Eagle Rock Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Idaho Falls, Idaho.
- Location
- 840 East Elva Street, Idaho Falls, Idaho 83401
- CMS Provider Number
- 135092
- Inspections on file
- 21
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Eagle Rock Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that the facility failed to document that required pertinent health information, including care plan goals and advance directive details, was provided to hospitals when multiple residents were transferred for issues such as falls with head injuries, lacerations, respiratory problems, altered mental status, chest pain, and gastrointestinal symptoms. Although eINTERACT transfer forms were completed in the EHR, the residents’ records did not show that this critical information accompanied them to the receiving facilities, contrary to the facility’s discharge and transfer policy.
The facility did not complete and lock baseline care plans within 48 hours of admission for two residents with conditions including chronic respiratory failure, dementia, diabetes, and need for assistance with personal care, contrary to facility policy. In addition, the facility did not document that baseline care plans were provided and discussed with five cognitively intact or medically complex residents, including those with COPD, CKD, bipolar disorder, anxiety, interstitial lung disease, heart failure, and obstructive sleep apnea, or with their representatives. The CNO acknowledged that required baseline care plans were either not completed timely or not documented as shared with residents or their representatives.
Surveyors found that medications and treatment supplies on two medication carts and one treatment cart were not properly labeled, dated, or secured. On one cart, eye drops had illegible labels with old open dates and glucose test strips lacked an open date, while staff stated these items should only be used for 30 days after opening. A treatment cart containing medicated creams was observed unlocked in a hallway, and another cart contained undated glucose test strips, with an RN acknowledging they should have been dated and being unsure of their post-opening usability period.
The facility failed to follow infection control policies for oxygen and respiratory equipment and for disinfection of a shared glucometer. Multiple residents’ CPAP/BIPAP/VPAP masks, nebulizer masks, and oxygen tubing were observed uncovered on dressers, walkers, wheelchairs, and on the floor, rather than cleaned and stored in labeled bags as required. In one case, an RN placed oxygen tubing that had been on the floor directly into a storage bag without cleaning. A resident with COPD, depression, and cardiomegaly, ordered to receive continuous oxygen via nasal cannula, had the cannula picked up from the floor and reapplied by a CNA instead of being replaced. An LPN used a glucometer on a resident and wiped it with a disinfecting wipe but did not ensure the device remained wet for the full required contact time before returning it to its case, despite acknowledging the stated 2-minute dry time.
Surveyors found that staff failed to maintain resident dignity during personal care and catheter management. In one case, a CNA removed a resident’s shirt without closing the privacy curtain while the roommate was present. In another case, a resident’s urinary catheter bag was left uncovered and visible from the hallway with the room door open, despite facility policy requiring catheter bags to be covered to promote dignity.
A resident with COPD, depression, and cardiomegaly was started on Aripiprazole 5 mg daily without informed consent being obtained prior to initiation. Review of records showed that the psychoactive medication informed consent form, which included Aripiprazole along with Bupropion and Fluoxetine, was signed only after the medication had already been started. The CEO confirmed that a psychotropic medication acknowledgement consent should have been signed before Aripiprazole was administered but was not.
A resident with paraplegia and depression was found with two ophthalmic medications (artificial tears and prednisolone acetate) stored at the bedside, despite facility policy requiring an assessment and physician order before self-administration and bedside storage. An LPN and the CNO both stated the resident should not have had eye drops at the bedside, and the IDT self-administration assessment documented that the ability to correctly administer eye drops was marked as not applicable. The resident’s record contained active physician orders for both eye medications, but there was no approval by the IDT for self-administration of eye medications, resulting in a failure to follow the facility’s self-administration policy.
The facility failed to assist a resident in exercising the right to formulate an advance directive. A resident with quadriplegia and depression had a POST form in the medical record but no documented advance directive and no documentation that the facility informed the resident or provided written information about the right to create one. The Administrator confirmed that only POST documents were on file for this resident, with no evidence of required advance directive information being provided.
Staff failed to maintain a safe, clean, and homelike environment in multiple areas, including two resident rooms and several shower rooms. One room had torn door frame molding with sharp, jagged edges, and another had a broken electrical outlet with jagged edges. Shower rooms had broken and missing floor tiles, rusted and broken wall heaters (including one with exposed wiring and another partially detached from the floor), dark black residue in grout and around drains, and large amounts of hair on a shower stall floor. A CNA reported the shower rooms did not appear to have been cleaned, and the Maintenance Director stated he was unaware of the needed repairs and the poor condition of the shower rooms.
Surveyors found that the facility did not review and implement hospital discharge instructions for two residents who used respiratory support devices. One resident with chronic respiratory failure and sleep apnea had a CPAP machine in the room and reported using it at night, but there was no corresponding physician order, care plan entry, or MDS documentation. Another resident with COPD and chronic kidney disease had an AVAP machine with detailed hospital transfer orders specifying pressure settings, respiratory rate, tidal volume, and O2 bleed-in parameters, yet no physician orders for AVAP use were entered in the medical record. The CNO confirmed that orders for both devices were missing, placing these residents at risk of delayed respiratory care and assessments.
A resident with chronic respiratory failure with hypoxia and dementia was started on hospice care per physician order and care plan documentation, but the facility did not complete the required significant change in condition/status MDS assessment within 14 days of this change. The MDS coordinator and CNO both acknowledged that the significant change MDS should have been completed but was not, resulting in the resident’s status not being accurately reflected in the assessment.
The facility failed to correctly complete a PASARR Level I screening for a resident with documented chronic PTSD and anxiety disorders, as required by facility policy. The resident’s Level I screenings did not include these mental health diagnoses, which should have triggered a PASARR Level II evaluation by the state-designated authority prior to admission. Review of the medical record showed that, despite the documented PTSD diagnosis, there was no evidence that a Level II PASARR had been completed by the time of surveyor review, indicating that the required in-depth evaluation and determination letter were not obtained as mandated.
