Life Care Center Of Coeur D'alene
Inspection history, citations, penalties and survey trends for this long-term care facility in Coeur D'alene, Idaho.
- Location
- 500 West Aqua Avenue, Coeur D'alene, Idaho 83815
- CMS Provider Number
- 135122
- Inspections on file
- 23
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Life Care Center Of Coeur D'alene during CMS and state inspections, most recent first.
A resident with a right-hand contracture and aphasia had a care plan for weekly nail trimming and daytime use of a hand grip splint, but after an initial OT discharge with an orthotic, there were no further therapy referrals despite ongoing pain and frequent refusals to wear the splint. Over several months, TARs showed repeated refusals of the orthotic, yet there was no documented follow-up with the physician, therapy, or the resident’s representative, and no documented interventions for contracture-related pain. Staff later reported they could barely open the resident’s hand and had not seen the palm or nails, and ADL records lacked evidence that nails were trimmed or that refusals to nail care were documented. The resident ultimately developed a swollen, painful contracted hand with nails embedded into the palm, white/yellow drainage, and a documented palm wound and infection attributed by the NP to the fingernails digging into the palm.
Surveyors found that medication refrigerators used to store narcotics, vaccines, and insulins were not consistently monitored and documented per facility policy, with numerous missing temperature entries on both AM and PM shifts across multiple months in two medication rooms. An RN, an RCM, and an SDC acknowledged the incomplete logs, and the facility policy required at least daily monitoring for medications and twice-daily monitoring for vaccines, creating the potential for residents to receive medications and vaccines stored outside recommended temperature ranges.
Surveyors found that food service staff failed to follow basic sanitation and labeling practices, including a diet aide repeatedly entering and working in the kitchen without proper hand hygiene and with an improperly worn hair net. In the main freezer, icicles from the air condenser unit were melting and dripping into an open box of frozen egg patties. Resident refrigerators contained brown streaks and spots, and both staff and resident food items were stored without required labels or dates, with some frozen meals marked only by room number. Dust buildup was observed on a refrigerator air condenser unit, and the dietary manager acknowledged that both cleaning and monitoring of equipment and food labeling were not being performed as required.
During an Influenza A outbreak, staff failed to follow required infection prevention and control practices for PPE and droplet precautions. A CNA entered a droplet‑precaution room with inadequate PPE, handled urinals without proper hand hygiene, and returned shared goggles to a storage bin without sanitizing them. An SDC cleaned multi‑use goggles but did not allow the required disinfectant contact time before returning them to the bin. An Activities Assistant moved consecutively between influenza‑positive and negative rooms offering coffee and activities, performing hand hygiene but not changing her mask or wearing a gown, while droplet precautions were in place requiring full PPE including mask, gown, eye protection, and gloves.
Surveyors identified that a resident shower room was not maintained in a clean and sanitary condition when a black substance was observed on the lower portion of the shower wall. The Maintenance Director confirmed the shower was not clean after attempting to scrub the substance, and the Housekeeping Director acknowledged that, despite a schedule for daily shower cleaning, this shower room had not been properly cleaned.
A resident with multiple chronic conditions had four medication cups labeled with her name found at the bedside while the MAR indicated that her medications had been administered. A grievance was filed, but the facility’s investigation and response only briefly stated that residents had missed medications, that an LPN was educated, and that a provider was notified, without further detail. The Administrator later confirmed there was no medication error report or documentation of staff education related to medication storage, administration, or medications left at the bedside, demonstrating that the grievance was not thoroughly investigated.
A resident with severe cognitive impairment and multiple medical conditions was observed lying in bed with stool-soiled linens and stool leaking from an incontinence brief, unable to state how long they had been soiled. Later, a CNA provided incontinence care to the resident without closing the window blinds or using the privacy curtain, leaving the resident partially visible from the courtyard. The CNA subsequently acknowledged that the resident could be seen from outside and that the blinds or privacy curtain should have been used.
A resident with dementia, cognitive communication deficit, history of TIA, and adult failure to thrive, and a severely impaired BIMS score, was found soiled with stool leaking from her incontinence brief and was unable to state how long she had been in that condition. Although documentation indicated she used her call light appropriately, surveyors observed that she did not activate the push-button call light when prompted and only smiled in response, even when a CNA asked her to demonstrate its use without pointing to it. The facility failed to provide an appropriate adaptive call light despite the resident’s inability to effectively use the standard device, resulting in a lack of reasonable accommodation of her needs and preferences.
A resident with encephalopathy, DM, urinary retention, and a UTI was documented by Social Services as not having an advance directive, yet there was no record that the resident or representative received required information or assistance to formulate one, despite facility policy requiring such materials be provided upon admission. The SSD confirmed the resident had no advance directive and acknowledged the resident and/or representative should have been offered the opportunity to create one.
A resident with diabetes, severe protein-calorie malnutrition, and dependence on staff for personal care had a care plan and physician order requiring timely provider notification for changes in condition and for blood glucose levels above a specified threshold. Review of the MAR showed multiple blood glucose readings above that threshold, for which the order required both administration of Insulin Aspart and notification of the provider. Surveyors found no documentation that the provider had been notified for any of these elevated readings, and the DON confirmed that such documentation could not be located.
The facility did not provide required written bed-hold policy notifications to three hospitalized residents or their representatives. One resident with dementia, heart disease, and DM was hospitalized, and the Admissions Director acknowledged speaking with the POA but not providing a bed-hold document. Another resident with hemiplegia, hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety, and a third resident with UTI, DM, heart failure, and CKD were also hospitalized, yet their records contained no documentation of bed-hold notifications. The Administrator confirmed there was no record of such notifications for these two residents.
