Life Care Center Of Idaho Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Idaho Falls, Idaho.
- Location
- 2725 East 17th Street, Idaho Falls, Idaho 83406
- CMS Provider Number
- 135091
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Life Care Center Of Idaho Falls during CMS and state inspections, most recent first.
The facility did not follow its policy requiring an IDT assessment before allowing a resident to self-administer medications. A resident with multiple myeloma and diabetes was observed independently instilling eye drops, with a bottle of Refresh Tears at the bedside. Record review showed no MD order for the eye drops and no documented IDT self-administration assessment. The DON confirmed the resident had not been assessed for self-administration and should not have had the eye drops at the bedside.
The facility did not follow its policy to provide all residents or their responsible parties with information and assistance to formulate advance directives upon admission. Record review and staff interviews showed that four residents with significant medical conditions, including polyneuropathy, diabetes, dementia, stroke-related hemiplegia, cancer, hypertension, and lumbar spinal stenosis, had no healthcare advance directives in their records and no documentation that they were informed of their right to create one. The Social Services Director and DON confirmed these residents only had financial or general POA documents and were not offered the opportunity to establish a healthcare advance directive.
The facility did not follow its own policies requiring daily toilet cleaning and twice-daily shower/bath area cleaning, resulting in a resident room and multiple shower rooms with thick black and brown debris, staining, and missing caulking. Surveyors observed a resident room toilet with a heavy black ring above the water line and under the rim, and a sink with heavy brown residue. In two hall shower rooms, they found blackened debris on floors and tiles, toilets with black/brown debris at the water line and under the rim, rusty discoloration in bowls and around bases, discolored toilet seats, missing caulking, and black debris along floor and wall lines. The Maintenance Director acknowledged the showers did not appear to have been cleaned, and the Housekeeping Manager reported that CNAs were supposed to wipe down showers between use and housekeeping was to check them at day’s end, but confirmed the shower rooms had not been cleaned as required, creating potential for diminished quality of life and resident safety including infection and cross-contamination.
Surveyors found that the facility did not follow its own discharge and bed-hold policy requiring written notice of transfer, reasons for the move, and bed-hold information before hospital transfers. Record review showed that two residents with complex medical conditions, including stage IV pressure ulcers, diabetes, spinal cord injury, cancer, hypertension, and lumbar spinal stenosis, were transferred to the hospital without any documented Notice of Transfer or Bed Hold Policy in their charts. In an interview, the DON confirmed that the facility did not have the required transfer and bed-hold documentation for these residents.
A deficiency was cited when a resident’s comprehensive care plan included an intervention for high-risk medication management of insulin "per MD order" for diabetes, despite the absence of any physician order for insulin in the medical record. Facility policy required person-centered care plans with interventions aligned to each resident’s physical and psychosocial needs and updated with each MDS assessment. Record review showed the care plan had not been updated to remove the incorrect insulin intervention, and the DON confirmed the resident had never had an insulin order and that insulin should not have been listed on the care plan.
A resident with multiple chronic conditions had standing PRN orders for a bowel protocol, including Senna, Bisacodyl (oral and suppository), and a Fleet enema, to be used based on specific time intervals without a BM and to notify the MD if there was no response. Record review showed the resident went more than five days without a BM, with no documentation that the ordered bowel medications were administered during part of this period and no documentation that the physician was contacted after more than 96 hours without a BM. The ED acknowledged that nursing staff should have notified the physician and did not.
Two residents were affected when the facility failed to prevent environmental hazards and to timely document a fall. One resident with respiratory failure and diabetes was found using a multi-outlet extension cord in her room to power a bed, power wheelchair, and cellphone, contrary to guidance that extension cords not replace permanent wiring and be used for only one device. Another resident with hemiplegia and hemiparesis reported left shoulder pain to therapy staff and a physician after falling from a wheelchair, with imaging later indicating osteoporosis and a likely acute clavicle fracture. An LPN assessed the resident after the fall and instructed another LPN to enter the event into the risk management system, but this documentation was not completed, and the ED reported he did not become aware of the fall until much later during an internal investigation.