A resident with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, did not have their PTSD addressed in the comprehensive person-centered care plan, despite facility policy requiring that all individual conditions and needs be reflected with measurable goals and interventions. Review of the care plan showed no focus, interventions, or tasks related to PTSD, and the CNO acknowledged that the PTSD diagnosis should have been included in the care plan but was not.
Surveyors found that the facility did not revise care plans to include new physician orders for two residents. One resident with a right leg fracture and edema had an order for a Tubi grip for edema management, but this intervention was not added to the care plan or TAR, and the resident was repeatedly observed without the Tubi grip in place despite reporting ongoing swelling. Another resident with COPD, depression, and cardiomegaly had a new order for continuous O2 at 3 LPM via NC, but the care plan still listed only older O2 orders at different settings and was not updated to reflect the current prescription.
Two residents experienced deficiencies in care when physician orders and facility protocols were not followed. One resident with Parkinson's disease and chronic kidney disease went more than four days between documented BMs without bowel protocol medications being administered or physician notification documented, despite standing orders outlining stepwise interventions. Another resident with interstitial lung disease and heart failure had a PICC line with an undated, loose dressing and unsecured tubing, and nursing staff could not locate current orders for the line after IV antibiotic therapy had ended, nor confirm whether it should still be in use or removed.
A resident with paraplegia and dysphagia, who received medications via an enteral tube, had a physician order requiring tube placement to be checked by auscultation before medication administration. An RN administered water and liquid hydroxyzine HCl through the tube and flushed it without verifying tube placement. The facility’s policy referenced following professional standards and verifying tube placement per protocol, but the RN reported not knowing the policy on checking placement or residual, and the CNO stated the G-tube policy did not require checking placement or residual before medications or feedings, relying only on x-ray at insertion. This resulted in a deficiency related to inadequate care and treatment for enteral tube use.
The facility failed to follow physician orders and manufacturer instructions for oxygen and PAP therapy for three residents. One resident with COPD and cardiomegaly had an order for continuous O2 at 3 LPM via nasal cannula but was repeatedly observed without the cannula in place. Another resident with PTSD and obstructive sleep apnea had orders for CPAP with supplemental O2 at HS and O2 every shift, yet was observed not using O2 during the day, and oxygen was allowed to bleed into a CPAP device that was turned off without the required pressure valve installed. A third resident with osteomyelitis and a lumbar fracture had an order and care plan for continuous 2 LPM O2 to maintain SpO2 ≥ 90%, but was observed off oxygen and had documented SpO2 readings of 88% on room air. The CNO acknowledged staff had not ensured ordered oxygen use and was unaware of the required pressure valve for PAP devices.
A resident with acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture had a care plan calling for non-pharmacological pain interventions in addition to PRN Hydrocodone-Acetaminophen. Review of the MAR showed that staff administered the PRN opioid on multiple occasions without any documented attempt to use non-pharmacological pain management beforehand, contrary to facility policy and the resident’s care plan. The CNO acknowledged that non-pharmacological interventions should have been offered prior to giving the hydrocodone but were not, resulting in inadequate pain management.
The facility failed to ensure staff competency in medication administration when an LPN administered Metoprolol to a resident with interstitial lung disease, heart failure, and hypertension without obtaining required vital signs beforehand, despite a physician order to hold the drug for SBP < 100 or HR < 50 and a facility policy and completed competency indicating vital signs must be taken prior to preparing parameter-based medications. This issue was identified in 1 of 5 nurses observed and was determined to have the potential to affect all residents and increase the risk of harm.
The facility failed to accurately complete and post daily nurse staffing information for all shifts, resulting in multiple days where RN, LPN, or CNA staffing data were missing or entire staffing sheets were not available. On several occasions, posted information lacked RN or LPN data for specific shifts, omitted CNA data for all shifts, or showed only one RN for part of a shift with no other licensed nurses listed. The Staffing Coordinator later acknowledged that these staffing sheets and data should not have been missing but were, affecting the ability of residents, their representatives, visitors, and others to review accurate staffing levels.
A resident with COPD and diabetes was moved to a different room without receiving the required prior written notice explaining the nature and date of the transfer. Review of the medical record and staff interviews confirmed that no written documentation was provided to the resident regarding the room change.
The facility did not send required discharge or transfer notices to the State LTC Ombudsman for three residents with complex medical needs who were transferred to the emergency department or discharged to another care setting. This failure occurred over several months when the Social Worker position was vacant, and no documentation of notification was found in the residents' records.
A resident with documented allergies to tomatoes and melon was served a meal containing a tomato-based sauce, despite these allergies being clearly noted in the medical record and on the meal ticket. The food service manager confirmed the error after investigation, indicating a failure to follow the facility's nutrition policy regarding accommodation of dietary needs.
The facility failed to maintain kitchen sanitation and proper food storage, with food items stored only 4.5 inches above the floor and a pink slimy substance found in the ice machine. Kitchen cookware had black residue despite being cleaned, and dust particles were observed in the walk-in refrigerator. These issues were confirmed by the Culinary Director and Registered Dietitian.
The facility failed to develop comprehensive care plans for four residents, leading to deficiencies in their care. A resident with dementia did not have care directions for her condition, while another with a foley catheter lacked care instructions in his plan. A third resident's activity preferences were not addressed, and a fourth resident's care plan did not reflect new orders for a foley catheter. The CEO confirmed these omissions.
A facility failed to update a resident's care plan after changes in medication orders, despite the resident having multiple diagnoses including bipolar and psychotic disorders. The care plan still documented the use of antidepressant medications even after they were discontinued, as confirmed by the CEO. This oversight risked adverse outcomes due to the care plan not reflecting the resident's current needs.
A resident with COPD was found receiving oxygen therapy at two liters per minute, contrary to the physician's order of one liter per minute. This discrepancy was confirmed by an RN, highlighting a failure to adhere to prescribed oxygen therapy, potentially compromising the resident's respiratory care.
Two residents in an LTC facility experienced significant medication errors. One resident received incorrect doses of oxycodone due to a transcription error in the MAR, while another received a lower dose of Lyrica than prescribed. These errors were confirmed by the CEO, indicating a failure in ensuring accurate medication administration.
