm, and the DON confirmed that the carrot splint should have been in use as ordered.
Failure to Update Care Plan With Required Dining Room Supervision After Fall
Penalty
Summary
The facility failed to ensure a resident’s fall-prevention intervention was timely incorporated into the care plan, resulting in the resident being left unsupervised in the dining room and experiencing repeat falls. The resident was admitted with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking. On 12/1/25, an IDT fall investigation documented that the resident had fallen from her wheelchair while unattended in the dining room and concluded that she was to be always supervised while in the dining room to avoid future falls. However, this supervision intervention was not added to the resident’s care plan at that time. On 1/23/26, the resident again fell from her wheelchair when a staff member left her unsupervised in the dining room, as documented in a 1/26/26 fall investigation report. The care plan was not revised to include constant supervision in the dining room until 1/27/26, and the DON confirmed that the supervision intervention should have been added in December 2025 but was not. The deficiency centers on the facility’s failure to update the resident’s care plan after the first documented fall and identified intervention, leaving staff without a formalized directive to provide constant supervision in the dining room between early December 2025 and late January 2026. During an interview on 3/4/26, the DON acknowledged that the care plan related to staff supervision for this resident was not added until 1/27/26, despite the IDT’s earlier determination on 12/1/25. When asked if the fall on 1/23/26 could have been prevented had the care plan been updated in December 2025, the DON declined to answer.
Failure to Complete Recommended Antipsychotic Movement-Disorder Monitoring
Penalty
Summary
The facility failed to ensure recommended monitoring for adverse effects of antipsychotic medication was completed for one resident receiving psychoactive medication. The resident was readmitted with multiple diagnoses, including bipolar disorder, anxiety disorder, and traumatic brain injury, and had a care plan directing staff to monitor and report side effects and adverse reactions related to psychoactive medications. A physician’s order documented that the resident was to receive Seroquel 300 mg by mouth once daily for traumatic brain injury. A pharmacy review noted that antipsychotic medications can cause tardive dyskinesia and other movement disorders and recommended that a movement-disorder assessment, such as an AIMS or DISCUS test, be completed at least every six months while the resident remained on antipsychotic therapy. Record review showed the last AIMS assessment was completed more than six months before the pharmacy recommendation and outside the recommended monitoring interval, and the DON confirmed that the pharmacy recommendation had not been acted upon and the record did not contain a current AIMS assessment.
Failure to Monitor and Document Anticonvulsant Side Effects
Penalty
Summary
Surveyors identified a failure to ensure residents’ drug regimens were free from unnecessary drugs by not monitoring for side effects of anticonvulsant medications as required by the residents’ care plans. One resident with major depressive disorder, anxiety disorder, and alcohol dependence had a physician order for Depakote 250 mg by mouth three times a day for alcohol dependence. The resident’s comprehensive person-centered care plan, revised 8/6/25, directed staff to monitor, notify the provider, and document specific anticonvulsant side effects, including over-sedation or lethargy, restless agitation, increased confusion or poor concentration, mental status change, visual disturbance, change in gait, behavioral changes, and weight change. Record review showed no documentation that staff were monitoring for these anticonvulsant side effects. Another resident with borderline personality disorder, Alzheimer’s disease, and suicidal ideations had a physician order for Depakote sprinkles 750 mg by mouth two times a day for borderline personality disorder. This resident’s care plan, revised 10/14/24, contained the same directives for staff to monitor, notify the provider, and document anticonvulsant side effects, listing the same potential symptoms. Record review similarly showed no documentation that staff were monitoring for these side effects. On 3/5/26 at 8:32 AM, the DON confirmed that the records for both residents did not include anticonvulsant monitoring, and the report stated this failure created the potential for harm if side effects were undetected.