Two residents’ MDS assessments were inaccurately completed, leading to incorrect transmission of assessment data. For one resident with anxiety, depression, and personal care needs, a Quarterly MDS incorrectly indicated the use of physical restraints in bed or chair less than daily. For another resident with hemiplegia/hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder, the record showed a completed PASRR Level II, but the Annual MDS incorrectly documented that no PASRR Level II existed. These errors were identified through record review and confirmed by the DON.
Surveyors found that a resident with documented PTSD, anxiety, and depression did not have these mental health conditions recorded on the PASRR Level I, and no PASRR Level II was submitted to the state agency as required. The SSD later acknowledged that the PASRR Level I should have been corrected and a Level II completed, indicating that coordination of PASRR assessments and related care planning for this resident was not properly carried out.
Surveyors found that the facility did not consistently revise care plans or hold required care conferences. One resident with mobility and postural issues had outdated ambulation and neck brace interventions left on the care plan after treatment changes. Another resident with cellulitis and muscle weakness had a physician order for continuous offloading boots that was never added to the care plan and was repeatedly observed without the boots. A third resident who transitioned to hospice care did not have hospice/comfort care interventions incorporated into the care plan. In addition, quarterly care conferences were missed for a resident with PTSD, anxiety, and depression, and staff acknowledged these conferences had been overlooked.
Two residents did not receive medications in accordance with professional standards and physician orders. One resident with hypertension received metoprolol ER and lisinopril from an LPN without current BP and HR being checked, despite orders requiring parameters for holding the medications. Another resident with diabetes, kidney disease, and an ileostomy had active PRN orders for rectal Dulcolax suppositories and a Fleet enema, even though, as confirmed by the SDC, this resident should not have any rectal medication orders or those medications at all.
A resident with multiple comorbidities, including UTI, diabetes, heart failure, and CKD, experienced a significant change in condition characterized by somnolence, poor oral intake, and possible sepsis. Nursing staff sent an SBAR to the physician reporting the change and requesting further evaluation and treatment, and later sent a second SBAR noting ongoing lethargy, congestion, and refusal of medications and food, and asking for an exam, labs, or a portable CXR. The resident was later found catatonic and unresponsive and was sent to the ER after the physician was called. There was no documentation of any physician communication or response between the initial and subsequent SBARs, and facility leadership confirmed there was no record of a response to the first SBAR.
A resident with a right-hand contracture and history of stroke was discharged from OT with a right grip orthotic to be worn during the day as tolerated, and the care plan directed staff to apply the splint for extended periods. Over multiple months, documentation showed frequent refusals to wear the orthotic and increasing tightness of the hand, with CNAs reporting pain when attempting to open the hand. Although a physician note early on recommended re-evaluation for therapy, there was no further documentation that the physician, therapy department, or the resident’s representative were notified of the continued refusals, and no additional therapy referrals occurred. A restorative PROM program was started later, but the Restorative Coordinator was unaware of how long the hand had been unable to open, and the DON could not recall being informed of the ongoing refusals, demonstrating a failure to ensure appropriate ROM treatment and services and to communicate changes to the IDT.
A resident with diabetes, severe protein-calorie malnutrition, and personal care needs had physician orders for sliding-scale Insulin Aspart and scheduled and PRN Morphine Sulfate. Review of the MAR showed multiple evening shifts with no documented blood glucose checks or insulin administrations despite active sliding-scale orders, and the DON confirmed multiple blanks where insulin doses should have been recorded. In a separate incident, a nurse administered a full 15 mg PRN morphine tablet instead of the ordered half tablet, with the error identified when the resident questioned the dose and the order was re-checked.
A resident with multiple diagnoses, including diabetes and severe protein-calorie malnutrition, was receiving hospice services with a documented DNR status, but the facility failed to maintain required hospice documentation in the medical record. Review of the chart showed there was no current hospice plan of care and no current terminal diagnosis certification. When requested by the surveyor, the DON produced only an expired terminal certification and a facility-generated care plan, and the Administrator confirmed that a current hospice plan of care and terminal certification were not present in the record.
The facility did not have a qualified director of food and nutrition services, affecting 82 residents. The Dietary Manager (DM) lacked the required Serv Safe Food Manager Certification, despite being employed for one and a half years. The DM cited working six months without a day off as the reason for not completing the necessary training. The Registered Dietitian (RD), present two days a week, was aware of the DM's lack of certification and highlighted its importance for managing the kitchen.
The facility failed to provide sufficient staffing and training in the dietary department, impacting the ability to safely and effectively serve meals to 81 residents. The dietary schedule showed inadequate staffing, with only two employees for most dinner services and one on Tuesdays. The Dietary Manager and staff reported severe understaffing, lack of training, and no in-service training since December 2022. The Registered Dietitian noted unaddressed suggestions and a failure to update a resident's diet tray ticket. Staff reported rushed work and mistakes due to understaffing.
The facility failed to maintain proper sanitation and food handling practices. Mold-like substance was found in the ice machine, and food items were improperly stored on the floor. A cook handled plates and food with bare hands and wiped his hands on his pants during tray line service. The Dietary Manager acknowledged the need for more training, and the Registered Dietitian noted that her recommendations were not followed.