Two residents in a facility experienced significant medication errors. One resident was hospitalized after receiving another resident's medications due to an LPN's confusion over room assignments and similar first names. Another resident was potentially given the wrong insulin type, but did not require further medical intervention. The errors were confirmed by the DNS and Regional Clinical RN.
A resident's medications were crushed and mixed with food without a physician's order, and Levothyroxine was administered at night instead of the prescribed 5:30 AM. The LPN altered the administration time to avoid waking the resident early, and the facility's DNS and Regional Clinical RN were unaware of these practices until informed by surveyors.
A facility failed to remove discontinued hydrocodone from a medication cart, affecting a resident with multiple diagnoses, including metabolic acidosis, diabetes, and hypertension. The medication was discontinued but remained in the cart, posing a risk for medication errors and diversion. An LPN acknowledged the oversight, and the CRN confirmed that such medications should be removed by the next working day.
A medication labeling deficiency was identified when a resident's blister pack for oxycodone 5 mg did not reflect the updated order of four times a day (every 6 hours) and instead stated every 4 hours as needed. This was discovered during a medication cart inspection with an LPN present. The resident had multiple diagnoses, including a left arm fracture, heart failure, hypertension, and pain, and had their medication order changed, but the label was not updated accordingly.
Failure to Document Transmission of Pertinent Health Information During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pertinent health information, including care plan goals and advance directive information, was provided to receiving hospitals when residents were transferred. Policy review showed that the facility’s “Discharge or Transfer” policy, revised on 8/30/25, required that information conveyed to receiving providers for residents being transferred or discharged be provided in accordance with federal guidance. Despite this policy, surveyors found multiple instances where the medical records did not contain documentation that the required information was sent with the residents at the time of transfer. For one resident with progressive supranuclear ophthalmoplegia and a history of pulmonary embolism, eINTERACT Transfer Forms documented several discharges to the hospital for head pain and falls on multiple dates. However, for each of these transfers, the resident’s medical record lacked documentation that care plan goals and advance directive information were provided to the hospital. Another resident with Parkinson’s disease and chronic kidney disease was transferred to the hospital for lacerations on two separate occasions, and in both cases, the medical record did not show that the required pertinent medical information, including care plan goals and advance directives, was sent to the receiving facility. Additional residents with diagnoses such as bipolar disorder, anxiety, COPD, obstructive sleep apnea, heart failure, and COPD were also transferred to the hospital on multiple occasions for issues including shortness of breath, pain, diarrhea, elevated heart rate, altered mental status, chest pain, and other conditions. For each of these transfers, the medical records similarly lacked documentation that care plan goals and advance directive information were provided to the receiving hospitals. During an interview, the CNO stated that nurses had completed the eINTERACT charting in Point Click Care but had not documented which forms were sent to the hospital, acknowledging that this documentation should have been completed.
Failure to Complete and Share Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to complete and lock baseline care plans within 48 hours of admission for two residents and failed to provide and document provision of baseline care plan summaries to several other residents or their representatives. Policy revised 9/3/25 required initiation of a baseline care plan for each resident within 48 hours of admission, and that the facility review and provide the resident and/or representative with a summary of the baseline care plan and provider orders in an understandable language, with evidence of this in the medical record. Resident #4, admitted with chronic respiratory failure with hypoxia and dementia, had a baseline care plan that was not signed and locked until four days after admission, and the CNO confirmed it should have been completed and locked within 48 hours. Resident #70, initially admitted and later readmitted with diabetes and a need for assistance with personal care, had no baseline care plan documented in the medical record, which the CNO also confirmed. The facility also did not document that baseline care plans were provided and discussed with five residents or their representatives. Resident #7, with bipolar disorder and anxiety and assessed as cognitively intact on a quarterly MDS, had a 48-hour care plan form that did not document that she or her representative received a copy of the baseline care plan. Resident #9, with COPD and chronic kidney disease and documented as cognitively intact on a comprehensive MDS, had no documentation in the medical record that a baseline care plan was provided and discussed with her or her representative. Residents #11, #21, and #28, each with multiple diagnoses including COPD, obstructive sleep apnea, interstitial lung disease, heart failure, and COPD, similarly had no documentation that their baseline care plans were provided and discussed with them or their representatives. The CNO stated there was no documentation that these residents or their representatives had received copies of their baseline care plans.
Improper Medication Labeling, Dating, and Security on Medication and Treatment Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were properly labeled, dated, and securely stored in accordance with its own “Medication Storage In The Facility” policy. The policy required all medications to be stored in pharmacy-labeled containers, for outdated or deteriorated medications to be immediately removed and destroyed, and for certain products such as ophthalmic solutions and blood sugar testing supplies to be assigned shortened expiration dates once opened. During observation of the Yellowstone Hall medication cart, surveyors found a bottle of eye drops with an illegible label and an open date of 12/20/25, another bottle of eye drops with an illegible label and an open date of 2/20/26, and a bottle of glucose test strips with no open date. The LPN present stated that eye drops and glucometer strips were considered good for only 30 days after opening, acknowledged the eye drops should have been wasted, and that the undated strips should have been discarded. The CNO later stated that eye drop bottles should be dated with the open date and that he would need to check pharmacy policy for the exact duration of use. Additional observations showed failures in securing medication and treatment supplies. A treatment cart was observed unlocked in a hallway outside a resident room, and an LPN confirmed that the cart contained medicated creams and should have been locked. On a separate medication storage observation of the Mesa Falls Hall medication cart, surveyors again found an undated bottle of glucose test strips. The RN present acknowledged that the strips should have been dated when opened and was unsure how long they remained usable after opening. These findings demonstrated that medications and treatment supplies on multiple carts were not consistently dated, labeled legibly, or kept locked and inaccessible as required by facility policy.