A resident with chronic respiratory failure with hypoxia and a history of stroke had a physician order and care plan for continuous oxygen at 1 L/min via nasal cannula, with the MAR reflecting administration at that rate. However, surveyors observed the resident’s oxygen concentrator set at 2 L/min on one occasion and 2.5 L/min on another, and the resident reported being on 2 L/min. An RN acknowledged the oxygen should have been set at 1 L/min but was not, and the DON stated that staff should check the concentrator liter flow at least every shift but had not done so, creating the potential for increased fatigue and low O2 levels.
A resident with hypothyroidism and dementia was observed on multiple occasions with bilateral upper side rails in the up position, but the facility failed to follow its bed rail policy. The record lacked an assessment for bed rail use, documentation of alternatives attempted and how they failed, the intended purpose of the rails, a physician order, and a documented risks/benefits discussion with signed consent. The DON confirmed that none of these required steps had been completed, creating potential for injury, entrapment, and/or death.
The facility failed to accurately post required daily nurse staffing information, including the number of CNAs present and their hours worked on one date, and RN hours worked for all shifts on another date. Federal regulations require posting of the facility name, date, total number and actual hours worked by RNs, LPNs/LVNs, and CNAs per shift, along with the resident census. Surveyors observed missing CNA and RN data on the posted staffing sheets, and the Executive Director acknowledged that these staffing details should have been documented but were not.
The facility failed to follow its policy requiring two nurses to count and document controlled substances at each shift change, resulting in missing nurse signatures on narcotic count sheets for both medication carts reviewed. During audits of two halls, surveyors found multiple dates where only one or no licensed nurse signatures were recorded on Narcotic Card Item Count sheets, despite the expectation that two nurses sign when accepting or releasing the cart. An LPN on each hall and the DON confirmed that two signatures were required but not consistently obtained, affecting all residents receiving controlled medications.
A resident with acute osteomyelitis of the left ankle and foot had PRN orders for acetaminophen for mild pain and Percocet for moderate to severe pain. Documentation showed acetaminophen was given only once for a pain level of 4 and then not administered for several days, while Percocet was administered multiple times for documented pain levels of 3, below the ordered indication for moderate to severe pain. The facility’s pain management policy required pain assessment every shift with documentation of the pain scale and type of pain, and the DON reported that physicians had moved away from relying on the numeric pain scale because residents might underreport their pain.
Surveyors found that glucose control solutions used for blood glucose testing were not dated when opened, despite manufacturer instructions and facility policy requiring documentation of an open date and three-month discard date. Review of blood glucose logs showed the same undated solutions were used over several months, and staff acknowledged they should have been dated and limited to three months of use. In addition, a medication cart on one hall was observed left unlocked and unattended, contrary to facility policy requiring carts to be locked when out of sight, and both an RN and the DON confirmed the cart should not have been left unlocked.
Surveyors found that the facility failed to follow its IPCP requirements for appropriate storage and handling of medical equipment when a resident’s power wheelchair, with personal items and a Hoyer sling, along with a resident lounge shower chair, a Hoyer lift, and a bariatric shower chair, were stored in an Out of Order shower room that was visibly soiled with a dirty toilet, brown substances on floors and walls, and used paper towels on surfaces. The Infection Preventionist acknowledged that staff should not be storing resident equipment in this Out of Order shower room.
A resident with chronic kidney disease and diabetes was found unresponsive, and despite clear DNR/DNI orders in the medical record and care plan, an LPN mistakenly initiated CPR after referencing a POST document for another resident. CPR was discontinued only after the correct code status was confirmed by emergency responders.
A medication cart review revealed that the narcotic accountability record was missing a required nurse signature, with only one instead of two signatures documented. Both an RN and the Admissions Nurse confirmed that two nurses should have signed the record when accepting or releasing the cart, indicating a failure to properly track and secure controlled medications.
A resident with a DNR/DNI order was resuscitated and intubated by facility staff and EMS without verification of her code status. Despite having a POST indicating DNR/DNI, staff initiated CPR and used an AED, and EMS was not informed of her status until after intubation. The resident's family confirmed her wishes, and she later expired at the hospital.
The facility failed to store food safely and sanitarily, with expired yogurts, unlabeled salad, and undated chicken found during inspections. Ants were also observed on a food prep table, despite recent pest control. The Food Service Director acknowledged these issues, highlighting risks of food contamination.