The facility failed to serve meals consecutively at five of seven tables during meal service, affecting resident dignity and satisfaction. A resident expressed dissatisfaction with the daily meal service, attributing delays to having only one server. Interviews revealed staff were unaware of the policy to serve all residents at a table before moving to the next.
The facility exceeded the acceptable medication error rate, reaching 7.69% during observations. One resident received Lantus Solostar insulin later than the prescribed time, while another resident was administered multiple medications through a PEG tube in a manner inconsistent with facility policy. These actions were confirmed by the nurse involved.
A resident with diabetes experienced inadequate documentation of their blood sugar management in an LTC facility. An LPN failed to document a hypoglycemic event and the administration of glucose and glucagon. Similarly, an RN did not document the administration of insulin for hyperglycemia or recheck the blood sugar as required. These lapses in documentation raised concerns about the accuracy of the resident's medical records and their diabetes management.
A facility failed to implement proper infection control procedures for a resident requiring enhanced barrier precautions due to an invasive device. The resident, with diagnoses including stroke and diabetes, had orders for tube feeding and medication administration through a PEG tube. An RN was observed administering medications without wearing a protective gown, despite the requirement for such precautions. The RN confirmed the oversight in infection control measures.
A cognitively intact resident engaged in inappropriate sexual contact with two cognitively impaired residents in an LTC facility. Despite being educated about the inability of the residents to consent, the resident continued the behavior. The facility's response included supervision and eventual discharge of the offending resident, but the care plan interventions were insufficient to prevent further incidents.
Failure to Manage Hand Contracture and Nail Care Resulting in Palm Wound and Infection
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent and necessary care to prevent a pressure-type ulcer and infection in a resident with a right-hand contracture following a stroke. The resident had aphasia and a care plan that directed staff to trim and file his nails weekly and as needed, and to apply a right-hand grip splint during the day as tolerated. Occupational therapy initially evaluated the resident in July 2025 for feeding and right-hand contracture, discharged him on 7/15/25, and provided an orthotic splint to keep his fingers in a resting position. After this discharge, there were no further therapy referrals despite ongoing issues with the contracture. The resident frequently refused to wear the hand grip orthotic, with refusals documented on the TAR for most days over several consecutive months. A communication note to the physician on 10/6/25 documented that CNAs reported the resident refused to wear his brace and had high levels of pain when staff attempted to place their fingers into his contracted hand, and a re-evaluation for therapy options was recommended. However, there was no subsequent documentation that the physician, therapy department, or the resident’s representative were notified of the continued refusals after that date, and no documentation of further interventions or treatment for pain related to the right-hand contracture. Monthly summaries in early 2026 noted the contracture and refusal to wear the orthotic, but did not reflect additional action. By March 2026, the resident’s contracted hand had become swollen and painful, with nails digging into the palm and white/yellow drainage noted. A communication note on 3/12/26 recorded provider orders to trim nails, apply triple antibiotic ointment, and cover the wounds, along with a handwritten note that staff were unable to open the right hand to trim nails or apply ointment due to contraction and swelling. A provider note on 3/13/26 documented that the nails were embedded into the palm causing skin infection, and that after soaking the hand, the nails were trimmed and antibiotic cream placed in the palm. Staff interviews revealed that restorative staff could barely open the hand and had not seen the palm or fingernails, and that an LPN was aware of the resident’s refusal to wear the splint but did not document family education. The DON could not find documentation that the resident’s fingernails were trimmed or that refusals to nail care were recorded, and the nurse practitioner stated the wound was due to the fingernails digging into the palm. The National Library of Medicine reference cited in the report noted that spastic fingers pressing into the palm with overgrown nails can cause skin breakdown and atypical pressure ulceration.
Failure to Consistently Monitor and Document Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that medication refrigerator temperatures were routinely monitored and documented as required by its Medication Storage in Refrigerator/Freezer policy. That policy stated that medications and biologicals must be stored at appropriate temperatures per manufacturers' specifications, that medication storage areas should be monitored at least once daily, and that vaccine storage temperatures should be monitored twice daily. During inspection of the A-Wing medication storage room with an RN, surveyors observed two refrigerators: a black refrigerator storing narcotic medications and a silver refrigerator storing vaccines and insulins. Review of the temperature logs showed multiple days with no recorded temperatures. For the silver refrigerator, morning shift temperatures were missing on 5 of 28 days in February and 8 of 20 days in March, and PM shift temperatures were missing on 2 of 28 days in February and 5 of 20 days in March. For the black refrigerator, morning shift temperatures were missing on 5 of 28 days in February and 10 of 20 days in March, and PM shift temperatures were missing on 3 of 28 days in February and 5 of 20 days in March. When the RCM reviewed the A-Wing refrigerator temperature logs, she stated she did not think temperature monitoring was being done as required. In the D-Wing medication storage room, inspected with the SDC, the refrigerator containing narcotic medications also had inconsistently documented temperatures. Review of those logs showed that on the AM shift, temperatures were not recorded on 15 of 30 days in January and 16 of 28 days in February, and on the PM shift, temperatures were not recorded on 2 of 28 days in February and 2 of 20 days in March. The SDC stated there should not be blanks on the medication room refrigerator temperature logs. The deficient practice created the potential for harm if residents received vaccines or medications with reduced potency and safety from improper storage.