Failure to Maintain Infection Control for Oxygen Equipment and Glucometer Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies for oxygen and respiratory equipment storage/handling and for disinfection of shared blood glucose meters. Facility policy required oxygen and respiratory supplies to be changed weekly and when visibly soiled, and to be stored in labeled bags when not in use. Observations showed multiple residents’ respiratory devices and oxygen supplies left uncovered and improperly stored: a CPAP lying uncovered on a dresser, a nebulizer mask hanging uncovered on a walker, oxygen nasal cannula tubing lying on the floor, a BIPAP mask on a dresser and oxygen tubing draped over a wheelchair uncovered, and a VPAP mask lying over the machine uncovered. In one instance, an RN acknowledged that oxygen tubing should not be on the floor and nebulizers should not be stored on walkers, but then placed tubing that had been on the floor directly into an oxygen bag without cleaning and placed a nebulizer mask on a dresser. The Infection Preventionist later stated that oxygen tubing should be bagged when not in use, nebulizer masks should be cleaned and dried after each use, and CPAP/BIPAP/VPAP equipment should be cleaned and set up for nighttime use. The facility also failed to follow manufacturer instructions for disinfecting a shared glucometer. The TRUE METRIX Pro Glucose Meter manual required use of PDI Super Sani Cloth (or equivalent EPA-registered product) with all external surfaces kept wet for 2 minutes to disinfect the device. An LPN checked a resident’s blood sugar, wiped the glucometer with a Sani wipe, and then immediately returned it to its case, later stating that although she knew the dry time was 2 minutes, she did not realize the meter had to remain wet for that duration. Additionally, a resident with COPD, depression, and cardiomegaly had a physician order for continuous oxygen at 3 LPM via nasal cannula. This resident was observed not wearing oxygen, and a CNA picked the nasal cannula up from the floor and assisted the resident in placing it without replacing the tubing. The CNA stated the cannula and tubing should have been discarded and replaced when found on the floor, and the CNO confirmed oxygen supplies should be discarded and replaced weekly or when found on the floor and not used.
Failure to Maintain Resident Dignity During Personal Care and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect in accordance with its Dignity policy dated 9/12/25, which states that each resident has the right to be treated with dignity and respect and specifies avoiding demeaning practices such as leaving urinary catheter bags uncovered. For one resident with diabetes and a need for assistance with personal care, a CNA removed the resident’s shirt without pulling the privacy curtain, even though the resident’s roommate was present in the room and able to observe the undressing. The resident later stated she usually pulls the curtain so her roommate cannot see her being changed but had forgotten on this occasion, and the CNA acknowledged she should have provided privacy before removing the shirt. For another resident with multiple diagnoses including enterocolitis due to Clostridium difficile and COPD, surveyors observed from the hallway that the resident’s urinary catheter bag was hanging on the side of the bed without a privacy bag or cover, with the room door open and the bag visible from the hallway. Nursing staff later stated the catheter bag had not been covered because the resident had just returned to the room and that the CNA must have forgotten to cover it. The CNO confirmed that the catheter bag should have been covered or placed in a privacy bag and that it had not been, contrary to the facility’s policy on promoting resident dignity.
Failure to Obtain Informed Consent Before Initiating Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to initiating a psychotropic medication for one resident reviewed for unnecessary medications. The resident, who had diagnoses including COPD, depression, and cardiomegaly, was ordered Aripiprazole 5 mg by mouth once daily on 11/27/25. Record review showed that the resident’s Psychoactive Medication Informed Consent form, which listed Aripiprazole 5 mg along with Bupropion 150 mg and Fluoxetine 40 mg, was not signed until 1/16/26, after the medication had already been started. In an interview, the CEO acknowledged that the resident should have signed a Psychotropic Medication Acknowledgement Consent prior to administration of Aripiprazole but had not done so.
Failure to Assess and Authorize Resident Self-Administration of Eye Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy for assessing and authorizing resident self-administration of medications. The facility’s Self-Administration of Medication policy, revised 9/16/25, states that residents may self-administer medications when it is determined to be safe and appropriate, that the assessment will include whether bedside storage is appropriate, and that if self-administration is approved, a physician’s order will be obtained and the care plan updated. Resident #59, who had diagnoses including paraplegia and depression, was observed on 3/30/26 at 10:07 AM with one bottle of Artificial Tears eye drops and one bottle of Prednisolone Acetate eye drops sitting on the bedside table. At 10:22 AM the same day, an LPN stated that this resident should not have had the Artificial Tears and Prednisolone Acetate eye drops at the bedside. Review of the resident’s medical record at 1:27 PM showed an IDT self-administration assessment dated 3/17/26, in which the criterion "Can correctly administer eye drops or eye ointments according to proper procedure" was marked as "Not applicable." The medical record also contained physician orders for Prednisolone Acetate ophthalmic suspension 1% with a start date of 3/19/26 and Artificial Tears ophthalmic solution 0.2-0.2-1% with a start date of 3/20/26. On 3/31/26 at 5:17 PM, the CNO confirmed that the resident should not have had eye drops at the bedside and had not been approved by the IDT for self-administration of eye medications. The report states this failure created the potential for adverse effects if medications were self-administered inappropriately by the resident.
Failure to Assist Resident in Formulating an Advance Directive
Penalty
Summary
The facility failed to ensure a resident and their representative received assistance to exercise the right to formulate an advance directive. Record review showed that one resident, admitted with multiple diagnoses including quadriplegia and depression, had a Physician Orders for Scope of Treatment (POST) form in the medical record but no documented advance directive. The record also lacked documentation that the facility had informed the resident or provided written information about the right to formulate an advance directive. During interview, the Administrator stated that the facility only had POST documents for this resident, confirming the absence of advance directive documentation or evidence of required information being provided. This deficient practice created the potential for harm or adverse outcomes if the resident’s wishes were not followed or documented regarding their advance care planning.