The facility failed to ensure accurate MDS assessments for multiple residents, leading to potential negative outcomes. A resident with Cerebral Palsy was incorrectly documented as not receiving tube feeding, while another with schizophrenia was not marked for major mental illness. Similar inaccuracies were found in assessments for residents with bipolar disorder, schizoaffective disorder, and those requiring feeding tubes, highlighting a significant deficiency in resident assessments.
The facility failed to update care plans for four residents, leading to discrepancies between documented care and current needs. A resident's care plan inaccurately listed clostridium difficile, another's did not include self-administration of Biofreeze, a third's omitted treatment for excoriation, and a fourth's incorrectly documented a discontinued Dobhoff tube. Staff acknowledged these oversights.
The facility failed to ensure a safe, clean, and homelike environment, with water temperatures exceeding safe limits and various cleanliness and maintenance issues in resident rooms and common areas. Observations included high water temperatures, missing drawer fronts, black substances in showers, and dust on kitchen ceilings and vents.
The facility failed to complete PASARR Level II evaluations for residents with major mental illnesses, including those with bipolar disorder, PTSD, and borderline personality disorder. This oversight involved four residents, where necessary screenings and referrals were not conducted, potentially impacting the provision of specialized mental health services.
A facility failed to follow a resident's care plan requiring two staff members for bed mobility due to fragile bones. Despite the care plan's directive, documentation showed that only one CNA or NA assisted the resident on multiple occasions. The DON confirmed the need for adherence to the care plan.
A resident with kidney disease and bladder pain refused a prescribed Nicotine Transdermal Patch 11 out of 12 times. The facility's policy required notifying the physician after three refusals, but there was no documentation of such notification. The DON confirmed the physician should have been informed, indicating a failure to adhere to professional standards.
The facility failed to follow professional nursing standards for two residents. A resident with wounds on her knee lacked documented wound care orders, and an LPN treated the wounds without proper orders. Another resident with emphysema was using oxygen without documented orders in his electronic medical records, despite standing orders being present in paper records. Nurses did not document the completion of these orders.
A resident with atrial fibrillation using sequential compression devices had the compressor plugged into a power strip, contrary to safety guidelines. The State Operations Manual specifies that power strips should not be used for medical devices in patient care areas. The Maintenance Director acknowledged the error, highlighting a failure to follow safety protocols.
A facility failed to ensure licensed nurses followed standing orders for oxygen administration, as evidenced by multiple instances where a resident with low SpO2 levels did not receive the required intervention. Despite having standing orders to titrate supplemental oxygen for SpO2 below 88%, the nursing staff did not document any follow-up actions or notify the physician, as confirmed by interviews with an LPN and the DON.
The facility failed to store medications and supplies appropriately for two residents, leading to potential safety risks. One resident had medication left on the bedside table without a self-administration assessment or care plan, while another had wound care supplies left out in the room. Staff confirmed these practices were against facility policy.
The facility failed to employ a qualified director of food and nutrition services, as required by regulations. The current Food Service Director did not meet the necessary qualifications, such as certification or relevant experience and education. This deficiency had the potential to affect all residents receiving meals prepared in the facility's kitchen.
The facility failed to maintain infection control practices, with issues in oxygen equipment storage, catheter bag placement, and glucometer cleaning. Oxygen supplies were improperly stored, catheter bags were found on the floor, and glucometers were not cleaned per protocol, risking cross-contamination.
The facility failed to consistently perform glucometer solution tests for two medication carts, Hall 300 and Hall 400, as required by the Assure Prism Blood Glucose Monitoring System manual. The tests were not done consistently from December 2024 to January 2025 for Hall 400 and in January 2025 for Hall 300. An LPN confirmed that these tests should have been conducted daily by the night shift.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident’s ability to self-administer medications in accordance with its Self-Administration of Medication policy, which requires that any resident requesting to self-administer medications be evaluated by the interdisciplinary team (IDT) and that the assessment be documented in the electronic medication record and reviewed with the resident and/or responsible party. The resident, who had multiple diagnoses including multiple myeloma and diabetes, was observed sitting in his room placing eye drops in his eyes, and a bottle of Refresh Tears was seen on his bedside table. Review of the resident’s medical record showed no physician order for Refresh Tears and no IDT self-administration assessment. The DON stated that the resident should not have had the Refresh Tears at his bedside and confirmed that the resident had not been assessed by the IDT for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident.