Expired Acetaminophen Suppositories Found in Medication Storage Room
Penalty
Summary
Surveyors identified a failure to ensure drugs and biologicals were properly managed and stored when expired medications were found in the facility’s medication storage room. During an inspection of the medication room refrigerator with the ADON, five acetaminophen suppositories with an expiration date of 10/2025 were observed still stored inside. The ADON acknowledged that the acetaminophen suppositories were expired and confirmed they should not have been kept in the refrigerator. This deficiency involved the medication storage area only; no specific residents or administrations of the expired medications were described in the report. The report stated that this failed practice created the potential for adverse effects if residents received expired medications with decreased efficacy.
Failure to Follow Antibiotic Stewardship and McGeer’s Criteria for UTI Treatment
Penalty
Summary
The deficiency involves failure to follow the facility’s Antibiotic Stewardship Policy and McGeer’s Criteria when initiating antibiotic therapy for a suspected urinary tract infection (UTI). The policy, revised 8/10/25, states the facility focuses on improving antibiotic use through an Antibiotic Stewardship Program, utilizes McGeer’s Criteria to validate infections, and routinely reviews culture and sensitivity reports as part of infection surveillance. McGeer’s Criteria for UTI without an indwelling catheter require at least one specified clinical sign or symptom and at least one qualifying microbiologic criterion. Despite these requirements, the facility initiated antibiotic treatment before culture and sensitivity results were available and in a situation later confirmed by the DON not to meet McGeer’s criteria for UTI. The resident involved was readmitted with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care. The resident’s care plan, revised 3/27/25, directed staff to encourage fluids and monitor for specific urinary and systemic symptoms such as urinary frequency, malaise, foul-smelling urine, dysuria, fever, nausea, vomiting, flank pain, suprapubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and behavioral changes. On 3/27/25 at 4:43 PM, the resident was observed to be increasingly lethargic with decreased muscle function, and the provider was notified. New orders were obtained for a CBC, CMP, urinalysis with culture and sensitivity, and cefdinir 300 mg by mouth twice daily for 5 days for a diagnosis of UTI. The urine specimen was collected earlier that day, and the culture and sensitivity were not completed until 3/29/25, three days after antibiotics were started. On 3/5/26 at 4:12 PM, the DON confirmed the resident did not meet McGeer’s criteria for antibiotics for a UTI.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to honor resident rights by not making the past three years of state survey results and plans of correction readily accessible to residents and their representatives. On multiple days of observation, a binder labeled “State Survey Results” was located in a pocket folder on the wall of a corridor leading to the courtyard, but access to the binder was blocked by a stuffed chair with large equipment stacked on it, two vital signs towers, and an extra-large padded specialized wheelchair. During a Resident Council group discussion with surveyors, residents reported they were not aware that the facility was responsible for making the past three years of survey results readily accessible, nor were they aware of their right to review these results and plans of correction, and they stated they did not know where the survey results were posted. The Administrator later confirmed that the survey results were not accessible because they were blocked by stored equipment. No specific resident medical histories or clinical conditions were described in relation to this deficiency.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours per day, 7 days a week, as required. This deficiency was identified during a review of the facility's staffing records and staff interviews, which revealed that on one of the 38 days reviewed, specifically on 9/1/24, there was no RN on duty for the required duration. Instead, the RN duties were covered by a Licensed Practical Nurse (LPN) on that day. This lapse in staffing created the potential for harm if routine and/or emergency nursing needs went unmet, potentially affecting all residents living in the facility.