Food Service Sanitation and Labeling Deficiencies in Dietary and Resident Refrigeration Areas
Penalty
Summary
Surveyors identified multiple food service and sanitation deficiencies affecting 75 of 76 residents who received food prepared in the facility’s kitchen. A diet aide was observed working with an improperly worn hair net that did not cover the front portion of her head, leaving tendrils of hair framing her face. The same diet aide was seen taking food carts out of the kitchen and returning without performing hand hygiene, and later entering the kitchen again without washing her hands or wearing her hair net appropriately, despite the dietary manager’s acknowledgement that all food service employees are required to wear hair nets correctly and perform hand hygiene when entering the kitchen. In the main kitchen freezer, surveyors twice observed 2‑inch icicles forming on the air condenser unit and melting, with water dripping directly into an opened box of frozen egg patties. The dietary manager stated that trays under the condenser should catch the ice but sometimes do not, and that food should not be left unwrapped. In the A‑Wing resident refrigerator, brown streaks were present on the interior upper door, staff food and resident food items were stored without labels or dates, and frozen resident meals were marked only with room numbers and lacked names and dates, contrary to the dietary manager’s statement that all resident food should be labeled with name and date. Dust particles were observed hanging from the bolts of the refrigerator air condenser unit on two occasions, and the dietary manager stated the unit should have been cleaned more frequently. In the D‑Wing resident refrigerator, brown spots were observed on the interior door and back wall, and the dietary manager stated housekeeping was responsible for cleaning the refrigerators daily.
Improper PPE Use and Droplet Precautions During Influenza A Outbreak
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of PPE and droplet precautions during an Influenza A outbreak. A CNA entered a room with residents on droplet precautions wearing only goggles and one glove, handled a resident’s urinal, then returned it to the nightstand without gloves. She then went to the roommate’s bedside, applied gloves without performing hand hygiene, handled and emptied a second urinal, and returned it to the bedside. After exiting, she removed her gown and gloves and performed hand hygiene, but removed her goggles and placed them back into a shared storage bin without sanitizing them. The CNA acknowledged she should have performed hand hygiene before donning gloves and should not have returned the goggles to the bin without cleaning them, and she reported that sanitation wipes for the multi‑use goggles were not sufficiently available. Surveyors also observed the Staff Development Coordinator (SDC) cleaning multi‑use goggles with an alcohol wipe and immediately returning them to the storage bin without allowing the required contact time for disinfection, despite stating that goggles should remain out on a clean barrier until dry or for 2 minutes. During the same Influenza A outbreak, multiple rooms were identified as positive for Influenza A and placed on droplet precautions requiring staff to wear face masks and perform hand hygiene before entry. An Activities Assistant was observed repeatedly entering both Influenza A–positive and negative rooms in succession to offer coffee and coloring sheets, performing hand hygiene between rooms but not changing her mask, and stating she did not need a gown and did not need to change her mask because she was not performing cares. The Infection Preventionist later confirmed that precautions for these residents should have included hand hygiene, face mask, gown, eye protection, and gloves, and the DON confirmed new positive Influenza A cases among additional residents and roommates during this period.
Unclean Resident Shower Room with Black Microbial Substance on Shower Wall
Penalty
Summary
The facility failed to ensure that a resident shower area was maintained in a clean and sanitary condition, affecting 1 of 1 shower rooms observed. During an inspection of a resident shower room, surveyors observed a black substance on the lower portion of the shower wall. When the Maintenance Director used the tip of a thermometer to scrub the black substance, he stated that the shower was not clean. The Housekeeping Director reported that showers were scheduled to be cleaned daily and confirmed that the shower room was not clean. The report notes that this failure created the potential for harm if residents were exposed to black microbial substances on the grout of the shower walls.
Incomplete Investigation of Medication-Related Grievance
Penalty
Summary
The facility failed to thoroughly investigate a grievance related to medication administration and handling for a resident who had been readmitted with multiple diagnoses including Parkinson's disease, diabetes, hypothyroidism, pulmonary hypertension, and chronic kidney disease. A grievance filed on 8/2/25 documented that four medication cups labeled with this resident’s name were found at her bedside, while a review of her MAR for the same date showed that she had been documented as having received her medications. The grievance investigation and response completed on 8/4/25 stated that the residents involved had missed their medications, that the LPN involved had been educated, and that the provider was notified, but did not include additional information about the investigation. During an interview on 3/20/26, the Administrator stated there was no record of a medication error report or staff education related to medication storage, administration, or medications left at the resident’s bedside, and acknowledged that such documentation should have existed. This failure to conduct and document a complete investigation of the grievance, including the apparent discrepancy between the MAR and the medications found at the bedside, resulted in the facility not honoring the requirement to fully investigate and resolve resident grievances.
Failure to Maintain Resident Dignity and Privacy During Incontinence Care
Penalty
Summary
The deficiency involves failure to ensure a resident was treated with dignity and respect during incontinence care and toileting needs. The resident had multiple diagnoses including cognitive communication deficit, history of TIA, adult failure to thrive, and dementia, with an Annual MDS BIMS score of 5 indicating severe cognitive impairment. During observation, the resident was found in bed with blankets folded back and linens soiled with stool, with a distinct stool odor and stool leaking from the left side of the incontinence brief. The resident pointed to the brief and said "mess" but was unable to state how long she had been soiled and did not indicate whether she had used the call light for assistance. Later the same day, a CNA entered the resident’s room to perform bowel and bladder rounds and incontinence care. During this care, the window blinds remained open with the courtyard visible, and the privacy curtain was not in use, remaining pulled back to the corner of the room above the bed. When questioned, the CNA acknowledged she did not use the privacy curtain and initially stated that resident rooms could not be seen from outside. After accompanying the surveyor to the courtyard, the CNA was able to see part of the resident through the open blinds and acknowledged she should have closed the blinds or used the privacy curtain during care.