Failure to Assist Residents With Formulating Healthcare Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advance directive, as required by the facility’s Advance Directives policy. That policy, last reviewed on 12/1/25, stated that all residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the formation of advance directives upon admission. Record review showed that four residents admitted with multiple medical diagnoses did not have an advance directive for healthcare in their medical records, nor documentation that they were provided information on their right to formulate one. One resident with polyneuropathy and diabetes, another with a left femur fracture and dementia, another with hemiplegia and hemiparesis following a stroke, and another with cancer, hypertension, and lumbar spinal stenosis all lacked healthcare advance directives or documentation of being informed of their right to create one. The Social Services Director and the DON confirmed that these residents only had financial or general powers of attorney on file and did not have a Durable Power of Attorney for Healthcare or other healthcare advance directive, and that they were not offered the opportunity to formulate one.
Failure to Maintain Clean and Homelike Resident Room and Shower Areas
Penalty
Summary
The facility failed to honor residents' right to a safe, clean, comfortable, and homelike environment as required by its own policies for daily room and shower cleaning. The Daily Room Cleaning policy required that resident bathroom toilets be cleaned daily, and the Housekeeping Services policy required that resident shower/bath areas be cleaned twice daily. Despite these policies, surveyors observed one resident room with a toilet that had a thick black ring of debris above the bowl water line and under the rim, and a room sink that was heavily stained with brown residue. Additional observations in common shower areas showed similar failures to maintain cleanliness. In one hall shower room, surveyors observed blackened thick debris on floors and tiles, a toilet with a black/brown debris line around the water line and rusty brown discoloration in the bowl, black debris around the wall and floor line, and a rusty brown area between tiles and the wall under the sink. In another hall shower room, there was blackened thick debris on floors and tiles, a toilet with black/brown debris at the water line and under the rim, a discolored toilet seat, a rusty brown and black ring around the entire toilet base, missing caulking at the floor and wall line, and black debris at the floor and wall line extending up two tiles on the wall. The Maintenance Director acknowledged that the showers did not appear to have been cleaned as they should have been, and the Housekeeping Manager stated that CNAs were expected to wipe down showers between resident use and housekeeping was to check shower rooms at the end of the day, but confirmed the shower rooms had not been cleaned as required. The report states this deficient practice created the potential for diminished quality of life and resident safety including infection and cross-contamination.
Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to residents or their representatives when residents were transferred to the hospital. Policy review showed the facility’s "Discharge Process and Bed Holds" policy, reviewed 12/1/25, required that before a transfer or discharge, the facility must notify the resident and representative in writing, in a language and manner they understand, of the transfer or discharge and the reasons for the move. The policy also required that before a resident is transferred to a hospital or goes on therapeutic leave, the facility must provide written information specifying the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence. Record review revealed that one resident with multiple diagnoses including stage IV pressure ulcers, diabetes, and spinal cord injury was transferred from the facility and admitted to the hospital on two occasions, and there was no documentation that he was provided with a Notice of Transfer or Bed Hold Policy prior to either transfer. Another resident with multiple diagnoses including cancer, hypertension, and lumbar spinal stenosis was transferred and admitted to the hospital, and her medical record also lacked documentation that she was provided with a Notice of Transfer or Bed Hold Policy prior to transfer. During an interview on 3/18/26 at 1:40 PM, the DON stated they did not have the Notice of Transfer or Bed Hold documentation for these two residents.
Inaccurate Diabetes Care Plan Intervention Without Corresponding Insulin Order
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a person-centered comprehensive care plan consistent with the resident’s actual medical orders and needs. The facility’s policy required development and implementation of a comprehensive person-centered care plan for each resident, including identification and implementation of interventions and treatments to address physical, functional, and psychosocial needs, and updating the care plan with each MDS assessment and periodically. Record review for one resident with multiple diagnoses, including hypertensive heart and chronic kidney disease and diabetes, showed the last care plan review was completed on 12/21/25 and included an endocrine/diabetes care plan with an intervention for “High Risk Medications: Insulin per MD order,” initiated on 12/15/25. However, review of the resident’s medical record on 3/17/26 showed there was no physician’s order for insulin during the resident’s stay, and the DON confirmed the resident had not had an insulin order and that insulin should not have been documented on the care plan. This discrepancy between the documented care plan intervention and the absence of a corresponding physician order demonstrated that the facility did not maintain an accurate, person-centered comprehensive care plan for the resident, as required by its own care planning policy.