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to appropriately store, label, and serve foods, as observed during a survey. The Idaho Food Code requires that refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours must be clearly marked with a date by which the food should be consumed, sold, or discarded. The facility's policy also mandates labeling of opened food products with contents and use-by dates. However, during the survey, three outdated yogurts with a date of 10/2/24 were found in the walk-in refrigerator on 10/7/24. Additionally, an ice cream container with an open date of 9/2/24 and a use-by date of 10/2/24 was observed in the resident snack freezer on 10/9/24. The Certified Dietary Manager (CDM) acknowledged that these items should have been removed by their respective use-by dates.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, as evidenced by incomplete physician orders and improper oxygen administration. Resident #5, diagnosed with panic disorder and dementia, was observed without his oxygen nasal cannula after being transferred to bed. A CNA admitted that the oxygen should have been in use at all times, as per a physician's order for 2 liters per minute via nasal cannula, but it was not replaced after the transfer. Resident #32, with diagnoses including hemiplegia and end-stage renal disease, had an incomplete medical order for oxygen usage that lacked the duration of use. Similarly, Resident #47, who had acute respiratory failure with hypoxia and chronic obstructive pulmonary disease, was observed with a nasal cannula attached to a portable oxygen unit set at zero liters per minute, contrary to the physician's order for 2 liters per minute. The medical record for Resident #47 also had an incomplete order lacking the duration of use, which was confirmed by a CRN.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide a resident with written notice prior to a room change, which is a violation of the resident's rights. The deficiency involved a resident who was initially admitted to the facility with multiple diagnoses, including schizoaffective disorder, borderline personality disorder, COPD, and diabetes. The resident was transferred from a single-bed room to a four-bed room on January 3, 2024, without receiving the required written notice. During an interview, a Clinical Registered Nurse (CRN) confirmed that there was no documentation in the resident's record indicating that the resident had been notified in advance of the room change.
Peeling Paint in Shower Room Compromises Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, specifically in one of the three shower rooms observed. On October 8, 2024, at 9:22 AM, it was observed that the paint was peeling away from the ceiling in various areas of the east shower room. A Certified Nursing Assistant (CNA) mentioned that the paint had started peeling a few months ago. Upon reviewing the facility's maintenance work orders for the past six months, no work order was found for the peeling paint issue. Later that day, at 3:30 PM, the Maintenance Director stated that he was not aware of the peeling paint in the east hall shower room and acknowledged that it needed to be fixed. This oversight created the potential for a diminished quality of life for all residents using the east shower room.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by an incident involving two residents. Resident #111, who had a history of dementia and hypertension, exhibited aggressive behavior towards Resident #32, who was diagnosed with hemiplegia and end-stage renal disease. On one occasion, Resident #111 approached Resident #32 from behind and placed him in a chokehold, threatening to kill him. This incident was part of a pattern of aggressive behavior by Resident #111, who had previously yelled at another resident and lunged at their neck, as well as pushed Resident #32 in his wheelchair, causing him to bump his knee into a cabinet. The facility's investigation into the incident on 3/9/24 revealed that the administrator believed Resident #111 intended to harm Resident #32. Despite the aggressive behavior exhibited by Resident #111, the facility did not take adequate measures to prevent further incidents, thereby failing to ensure the safety and protection of its residents. The lack of timely intervention and effective management of Resident #111's behavior placed all residents at risk of ongoing abuse and potential harm.
Failure to Provide Bed-Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives upon transfer to the hospital, as evidenced by the case of a resident with multiple diagnoses including schizoaffective disorder, borderline personality disorder, COPD, and diabetes. This resident was initially admitted to the facility and later readmitted, with a documented transfer to the hospital for evaluation and treatment of worsening respiratory symptoms. However, there was no documentation in the resident's record indicating that a bed-hold notice was provided at the time of transfer. During an interview, the Director of Nursing confirmed the absence of documentation for the bed-hold notice, highlighting a deficiency in the facility's process for informing residents or their representatives of their right to return to their former bed within a specified time frame.