Environmental Hazards and Poor Sanitation in Resident Rooms and Shower Areas
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident care areas, including two resident rooms and several shower rooms. In one resident room, the door frame protective molding was torn with sharp, jagged edges, and in another room, an electrical wall outlet was broken with jagged edges. These conditions were directly observed by surveyors on multiple dates. The Maintenance Director later stated he had been unaware of the needed repairs to the room door frame molding and the broken electrical outlet. Additional environmental deficiencies were observed in several shower rooms. In the Grand Teton Hall shower room, the tile floor at the entry door had broken tile and missing grout. In the Palisades Hall shower room, the wall heater had broken and rusted areas on the front and sides, with the heater base broken, jagged, and partially disconnected from the floor; the tile floor had dark black residue in the grout and around the floor drain, and several broken floor tiles with open divots and dark black residue in the exposed areas. In the Mesa Hall shower room, the wall heater cover was removed and lying on the floor, leaving exposed wiring on the bottom side of the heater. A CNA stated the shower rooms did not look like they had been cleaned and should have been. Later observation of the Palisades Hall shower stall revealed a large amount of dark strands of hair in the drain and on the shower stall floor. The Maintenance Director also stated he was unaware that the heaters needed repair and that the shower rooms did not appear to have been cleaned.
Failure to Implement Respiratory Device Orders on Admission
Penalty
Summary
The facility failed to ensure hospital discharge instructions were reviewed upon admission so that physician orders were in place to meet residents’ medical needs. One resident with chronic respiratory failure with hypoxia and obstructive sleep apnea was admitted with a CPAP machine present in his room and reported using it at night. Surveyors observed the CPAP machine on the resident’s dresser, and the resident confirmed nighttime use. However, the Chief Nursing Officer (CNO) later stated that there was no physician order for the CPAP, and it was not included on the resident’s care plan or Minimum Data Set (MDS), despite the resident’s diagnoses and reported use of the device. Another resident admitted with COPD and chronic kidney disease had an AVAP machine at bedside and stated she used it at night to help her breathe while sleeping. Review of this resident’s hospital transfer orders documented detailed AVAP settings, including IPAP and EPAP ranges, respiratory rate, tidal volume, and oxygen bleed-in parameters with humidification and SpO2 targets, as well as instructions for use each night. Despite these specific hospital discharge instructions, review of the resident’s medical record on a later date showed no physician orders for AVAP use. The CNO confirmed that the AVAP was not on the resident’s orders and acknowledged it should have been, and the survey findings stated that this failure placed the residents at risk of delayed respiratory care and assessments.
Failure to Complete Significant Change MDS After Initiation of Hospice Care
Penalty
Summary
The facility failed to complete a significant change in condition or status assessment MDS within 14 days after a resident began hospice care, resulting in an inaccurate reflection of the resident’s status. The resident was admitted with multiple diagnoses, including chronic respiratory failure with hypoxia and dementia. A physician order dated 2/19/26 documented end-of-life care with hospice services, and the resident’s care plan also documented that hospice care started on that date. Despite this documented change in condition and care approach, the facility did not complete the required significant change MDS assessment within the mandated timeframe. On 3/31/26, the MDS coordinator acknowledged that the significant change assessment had not been completed and stated it should have been. On 4/1/26, the CNO similarly stated that the significant change in condition or status assessment MDS should have been completed within 14 days of the start of hospice care and had not been. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments.
Failure to Accurately Complete PASARR Level I and Initiate Required Level II Evaluation
Penalty
Summary
The facility failed to ensure that a Level I Pre-admission Screening and Resident Review (PASARR I) was completed correctly for one resident, resulting in an omission of documented mental health diagnoses that should have triggered a Level II PASARR. Facility policy dated 8/29/25 required that a Level I PASRR be completed on potential admissions prior to admission, with a positive Level I screen leading to an in-depth Level II evaluation by the state-designated authority and a determination letter obtained prior to admission. The resident, who was initially admitted and later readmitted with multiple diagnoses including chronic post-traumatic stress disorder (PTSD) and joint replacement surgery aftercare, had Level I PASRR screenings dated 3/3/26 and 3/13/26 that did not document his PTSD and anxiety disorders. The resident’s medical record on 3/3/26 showed a medical diagnosis of chronic PTSD, yet as of 3/30/26 at 12:00 PM there was no documentation that a Level II PASARR had been completed, despite these qualifying mental health conditions. Staff later acknowledged that a Level II PASARR had only just been completed and sent for review, confirming that the required Level II process had not been initiated in a timely manner based on the resident’s documented diagnoses. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility.
Failure to Care Plan for Resident’s PTSD Diagnosis
Penalty
Summary
Surveyors found that the facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s diagnosed Post-Traumatic Stress Disorder (PTSD). The facility’s policy on Comprehensive Care Plan and Conferences, dated 9/3/25, required that care plans reflect residents’ individual conditions, risks, needs, behaviors, cultural values, and preferences, and include measurable goals, appropriate interventions, and realistic timeframes. Resident #13 was initially admitted and later readmitted with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, and the medical record dated 3/3/26 documented a diagnosis of chronic PTSD. However, on 3/31/26 at 2:09 PM, review of the resident’s care plan showed no focus, interventions, or tasks addressing the PTSD diagnosis. On 4/1/26 at 12:47 PM, the CNO confirmed that the resident’s PTSD diagnosis should have been care planned and had not been, demonstrating noncompliance with the facility’s care planning policy.
Failure to Update Care Plans for New Edema and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise resident care plans to reflect current physician orders and resident needs, as required by its Resident Care Plan Revisions policy. The policy, revised on 9/3/25, states that updates to the care plan will occur as needed based on the resident’s response to interventions or changes in condition. For one resident with a history including a right tibia fracture and anxiety, a physician order dated 3/6/26 directed edema management of the right lower leg with application of a Tubi grip in the morning and removal in the evening. On multiple observations on 3/30/26 and 4/2/26, the resident was seen sitting in her room without the ordered Tubi grip in place, and during an interview the resident reported that her right lower leg had been swollen for a while. Review of the resident’s care plan and Treatment Administration Record (TAR) on 4/2/26 showed no documentation of the Tubi grip order. A second resident, with diagnoses including COPD, depression, and cardiomegaly, had a physician order dated 3/9/26 for oxygen at 3 LPM continuously via nasal cannula using an oxygen concentrator and/or tank. Review of this resident’s care plan on 4/1/26 showed only prior oxygen interventions: oxygen via nasal prongs at 0–4 L PRN to maintain saturation at 90% or greater, initiated 2/10/25, and oxygen at 2 L/min continuously via nasal cannula, initiated 6/24/25. The more recent continuous 3 LPM oxygen order was not reflected in the care plan. In both cases, the CNO acknowledged that the residents’ care plans (and, for the first resident, the TAR) should have been updated to include the current physician orders but had not been revised.