Failure to Follow Bowel Protocol and Physician Orders for Constipation Management
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own bowel protocol policy for a resident requiring bowel management. The facility’s Bowel Protocol policy, reviewed on 9/15/25, stated that the facility, in coordination with the attending practitioner, would implement standing orders to address a lack of bowel movement. Resident #13 was admitted with multiple diagnoses including hypertensive heart and chronic kidney disease and respiratory failure. The resident’s medication administration record contained standing PRN orders dated 1/22/26 for Senna tablets to be given if there was no bowel movement (BM) in 72 hours, Bisacodyl delayed-release tablets if no BM in 96 hours, a Bisacodyl suppository if there was no BM by 10:00 the day after oral Bisacodyl, and a Fleet enema if there was no result two hours after the suppository, with instructions to call the MD if there was no BM within two hours of the enema. Record review on 3/18/26 at 2:01 PM showed that the resident had a BM on 2/21/26 at 03:56 and then not again until 2/26/26 at 22:39, a gap of over 120 hours. During this period, there was no documentation that any of the ordered bowel management medications were administered between 2/24/26 and 2/26/26, despite the standing orders tied to specific time intervals without a BM. Further review at 2:07 PM on 3/18/26 showed no nursing progress note documentation that the physician had been contacted on 2/25/26 through 2/26/26 regarding the absence of a BM for over 96 hours. In an interview at 2:20 PM on 3/18/26, the Executive Director stated that nursing staff should have contacted the physician after 96 hours without a BM and had not done so.
Failure to Prevent Environmental Hazards and Timely Document Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision, as evidenced by issues involving two residents. For one resident with respiratory failure and diabetes, surveyors observed an extension cord in the room with the bed electrical cord, wheelchair electrical cord, and cellphone electrical cord all plugged into it. The resident stated she had purchased the extension cord herself and used it for these devices. The Maintenance Director stated that medical devices should not have been plugged into an extension cord in the room, and the Executive Director stated he was unaware the resident had an extension cord and that medical devices should not have been plugged into it. The State Operations Manual, Appendix PP, specifies that extension cords should not be used in place of adequate wiring and should be connected to only one device to prevent overloading. The deficiency also includes the facility’s failure to timely document and report a fall for another resident with hemiplegia and hemiparesis following a stroke. Therapy notes on multiple dates documented the resident’s reports of left shoulder pain due to a fall from his wheelchair, including mention of hearing a pop at the time of the fall. A physician progress note later documented increased left shoulder pain since a fall, and an x-ray report showed osteoporosis, mild to moderate shoulder osteoarthritis, and a likely acute distal clavicular fracture. Subsequent physician documentation referenced the need for further imaging and screening for osteoporosis. The facility’s later investigation determined that the resident had fallen out of his wheelchair onto the grass in front of the facility, was assessed by an LPN, and assisted back into the wheelchair. The investigation documented that the LPN instructed another LPN to enter the fall into the Risk Management system on the day of the incident, but this was not done because the second LPN forgot, and the Executive Director stated he did not learn of the fall until weeks later when the investigation was initiated.
Failure to Follow Ordered Oxygen Liter Flow Settings
Penalty
Summary
Surveyors found that the facility failed to provide respiratory services as ordered by the physician for one resident with chronic respiratory failure with hypoxia and a history of stroke. The facility’s Oxygen Administration policy required oxygen orders to include a specific liter flow, and the physician’s order for this resident, dated 11/12/23, specified oxygen at 1 liter per minute via nasal cannula continuously. The resident’s care plan directed staff to provide supplemental oxygen per the medical order, and the MAR documented that oxygen was administered at 1 liter per minute on specified dates and shifts. However, on 3/16/26 at 1:29 PM, the resident was observed in bed with a nasal cannula in place while the oxygen concentrator was set at 2 liters per minute, and the resident stated she was on 2 liters per minute of oxygen. On 3/17/26 at 9:04 AM, the oxygen concentrator was again observed, this time set at 2.5 liters per minute. At 9:08 AM, an RN acknowledged that the oxygen should have been set at 1 liter per minute and had not been. On 3/18/26 at 9:28 AM, the DON stated that the resident’s oxygen concentrator liter flow setting should be checked often or at least every shift by nursing staff and that this had not been done. The report stated this failure created the potential for residents to experience increased fatigue and low oxygen levels.