Failure to Complete PASARR Level 2 Evaluations for Residents with Major Mental Illness
Penalty
Summary
The facility failed to refer residents for further evaluation when diagnosed with a major mental illness, as required by the Pre-Admission Screening and Resident Review (PASARR) program. This deficiency was identified for two residents who were reviewed for PASARR level 2 evaluations. The facility's policy mandates that positive level 1 PASARR screenings, indicating a major mental illness, must be forwarded to the state-designated authority for a level 2 evaluation. However, this procedure was not followed for the residents in question. One resident was admitted with multiple diagnoses, including bipolar disease, and was prescribed antianxiety and antipsychotic medications. Despite the diagnosis of bipolar disease, the resident's medical record lacked a completed PASARR level 1 screening or a level 2 evaluation. Another resident, admitted with schizophrenia and non-Alzheimer's dementia, had a PASARR level 1 screening completed 36 days post-admission, which identified schizophrenia as a major mental illness. The screening instructed that it be forwarded for a level 2 evaluation, but the resident's medical record did not document the completion of this evaluation. The facility's Clinical Resource Nurse confirmed the absence of PASARR level 2 evaluations for both residents.
Failure to Complete Timely PASARR Screenings
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) was completed within the required timeframe for two residents. According to the facility's policy, a PASARR Level 1 should be completed prior to admission. However, for Resident #42, who was admitted with diagnoses including bipolar disease, there was no documentation of a PASARR Level 1 being completed. This resident's care plan and admission MDS indicated the presence of a mental disorder, yet the necessary screening was not conducted as required. Similarly, Resident #46, admitted with schizophrenia and non-Alzheimer's dementia, did not have a PASARR Level 1 completed prior to admission. The screening was only completed 36 days after admission, revealing a major mental illness and necessitating a PASARR Level 2 evaluation. The absence of timely PASARR screenings for these residents indicates a failure to comply with regulatory requirements, potentially impacting the provision of specialized mental health services.
Failure to Revise Care Plan for Fall Intervention
Penalty
Summary
The facility failed to revise a comprehensive person-centered care plan for a resident who required 30-minute checks following a fall. The resident, who had been admitted with diagnoses including Parkinson's disease and bipolar disorder, had a care plan that documented the need for 30-minute checks due to a fall on June 9, 2024. An interdisciplinary team progress note dated June 15, 2024, confirmed the plan for continuous 30-minute checks for increased safety. However, the resident's medical record did not document that these checks were performed. On October 10, 2024, the Director of Nursing acknowledged that the care plan should have been updated and the 30-minute checks should have been removed.
Deficiencies in Resident Transfer and Weight Monitoring
Penalty
Summary
The facility failed to adhere to standard practices during resident transfers and did not follow a comprehensive person-centered care plan to maintain resident body weight. For one resident with major depressive disorder and dementia, a CNA used the resident's belt loop instead of a gait belt during a bed to wheelchair transfer, contrary to the facility's policy that mandates the use of gait belts for safety. Another resident with dementia and diabetes experienced a 5.84% weight loss over a month, but there was no documentation that the medical director was notified of this significant change, as required by the care plan. These deficiencies created the potential for harm or adverse outcomes.
Failure to Provide Call Light Access
Penalty
Summary
The facility failed to ensure that all residents had access to their call lights while in bed, as observed in the case of Resident #5. Resident #5, who was admitted with multiple diagnoses including panic disorder and dementia, had a care plan initiated on 3/17/23 directing staff to keep his call light button within reach. On 10/8/24, it was observed that Resident #5 was in bed without access to his call light, which was placed across the room on his dresser. Resident #5 reported yelling for help due to pain but was not heard by staff. CNA #3 admitted to forgetting to provide Resident #5 with his call light. The Director of Nursing confirmed that staff should ensure all residents have access to their call lights while in bed.
Deficient Shower Floor Safety
Penalty
Summary
The facility failed to provide safe shower floors for residents using the east shower room, which had the potential to cause harm due to slips or falls. Resident #51, who was admitted with multiple diagnoses including stroke and diabetes, reported that the shower floor was very slippery and he had almost fallen because the anti-slip pads were missing. On observation, it was confirmed that the non-slip strips in the east hall shower room had peeled up and were missing. CNA #2 stated that the non-slip strips had been missing for about two months, and a work order had been submitted, but no action had been taken. The Maintenance Director acknowledged the need to replace the missing non-slip strips. A work order for the non-slip strips was created on 8/15/24, but the strips were not replaced until 10/8/24.
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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