Failure to Follow Bowel Protocol and PICC Line Orders
Penalty
Summary
The deficiency involves failure to follow physician orders and facility policies for bowel management and infusion therapy. For one resident with Parkinson's disease and chronic kidney disease, the facility had a standing bowel protocol with stepwise orders for Senna, Bisacodyl tablets, Bisacodyl suppository, and Fleet enema, including instructions to call the physician if no bowel movement occurred within specified time frames. The medication administration record showed this resident had a bowel movement on 3/17/26 and not again until 3/22/26, a gap of over 96 hours, without any bowel management medications documented as given between 3/20/26 and 3/22/26. There was no documentation in the nursing progress notes that the physician was contacted during this period despite the protocol requirements, and the Regional Clinical Specialist later stated that refusals had been recorded only on a separate bowel care worksheet and not on the MAR or in progress notes, where they should have been documented. The deficiency also includes improper management and documentation of a PICC line for another resident with interstitial lung disease and heart failure. Observation revealed a PICC line in the resident’s right upper extremity with an undated dressing, loose edges, and unsecured tubing, contrary to the facility’s infusion therapy policy requiring adherence to aseptic technique and proper maintenance of infusion equipment and catheters. An LPN acknowledged the absence of a date on the dressing and was unsure if the line was still in use. Review of the medical record showed an order for IV Ertapenem for sepsis related to pneumonia that ended on 3/1/26, and an RN reported she could not locate current orders for the PICC line and stated that the line may have been discontinued, but in either case it should have been removed or had active orders.
Failure to Verify Enteral Tube Placement Before Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility’s care and treatment of a resident with an enteral feeding tube when staff failed to verify tube placement prior to administering medication. The facility’s “Medication Administration Enteral Access Device” policy, released 9/16/25, directed staff to follow general professional standards for safe administration of medications and to verify tube placement per facility protocol. The resident, admitted with diagnoses including paraplegia and dysphagia, had a physician’s order dated 1/21/26 specifying that medications may be crushed or given in liquid form via the enteral tube and that tube placement must be checked via auscultation before medication administration. On 4/1/26 at 9:00 AM, an RN administered 30 mL of water through the resident’s enteral tube, followed by 20 mL of liquid hydroxyzine HCl, and then flushed the tube with 30 mL of water, without verifying tube placement beforehand. When interviewed shortly afterward, the RN stated she was unsure of the facility’s policy on checking tube placement and residual prior to administering medications, and the CNO reported that the facility’s G-tube policy did not require checking residual or placement before feedings or medication administration, indicating placement was only checked by x-ray at the time of insertion. This failure to verify tube placement before medication administration was determined to be a lack of adequate care and treatment for the resident reviewed for enteral tube use, creating the potential for harm if complications developed from improper medication administration via the enteral access device.
Failure to Provide Ordered Oxygen and Safe PAP Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services as ordered for three residents requiring continuous or prescribed oxygen and PAP therapy. Facility policy required BiPAP/CPAP therapy to be provided in accordance with physician orders and professional standards, and the PAP user manual specified that when oxygen is used with the device, a specific pressure valve must be installed between the device and oxygen source, and that the device must be turned on before oxygen and off after oxygen is turned off to prevent oxygen accumulation and fire risk. For one resident with COPD, depression, and cardiomegaly, a physician order dated 3/9/26 required oxygen at 3 LPM continuously via nasal cannula, yet surveyors observed on three separate dates and times that the resident was in her room without the nasal cannula in place. The CNO confirmed that this resident should have had her oxygen on continuously as ordered and had not. Another resident with PTSD and joint replacement aftercare had CPAP orders specifying CPAP with 2 L/min oxygen at bedtime and a separate physician order for oxygen at 3 L via nasal cannula every shift for obstructive sleep apnea. On observation with an RN present, the resident’s oxygen concentrator was on and bleeding 3.5 LPM of oxygen into the CPAP device while the CPAP device itself was turned off, and no required Respironics pressure valve was installed in the PAP circuit. Additional observations on two mornings showed the resident was not using ordered oxygen, and an RN stated the resident does not use oxygen during the day and questioned whether there was an order for daytime use. A third resident with acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture had a physician order and care plan for 2 LPM oxygen continuously via nasal cannula to maintain SpO2 at or above 90%, yet was observed not using oxygen, and medical record entries documented SpO2 readings of 88% on two dates while on room air only. The CNO stated staff should have ensured ordered oxygen use for the two residents, acknowledged oxygen should not bleed into a PAP device when not in use, and reported being unaware of the requirement for the Respironics pressure valve or whether any PAP devices in the facility had it.
Failure to Implement Non-Pharmacological Interventions Prior to PRN Pain Medication
Penalty
Summary
Surveyors identified a deficiency in pain management when the facility failed to follow its Pain Assessment and Management policy, which required development and implementation of both non-pharmacological and pharmacological interventions to address pain. The care plan for Resident #53, who had diagnoses including acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture, documented that the facility would attempt non-pharmacological pain interventions as part of the treatment plan. Physician orders dated 2/11/26 and 3/20/26 authorized Hydrocodone-Acetaminophen 5-325 mg every four hours as needed. However, review of the MAR on 3/30/26 showed no documentation that non-pharmacological pain management was attempted prior to administering the PRN hydrocodone on multiple dates (3/17/26, 3/18/26, 3/20/26, 3/23/26, and 3/24/26). In an interview on 4/1/26, the CNO confirmed that non-pharmacological pain management should have been offered before administering the hydrocodone and that it had not been, resulting in the facility’s failure to provide adequate pain management for this resident. This failure created the potential for residents to experience continual pain and distress.