Failure to Assess and Obtain Consent Prior to Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for the safe and effective use of bed rails for one resident. The facility’s policy, reviewed on 9/3/25, required that residents be assessed upon admission, readmission, or upon initiation of bed rail use using the Evaluation for Use of Bed Rails Assessment, that alternatives to bed rails be tried and evaluated, and that the risks and benefits of bed rail use be reviewed with the resident or representative and consent obtained prior to installation. Surveyors observed a resident with multiple diagnoses including hypothyroidism and dementia using bilateral upper side rails in the up position on three consecutive days. On review of the resident’s medical record, surveyors found no documentation of an evaluation of alternatives attempted, no documentation of the purpose or intended use of the side rails, and no documented discussion of risks and benefits with a signed consent for bed rail use. Additionally, there was no physician order for the bed rails. The DON confirmed that the resident had not been assessed for the use of bed rails and that the medical record lacked the required documentation of alternatives, intended purpose, physician order, and consent, despite the facility’s policy requirements. This failure created the potential for harm due to the risk for injury, entrapment, and/or death.
Incomplete Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted on a daily basis for each shift, as required by 42 CFR §483.35(g). The State Operations Manual, Appendix PP, specifies that facilities must post the facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, and CNAs directly responsible for resident care per shift, as well as the resident census. On 3/17/26 at 12:31 PM, surveyors observed that the daily staffing sheet for 1/20/26 was missing the CNA number of staff present and their hours worked. Later that same day at 12:45 PM, surveyors observed that the daily staffing sheet for 2/15/25 was missing RN hours worked for the day, evening, and night shifts. On 3/18/26 at 9:30 AM, the Executive Director confirmed that the CNA and RN worked hours and staff present data should have been documented on the daily staffing sheets for those dates and had not been. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels, because the posted information was incomplete and did not fully reflect the required nurse staffing data.
Failure to Properly Document Controlled Substance Counts on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure controlled medications were consistently tracked and secured in accordance with its own policy and procedures. The facility’s “Inventory Control of Controlled Substances” policy, revised 08/01/24, required incoming and outgoing nurses to count all Schedule II controlled substances and other medications with a risk of abuse or diversion at each shift change and document the results on a Controlled Substance Count Verification/Shift Change Sheet. The policy also required staff to count all Schedule III–IV controlled substances in accordance with facility policy and applicable law. During a medication cart audit on Hall 2 on 3/18/26 at 8:17 AM, surveyors observed Narcotic Card Item Count sheets dated 1/1/26 to 1/15/26, 2/1/26 to 2/15/26, and 3/1/26 to 3/15/26 that were missing one of the required licensed nurse signatures on 1/1/26, 2/3/26, 2/10/26, 2/11/26, and 3/10/26. During a medication cart audit on Hall 4 on 3/18/26 at 8:50 AM, surveyors observed a Narcotic Card Item Count sheet dated 3/11/26 to 3/21/26 that was missing one licensed nurse signature on 3/12/26. An LPN interviewed at 8:19 AM stated that two nurses should have signed the Narcotic Card Item Count sheet and had not. Another LPN interviewed at 8:55 AM similarly stated that two nurses should have signed the Narcotic Card Item Count sheet when they accepted or released the medication cart. At 10:16 AM, the DON confirmed that two nurses were expected to sign the Narcotic Card Item Count sheet when accepting or releasing the medication cart and acknowledged that this had not occurred. These findings were true for 2 of 2 medication carts reviewed and affected all residents receiving controlled medications in the facility.