Failure to Provide Adaptive Call Light for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s need for an appropriate adaptive call light despite the resident’s inability to use the standard push-button call light. The resident was admitted with multiple diagnoses including cognitive communication deficit, history of TIA, adult failure to thrive, and dementia, and had an Annual MDS assessment showing a BIMS score of 5, indicating severe cognitive impairment. A Social Services progress note documented that the resident used her call light appropriately to make needs and preferences known. However, during surveyor observation, the resident was found in her room with a distinct odor of stool and brown stool leaking from the left side of her incontinence brief. When asked how long she had been soiled, the resident stated she did not know, and when asked if she had used her call light to ask for help, she did not respond and shrugged her shoulders. Later that afternoon, a CNA entered the resident’s room and provided incontinence care. When interviewed, the CNA stated the resident was able to use the call light. Surveyors then asked the CNA to have the resident demonstrate how to use the call light. The resident smiled at the CNA and the surveyors but did not use the call light. When surveyors instructed the CNA not to point to the call light and the CNA again asked the resident to use it, the resident continued to smile without activating the device. These observations and interviews showed that the resident was not effectively able to use the standard push-button call light and had not been provided with an appropriate adaptive call light to accommodate her needs and preferences.
Failure to Provide Information and Assistance for Advance Directive Formulation
Penalty
Summary
The facility failed to ensure a resident received information and assistance to formulate an advance directive as required by its Advance Directives and Advance Care Planning policy. The policy, reviewed on 9/26/25, stated that residents or their responsible parties are to receive materials upon admission regarding their rights to make decisions about medical care, including accepting or refusing treatment and forming advance directives. Resident #74 was admitted with multiple diagnoses including encephalopathy, diabetes, urinary retention, and a UTI, and a Social Services assessment documented that the resident did not have an advance directive. However, there was no documentation in the resident’s record that information was provided to help formulate an advance directive, and the Social Services Director confirmed that the resident did not have an advance directive and that the resident and/or representative should have been offered the opportunity to formulate one. This deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored if they were incapacitated.
Failure to Notify Provider of Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician of elevated blood glucose levels as required by a physician’s order and the resident’s diabetic care plan. A resident with multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care, had a diabetic care plan revised on 1/22/26 that directed staff to provide timely notification to the physician for any change in condition. A physician’s order dated 2/2/26 specified administration of Insulin Aspart per sliding scale and required staff to give 6 units and notify the provider when blood glucose was greater than 351. Review of the MAR from 2/2/26 to 3/18/26 showed multiple blood glucose readings above 351 (384, 378, 366, 365, 362, 506, and 409), all meeting the threshold for provider notification. When surveyors requested documentation of provider notification for these elevated readings, the DON confirmed she was unable to locate any documentation that the provider had been notified. This failure to follow the physician’s order and the care plan regarding provider notification for elevated blood glucose levels constituted the cited deficiency.
Failure to Provide Required Bed-Hold Policy Notifications Upon Hospitalization
Penalty
Summary
The facility failed to provide residents and/or their representatives with written notice of the facility's bed-hold policy for residents whose records were reviewed for discharges. Record review and staff interviews showed that 3 of 6 residents in the discharge sample did not receive required bed-hold notifications. For one resident with dementia, heart disease, and diabetes who was hospitalized between specified dates, the medical record contained no documentation that a bed-hold notification was provided to her or her representative. The Admissions Director confirmed in an interview that, although she spoke with the resident's POA, she did not provide a bed-hold document. Another resident with hemiplegia, hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder was admitted and later readmitted to the facility, and was subsequently admitted to the hospital; however, there was no documentation that a bed-hold notification was provided to her or her representative at the time of hospitalization. A third resident with a urinary tract infection, diabetes, heart failure, and chronic kidney disease was also admitted to the hospital, and her record similarly lacked any documentation of a bed-hold notification. The Administrator stated that the facility did not have any record of a bed-hold notification being provided for the second and third residents.
Inaccurate MDS Coding for Restraints and PASRR Level II Status
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two of three residents reviewed, resulting in inaccurate transmission of assessment data. For one resident admitted with anxiety, depression, and a need for assistance with personal care, a Quarterly MDS dated [DATE] documented in Section P0100 that physical restraints were used in a chair or in bed less than daily, although the DON later confirmed this coding was inaccurate. For another resident admitted with hemiplegia/hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety disorder, the record showed a PASRR Level II completed on 7/13/21, but the Annual MDS dated [DATE] documented at A1500 that the resident did not have a PASRR Level II. On 3/18/25, the DON stated that this Annual MDS assessment was not accurately completed and that A1500 should have been marked "Yes" to reflect the existing PASRR Level II. These inaccuracies in MDS coding for physical restraints and PASRR Level II status were identified through record review and confirmed by staff interview with the DON.