Failure to Follow Vital Sign Parameters Before Administering Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse was competent in medication administration according to physician orders and facility policy. The facility’s Medication Administration policy, revised 9/10/25, required that when medications had vital sign parameters, vital signs must be taken prior to preparing the medication. Resident #21, admitted with interstitial lung disease and heart failure, had a physician’s order for Metoprolol Succinate ER 12.5 mg by mouth in the morning for hypertension, with instructions to hold the dose for systolic blood pressure (SBP) less than 100 or heart rate less than 50. On 3/30/26 at 9:35 AM, LPN #2 administered the resident’s medications, including Metoprolol, and only checked the resident’s blood pressure after the medication was given, contrary to the order and policy requiring vital signs beforehand. The CNO confirmed that the nurse should have checked the resident’s vital signs before administering the medication. Review of LPN #2’s oral medication administration competency form showed she had completed training, including the requirement that vital sign parameters be taken per facility practice before pouring medication, yet this was not followed in practice. This failure was identified for 1 of 5 nurses observed during medication administration and was determined to have the potential to affect all residents in the facility and increase the risk of harm to residents.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift, as required. On review of the posted daily staffing sheets on 3/30/26 at 4:17 PM, surveyors identified multiple dates with missing sheets or incomplete staffing data: on 5/6/25 there was no RN or LPN data listed for the day and evening shifts; on 9/8/25 there was no RN or LPN data listed for the evening shift; on 9/19/25 there was no CNA data listed for the day, evening, or night shifts; and on 12/7/25, 12/20/25, and 12/21/25 the daily staffing sheets were missing entirely. In addition, on 12/22/25 the posted information showed only one RN for 8 hours on the evening shift with no licensed nurses scheduled for the day or night shifts. On 3/31/26 at 4:00 PM, the Staffing Coordinator acknowledged that the missing staffing data and sheets for the identified dates should not have been missing but were. This deficient practice had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who might seek to review the facility’s staffing levels, by preventing accurate review of nurse staffing information for the affected dates and shifts.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide a resident with prior written notice regarding a room change, as required. A resident with chronic obstructive pulmonary disease and diabetes was admitted to the facility and was documented as being in a specific room. However, the resident was moved to a different room over a weekend without any written documentation or notification provided to the resident about the nature or date of the move. This was confirmed through observation, record review, and staff interviews, with the Director of Clinical Services acknowledging the absence of required written notice in the resident's medical record.
Failure to Notify State LTC Ombudsman of Resident Discharges and Transfers
Penalty
Summary
The facility failed to ensure that copies of residents' discharge or transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman, as required by facility policy. This deficiency was identified through interviews, policy review, and record review, and was found to affect three residents who experienced transfers or discharges. Specifically, one resident with a sacrum fracture and diabetes was transferred to the emergency department, another resident with hemiplegia and heart disease was transferred to the emergency department and did not return, and a third resident with heart disease and diabetes was discharged to an assisted living facility. In each case, there was no documentation that the required notice was provided to the State Ombudsman. Further investigation revealed that the facility's policy, last revised in April 2025, required that copies of discharge or transfer notices be sent to the Ombudsman, with notices to be sent monthly. However, the Region 6 State Ombudsman confirmed that no such notices were received for several months in 2025. The Director of Clinical Services stated that the facility's Social Worker had left in March 2025, and as a result, the required notices were not sent during March, April, May, and part of June 2025.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure that meals were prepared in accordance with residents' documented allergies, intolerances, and preferences, as required by its own nutrition policy. One resident with a documented allergy to tomatoes and melon was served chicken with a red, tomato-based sauce, which the resident could not eat due to his allergy. The resident's medical record and printed meal ticket both indicated these allergies, yet the meal was still provided. The food service manager confirmed, after investigation, that the resident had indeed been served a meal containing a tomato-based sauce, contrary to his dietary restrictions. This deficiency was identified through observation, policy review, and interviews with the resident and staff, and it had the potential to affect all residents with special dietary needs who dined in the facility.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food storage standards, as observed during a survey. Food items in the kitchen pantry were stored only 4.5 inches above the floor, contrary to the FDA Food Code requirement of at least 6 inches. This was confirmed by the Culinary Director. Additionally, the inside of the kitchen ice machine was found to have a pink slimy substance along the white panel, indicating inadequate cleaning of equipment that comes into contact with food. The Culinary Director and Registered Dietitian acknowledged the presence of the substance. Further observations revealed that kitchen cookware, including sheet pans, pots, and skillets, had black residue encrusted along various parts, despite being cleaned and sanitized according to manufacturer recommendations. The Culinary Director and Registered Dietitian were unable to explain the presence of the residue. Moreover, a layer of dust particles was observed hanging from the ceiling in front of the condenser fans in the kitchen walk-in refrigerator, which was verified by the Culinary Director. These deficiencies had the potential to affect the 53 residents who consumed food prepared by the facility.
Deficient Care Plans for Residents
Penalty
Summary
The facility failed to ensure that resident-centered care plans were comprehensively written for four residents, leading to deficiencies in their care. Resident #6, who was admitted with multiple diagnoses including metabolic encephalopathy, Parkinson's disease, and dementia, had a care plan that did not include directions for managing her dementia. The CEO acknowledged that the care plan should have included this information. Similarly, Resident #34, with diagnoses including heart failure and chronic kidney disease, had a physician order for a foley catheter, but his care plan lacked directions for its care, which was confirmed by the CEO. Resident #36, diagnosed with chronic obstructive pulmonary disease, had preferences for activities such as reading and listening to music, which were documented in an Admission MDS assessment. However, his care plan did not address these preferences, and he was observed without any reading materials in his room. The CEO confirmed the absence of an activity care plan. Additionally, Resident #8, with chronic kidney disease and neuropathic bladder, had a physician's order for a foley catheter, but his care plan did not reflect this order. The CEO confirmed that a care plan should have been developed to include these new orders.
Failure to Update Resident Care Plan After Medication Changes
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current needs and interventions, as required by the CMS SOM, Appendix PP. This deficiency was identified for one resident who had multiple diagnoses, including bipolar and psychotic disorders. The resident's physician orders indicated that several medications, including Depakote, Mirtazapine, and Lorazepam, were discontinued on specific dates. However, the resident's care plan, which was initiated earlier, still documented the use of antidepressant medications related to bipolar disorder and depression. The CEO confirmed that the care plan should have been updated to reflect the changes in the physician's orders when the medications were discontinued, but it was not. This oversight created a risk of adverse outcomes if care and services were not provided according to the resident's changing needs.
Failure to Administer Oxygen Therapy Per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy according to physician orders, which was identified during a survey. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), had a care plan that required supplemental oxygen to be administered via nasal cannula as ordered. A physician assistant's progress notes indicated that the resident's oxygen levels were consistently above 92 percent while on two liters of oxygen, leading to an order to reduce the oxygen to one liter per minute to prevent carbon dioxide retention and abdominal pain. During an observation, the resident was found receiving oxygen therapy at a rate of two liters per minute, contrary to the physician's order of one liter per minute. This discrepancy was confirmed by RN #1, who reviewed the physician's order and verified that the oxygen flow rate was incorrectly set. The failure to adhere to the prescribed oxygen therapy created the potential for harm by not meeting the resident's respiratory needs as directed by the physician.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by the cases of two residents. Resident #42, who was admitted with multiple diagnoses including amputation and gangrene, experienced a medication error involving oxycodone. The prescription indicated a dosage of 10 mg every four hours as needed for pain, but the Medication Administration Record (MAR) incorrectly documented the administration of 10 mg, while the controlled drug record showed that only 5 mg was administered on multiple occasions. This discrepancy was identified by an LPN, but not before the error occurred eight times over several days. Resident #48, admitted with conditions such as diabetes and chronic pain, also experienced a medication error. An order change increased the Lyrica dosage to 150 mg at bedtime, but the MAR showed that the resident received only 100 mg on three consecutive nights. This error was confirmed by the CEO, who acknowledged that the wrong dose was administered. These incidents highlight the facility's failure to ensure accurate transcription and administration of medication orders, leading to significant medication errors for both residents.
Medication Errors Lead to Hospitalization and Potential Harm
Penalty
Summary
The facility failed to protect residents from significant medication errors, affecting two out of four residents reviewed. Resident #1, who had multiple diagnoses including encephalopathy and high blood pressure, was mistakenly given another resident's medications by LPN #1. This error occurred because LPN #1 was unfamiliar with the hall she was assigned to and confused Resident #1 with Resident #2, who had the same first name. The medications intended for Resident #2 included several drugs that were contraindicated for Resident #1, leading to a significant change in Resident #1's condition, including altered mental status and decreased blood pressure, necessitating hospitalization. Resident #3, with diagnoses including end-stage renal disease and diabetes, was potentially given the wrong type of insulin by LPN #3. The LPN was unsure whether she administered Lantus instead of the prescribed NovoLog after checking the resident's blood sugar. The error was immediately reported to the physician, and the resident was monitored for adverse symptoms. Fortunately, Resident #3 did not require further medical intervention following the incident.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for a resident, leading to medication administration discrepancies. The resident, who was admitted with multiple diagnoses including an elbow fracture, Parkinson's Disease, and acute respiratory failure, had her medications crushed and mixed with food without a physician's order. This practice was based on a recommendation from a Speech Therapist, but it was not documented in the resident's medical record. The resident's medications, including Levothyroxine, Benztropine, Bupropion, Clonazepam, Donepezil, Doxycycline, and Memantine, were administered in this manner over a period of time. Additionally, the resident's Levothyroxine, which was ordered to be given at 5:30 AM, was administered in the evening by an LPN. The LPN stated that she was aware of the morning schedule but chose to administer it at night to avoid waking the resident early, as she was informed the resident disliked early wake-ups. The Director of Nursing Services and the Regional Clinical RN were unaware of these practices until alerted by the surveyors, and there was no physician approval for the time change of the Levothyroxine administration.
Failure to Remove Discontinued Medication from Cart
Penalty
Summary
The facility failed to ensure that medications were properly reconciled and removed from a medication cart when discontinued, as observed during a survey. This deficiency was identified in one of three medication carts inspected, specifically affecting a resident who had been prescribed hydrocodone 5/325 mg. The medication order for hydrocodone was discontinued on 10/12/24, yet the blister pack containing 31 tablets remained in the cart until it was discovered on 10/29/24. During the inspection, an LPN was observed preparing to dispose of the medication, acknowledging that it should have been removed the day it was discontinued. The CRN confirmed that opioid medications should be removed from the cart by the next working day after discontinuation. This oversight created a potential risk for medication administration errors and diversion, affecting 19 residents who received medications from the same cart. Resident #105, who was involved in this incident, was admitted with multiple diagnoses, including metabolic acidosis, diabetes, and hypertension. The failure to remove the discontinued hydrocodone from the medication cart was a significant oversight in the facility's pharmaceutical services, as it posed an increased risk for medication errors and potential harm to the residents.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were labeled correctly, as observed during an inspection of a medication cart. Specifically, the blister pack label for a resident's prescribed oxycodone 5 mg did not reflect the updated order of four times a day (every 6 hours) and instead stated every 4 hours as needed. This discrepancy was noted during an inspection of the 300 Hall medication cart with an LPN present. The resident involved had multiple diagnoses, including a left arm fracture, heart failure, hypertension, and pain, and had their medication order changed on 10/24/24. However, the label on the blister pack was not updated to reflect this change, which was acknowledged by the LPN, who stated that a sticker should have been placed on the blister pack to indicate the new order.
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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