Failure to Complete Correct PASRR Level I and Required Level II for Resident With Mental Health Diagnoses
Penalty
Summary
Surveyors determined that the facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program by not providing a required PASRR Level II to the designated state agency for one resident. The resident was admitted with multiple diagnoses, including PTSD, anxiety, and depression. A PASRR Level I completed on 3/27/25 did not document that the resident had PTSD or an anxiety disorder, despite these diagnoses being present. During an interview on 3/18/26 at 9:34 AM, the Social Services Director (SSD) acknowledged that the resident should have had a corrected PASRR Level I completed, along with a PASRR Level II, due to the PTSD and anxiety diagnoses. This failure resulted in incomplete coordination of care and lack of appropriate documentation of interventions in the resident’s care plan, as identified through observation, policy review, and staff interviews. The deficient practice was identified for 1 of 2 residents whose records were reviewed for PASRR documentation and was based on the discrepancy between the resident’s documented mental health diagnoses and the information recorded on the PASRR Level I, as well as the absence of a PASRR Level II referral to the state agency.
Failure to Revise Care Plans and Conduct Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans and to conduct required care conferences in accordance with its policy. The facility’s policy stated that care plans should be reviewed and revised when changes occur to update the plan of care. For one resident with heart disease, difficulty walking, abnormal posture, and kyphosis, the care plan still contained an outdated direction to ambulate with therapy only after a new restorative walking program was initiated, and it continued to list use of a neck brace even though the brace had been discontinued months earlier. The resident was observed holding her head at an angle with her hand, and no neck brace was present in the room. The Staff Development Coordinator acknowledged that the ambulation direction should have been discontinued when the new restorative program started and that the care plan was not updated when the neck brace was discontinued. Another resident with cellulitis of the right limb, muscle weakness, and a need for assistance with personal care had a physician order for offloading boots to be applied to both feet at all times, but this intervention was not included in the care plan, and the resident was repeatedly observed without the boots. The DON confirmed the care plan should have been revised to include this intervention. A third resident with hemiplegia and hemiparesis following a stroke transitioned to hospice services, as documented in a progress note, but the care plan did not include hospice or comfort care interventions; the ADON confirmed the care plan should have been revised upon admission to hospice. A fourth resident with PTSD, anxiety, and depression did not have documentation of quarterly care conferences for two required quarters, and the Social Services Director stated those conferences were overlooked and not completed.
Failure to Follow Medication Administration Standards and Verify Appropriate Routes
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans for two residents. For one resident with hypertension and acute pancreatitis, physician orders directed that lisinopril 10 mg by mouth daily be held for systolic blood pressure less than 100, and metoprolol succinate extended-release 25 mg by mouth daily be held for heart rate less than 55 or systolic blood pressure less than 100. On the morning of 3/19/26, an LPN administered both metoprolol and lisinopril without checking the resident’s blood pressure and heart rate at that time. The LPN later stated that vital signs had been taken earlier by a CNA and were 132/78, and acknowledged she probably should have checked the vital signs prior to administering the anti-hypertensive medications. The facility also failed to ensure correct medication orders and routes of administration for another resident with diabetes, kidney disease, and an ileostomy. This resident’s record contained active orders for Dulcolax (bisacodyl) 10 mg suppository to be inserted rectally as needed for constipation and a Fleet enema to be inserted rectally as needed for constipation, both ordered on 5/8/23. Given the resident’s ileostomy, the Staff Development Coordinator confirmed that the resident should not have any orders for medications to be given rectally and that the routes on the bisacodyl and enema orders were wrong, and further stated the resident should not even have those orders. These issues were identified through observation, record review, policy review, and staff interviews.
Failure to Obtain Timely Physician Response After Resident Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely physician response and quality treatment and care in accordance with professional standards of practice when the resident experienced a change in condition. The resident was admitted with multiple diagnoses, including urinary tract infection, diabetes, heart failure, and chronic kidney disease. In the early morning, a nursing progress note documented that an SBAR was sent to the resident’s physician at 12:42 AM, reporting the resident was hard to arouse, appeared somnolent, had slept most of the shift, had eaten no dinner, and might be showing signs and symptoms of sepsis or a urinary tract infection, and requested further evaluation and treatment. Later that day, at 3:45 PM, another nursing progress note documented a second SBAR to the physician, reporting congestion, refusal of medications and food throughout the day, and that the resident had been sleeping most of the day, and asked if the physician could see the resident, order labs, or a portable chest X-ray. At 4:10 PM, the nurse documented that the resident was found in bed catatonic and unresponsive when brought to the nurse at 3:20 PM, and the physician was called and approved sending the resident to the ER via emergency transport. There was no documentation that the physician communicated with the facility between the first SBAR at 12:42 AM and the second SBAR at 3:45 PM, and the Administrator later acknowledged the facility had no record of a physician response to the initial SBAR before the resident was sent to the ER.
Failure to Address Ongoing Refusal of Hand Orthotic and ROM Needs
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a right-hand contracture received appropriate treatment and services to maintain or improve range of motion (ROM) and prevent further decline. The resident, who had a history of stroke with aphasia and a right-hand contracture, was discharged from OT with a right grip orthotic/resting hand splint to be worn during daylight hours as tolerated, with an excellent prognosis to maintain function with consistent staff support. The care plan directed staff to apply the right-hand grip splint for eight hours as tolerated. Subsequent documentation showed the resident frequently refused to wear the orthotic, with TAR entries indicating refusals on numerous days over several consecutive months. A physician communication in early October documented that CNAs reported the resident refused to wear the brace daily and exhibited high pain when staff attempted to place fingers into his contracted hand, and a re-evaluation for therapy options was recommended. Despite ongoing refusals documented in the TAR and monthly summaries noting the resident’s contractures and refusal to wear the orthotic, there was no further documentation after early October that the physician, therapy department, or the resident’s representative were notified of these continued refusals. The resident was not referred back to therapy after his initial OT discharge in July, even though the OT and DOR confirmed no subsequent therapy referrals. A restorative program for PROM to the right hand was initiated in January, with care plan directions to perform PROM and approach the resident by asking to hold his hand, and restorative evaluations in February and March documented participation in the PROM program. However, the Restorative Coordinator stated she was unaware of how long the resident had been unable to open his right hand and that he was referred to the restorative program only in January due to tightness. The DON stated that the expectation when a resident continued to refuse a splint would be to refer to therapy, notify the representative, provide education, and notify the physician, but she did not recall being informed of the ongoing refusals. The lack of timely and consistent communication and follow-through with the interdisciplinary team regarding the resident’s persistent refusals to wear the orthotic and his increasing hand tightness led to the deficiency.
Failure to Administer Insulin as Ordered and Incorrect PRN Morphine Dose
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors related to insulin administration and morphine dosing. The resident had multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care. The resident’s diabetic care plan, revised 1/22/26, directed staff to provide timely notification to the physician for any change in condition, and a physician’s order dated 2/2/26 specified a sliding scale regimen for Insulin Aspart Injection Solution 100 units/mL based on blood glucose ranges, including instructions to give 6 units and notify the provider if the blood sugar was greater than 351. Review of the MAR from 2/2/26 to 3/18/26 showed no documented insulin administrations or blood sugar checks on multiple evening shifts (2/2, 2/8, 2/9, 2/12, 2/15, 2/23, 2/27, 3/5, 3/6, 3/12, 3/15, and 3/16). The DON confirmed that the insulin administration record contained multiple blanks and that there was documentation of blood sugar readings but no documentation of insulin doses administered. The facility also failed to follow physician orders for PRN morphine for the same resident. The resident’s record contained two morphine orders: Morphine Sulfate 15 mg, 0.5 tablet by mouth every 1 hour PRN for pain/dyspnea, and Morphine Sulfate 15 mg, 15 mg by mouth three times a day for pain. A nursing progress note dated 3/4/26 documented that the resident was given the wrong dose of PRN morphine. A medication error report from 3/4/26 at 3:15 AM recorded that a licensed nurse administered a full 15 mg tablet instead of the ordered half tablet for the PRN dose. The error was identified when the resident asked whether a whole or half tablet had been given and stated that only half should have been administered. The licensed nurse verified the order and acknowledged that a medication error had occurred, and the DON later confirmed the occurrence of this error.
Missing Current Hospice Plan of Care and Terminal Certification
Penalty
Summary
Facility staff failed to ensure that required hospice documentation was complete and available in the medical record for a resident receiving hospice services. The resident had multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care, and the hospice care plan revised on a specified date documented that the resident was on hospice and had a DNR code status. Record review showed there was no current hospice plan of care and no current terminal diagnosis certification in the resident’s chart, both of which are required to initiate and maintain hospice services. When the surveyor requested these documents, the DON later provided a terminal certification with a benefit period that had expired 23 days earlier and only a facility-generated care plan, and the Administrator acknowledged that there was no current terminal certification or hospice plan of care in the resident’s record. The absence of required hospice documents created the potential for delayed or incomplete care due to lack of access to the hospice plan of care and current terminal certification.
Lack of Qualified Food Service Director
Penalty
Summary
The facility failed to ensure a qualified director of food and nutrition services was in place to oversee the dietary department, potentially affecting 82 residents. The job description for the Food Service Director, dated 09/28/22, required a minimum course of study in food safety, such as the Serv Safe Food Manager Certification, to be completed before 10/01/23. However, during an interview on 10/01/24, the Dietary Manager (DM) revealed that he had been employed for one and a half years without obtaining the necessary certification or completing any Serv-Safe courses. The DM attributed this to working six months straight without a day off, leaving no time for training. Additionally, the Registered Dietitian (RD), who was present at the facility two days a week, acknowledged the DM's lack of certification and emphasized the importance of certification for managing the kitchen for long-term residents. The RD stated that she was responsible for completing resident assessments but did not manage the kitchen.
Inadequate Staffing and Training in Dietary Department
Penalty
Summary
The facility failed to ensure sufficient staffing with appropriate competencies and training in the dietary department, affecting the ability to safely and effectively carry out food and nutrition services for 81 of 82 residents. The dietary schedule revealed inadequate staffing, with only two employees scheduled to prepare, serve, and clean up the dinner meal for most days, and only one employee on Tuesdays. Observations confirmed that during the evening, only two staff members were present in the kitchen. Interviews with the Dietary Manager (DM) and other staff highlighted severe understaffing, lack of training, and the absence of in-service training since December 2022. The DM, who had been working without a day off for six months, admitted to not having time for certification or staff training. The Registered Dietitian (RD) was unaware of any training provided to the kitchen staff and noted that her suggestions during kitchen audits were not addressed by the DM. The RD also identified a failure to update a resident's diet tray ticket, which was supposed to reflect a change to a diet limiting tomatoes and potatoes. Staff interviews further revealed that the lack of adequate staffing led to rushed work and mistakes, with many staff members leaving the job due to the conditions. The DM acknowledged the need for additional staff and training but was not involved in the recruitment process, which was handled by the main office.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitation and food handling practices, as observed during a survey. In the kitchen, a black mold-like substance was found on the plastic lining inside the ice machine, which had not been cleaned since July, despite the facility's policy requiring regular maintenance. Additionally, food items such as health shakes and soda were improperly stored on the floor in both the walk-in freezer and dry storage area, contrary to professional standards. Cook1 acknowledged that these items had been delivered days prior and should not have been left on the ground. Further observations during the tray line service revealed that Cook2 handled plates and food with bare hands, placing his thumb on the center of the plates and arranging food without gloves. Cook2 also wiped his hands on his pants multiple times during service. The Dietary Manager admitted that the cook was newly hired and required more training. The Registered Dietitian confirmed that kitchen audits were conducted, but her recommendations were not being followed, emphasizing the need for adherence to the sanitation policy.
Failure to Serve Meals Consecutively Affects Resident Dignity
Penalty
Summary
The facility failed to serve residents consecutively at five of the seven tables during meal service, affecting the dignity and meal satisfaction of residents. The policy titled 'Resident Dining Services' required that residents seated together be served in consecutive order so they could eat at the same time. However, during a lunch meal observation, meals were served in a non-consecutive manner across different tables, leading to delays for some residents. For instance, meals were served at different times to residents at tables one, two, three, four, five, six, and seven, with the final meal being served at 11:49 AM, which was 12 minutes after the first meal was served. Resident 48, who was seated at table four, expressed dissatisfaction, stating that meals were served in this manner daily, and they often had to wait. The resident attributed this to having only one server. Interviews with Cook1 and the Dietary Manager revealed a lack of awareness regarding the policy requirement to serve all residents at a table before moving to the next. Cook1 mentioned serving plates as they came off the tray line, while the Dietary Manager admitted not knowing that residents were not being served consecutively at each table.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% during the observation of 26 medication administration opportunities. This deficiency was identified in two residents out of a sample of 29. For one resident, the facility did not adhere to the prescribed timing for administering Lantus Solostar insulin. The insulin was ordered to be administered at 8:00 AM, but it was observed being administered at 9:59 AM, which is beyond the one-hour window allowed by the physician's order. The registered nurse confirmed the late administration during an interview. Another resident received multiple medications through a PEG tube in a manner that did not comply with the facility's policy. The policy required each medication to be administered separately, but the nurse crushed several medications and mixed them with water before administering them together through the PEG tube. This action was confirmed by the nurse during an interview, indicating a deviation from the facility's established medication administration procedures.
Inadequate Documentation of Diabetes Management
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with diabetes, specifically regarding the treatment of high and low blood sugar levels. The resident, who had moderately impaired cognition, was on insulin therapy and had a history of blood sugar issues. On one occasion, the resident's blood sugar dropped to 50, but there was no documentation of the actions taken to address this hypoglycemic event, such as administering carbohydrates or notifying a physician, as required by the facility's protocol. The Licensed Practical Nurse (LPN) involved admitted to not documenting the incident, despite administering glucose and glucagon injections. In another instance, the resident's blood sugar was recorded at 566, but the Registered Nurse (RN) did not document administering the prescribed insulin or rechecking the blood sugar within the specified time frame. The RN claimed to have followed the physician's instructions and administered insulin, but there was no progress note to confirm this. The lack of documentation raised concerns about the accuracy of the resident's medical records and the adequacy of their diabetes management. Interviews with the Resident Care Manager and the Director of Nursing confirmed the absence of necessary documentation in the resident's medical records. The facility's policy required all medical record entries to be authenticated and documented by credentialed individuals, but this was not adhered to in the cases of both hypoglycemia and hyperglycemia incidents. This deficiency in record-keeping created the potential for inadequate treatment of the resident's diabetes.
Failure to Implement Proper Infection Control Procedures
Penalty
Summary
The facility failed to implement proper infection control procedures for a resident who required enhanced barrier precautions (EBP) due to having an invasive device, such as a feeding tube. The resident had diagnoses including stroke and diabetes and was admitted with orders for tube feeding and medication administration through a percutaneous endoscopic gastric (PEG) tube. Despite the requirement for staff to wear protective gowns during high-contact care activities, a registered nurse (RN) was observed administering medications to the resident via the PEG tube while only wearing gloves and not a protective gown. The RN confirmed the resident was under EBP and acknowledged the failure to don a gown prior to accessing the PEG tube for medication administration.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents, R140 and R18, from sexual abuse by another resident, R139. R139, who was cognitively intact, was observed placing R140's hand on his genitals and later placing his hand on R18's groin. R140 had a severely impaired cognition with a BIMS score of six, indicating she could not consent to sexual activity. Despite being educated about R140's inability to consent, R139 continued to engage in inappropriate behavior. The facility's policy on abuse prevention was not effectively implemented to prevent these incidents. R139's behavior was documented in the Facility Reported Incident (FRI) investigations. The first incident involved R140, who had a diagnosis of dementia and was severely impaired cognitively. R139 was observed by a CNA engaging in inappropriate contact with R140, who was unable to consent. The facility's response included separating the residents and placing them under supervision, but R139's care plan was not updated until several months later. R139 was eventually discharged to an all-male unit due to his behavior. The second incident involved R18, who had moderately impaired cognition. R139 was observed by CNA3 touching R18 inappropriately in the dayroom. Despite being placed on one-to-one supervision, R139 continued to seek out female residents with cognitive impairments. The facility's response included reporting the incident and placing R139 under observation, but the care plan interventions were not sufficient to prevent further incidents. The facility's failure to protect these residents from sexual abuse resulted in a deficiency in their care.
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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