Inadequate Assessment and Indication for Opioid Pain Medication
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when the facility failed to ensure appropriate assessment and indications for opioid pain medication use for one resident with other acute osteomyelitis of the left ankle and foot. The facility’s Pain Management policy dated 12/2/25 required that pain be assessed every shift, recorded on the eMAR, with the pain scale used and the type of pain documented, and that pain management be consistent with professional standards of practice and the resident’s care plan, goals, and preferences. For this resident, there was a physician order for acetaminophen 325 mg, two tablets by mouth every 8 hours as needed for mild acute pain, not to exceed 3000 mg/day. The record showed acetaminophen was administered once on March 8 at 0837 for a pain level of 4, with no further documented administration of acetaminophen from March 9 through March 16. The same resident also had a physician order for Percocet 5-325 mg (oxycodone with acetaminophen), one tablet by mouth every 4 hours as needed for moderate to severe acute pain related to the osteomyelitis diagnosis. However, the medical record documented that Percocet was administered on three occasions—March 13 at 0707, March 15 at 0621, and March 16 at 0625—each time for a documented pain level of 3, which is below the ordered indication of moderate to severe pain. During an interview on March 17 at 12:58 PM, the DON stated that physicians had moved away from using the pain intensity number scale because some residents might report a pain level of 3 when it is really a 6 or 7, indicating a discrepancy between the documented pain scores and the ordered criteria for opioid use.
Improper Labeling of Glucose Control Solutions and Unlocked Medication Cart
Penalty
Summary
The deficiency involves failure to ensure biologicals were labeled when opened and to store medications in locked compartments as required by facility policy and manufacturer instructions. The facility’s policy on storage and expiration dating of medications and biologicals required that once any medication or biological package was opened, manufacturer guidelines for expiration dates be followed. The Assure Prism Blood Glucose Monitoring System QA/QC manual specified that when a control solution bottle is first opened, the discard date (date opened plus three months) must be recorded on the label. Surveyors observed one set of Assure Prism glucose test solutions (CSYF24BN and CSYM26AM) that were not dated when opened and had no expiration date written on the label. An RN stated she did not know how long the test solutions had been opened and used. Review of blood glucose testing logs showed these same solutions were documented as opened and used for testing over multiple months, and the Infection Preventionist confirmed they should be dated when opened and used only for three months. The deficiency also includes failure to keep a medication cart locked when unattended, contrary to the facility’s General Dose Preparation and Medication Administration policy, which required medication carts to be locked when out of sight or unattended. Surveyors observed a Hall 2 medication cart left unlocked and unattended by the medication nurse. Shortly thereafter, an RN was seen pushing a Hoyer lift down the hall toward the medication room and stated the medication cart should have been locked when left unattended. The DON also stated the medication cart should have been locked when not attended by the nurse and acknowledged that it had not been.
Improper Storage of DME and Lift Equipment in Contaminated Out-of-Order Shower Room
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the storage and handling of residents’ durable medical equipment (DME). The facility’s Infection Prevention and Control Program and Plan, revised 6/2/25, required appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipment to reduce risks associated with procedures, medical equipment, and medical devices. Resident #71, admitted with multiple diagnoses including atrial fibrillation, heart failure, and hypertension, was observed on 3/16/26 operating her power wheelchair on the 200 Hall. Later that morning, the 200 Hall shower room, which was marked Out of Order, was observed to have a thick dirty black ring inside the toilet bowl, a dirty brown substance on the floor and walls, and used paper towels on the back of the toilet and on the sink. In this same Out of Order shower room, Resident #71’s power wheelchair was stored, with an open box of cereal in the bag attached to the back of the wheelchair and a Hoyer lift sling placed in the seat, along with a resident lounge shower chair. On subsequent observations, a Hoyer lift and a bariatric shower chair were also found stored in this Out of Order shower room on the 200 Hall. On 3/19/26, the Infection Preventionist stated that staff should not be storing resident equipment in the Out of Order shower room on Hall 200. These observations demonstrated that the facility did not follow its own IPCP requirement for appropriate storage and handling of DME and related equipment, as resident mobility devices and shared lift and shower equipment were stored in a visibly dirty, Out of Order shower room, contrary to the facility’s stated infection control methods.
Failure to Honor DNR/DNI Orders Due to Staff Error
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders. The resident, who had multiple diagnoses including chronic kidney disease and diabetes, was found unresponsive by CNA staff. Nursing staff assessed the resident and determined the code status was DNR. However, an LPN entered the room with a Physician Orders for Scope of Treatment (POST) document, incorrectly identifying the resident as a full code, and initiated CPR. The POST document was later found to belong to a different resident. CPR was stopped only after the ambulance crew arrived and the correct DNR status was confirmed. The resident's physician order, POST, and care plan all documented DNR status, and staff interviews confirmed that CPR should not have been started.
Failure to Properly Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by a missing licensed nurse signature on the narcotic accountability record for one medication cart during a review. The narcotic accountability record, covering a specific period, was found to have only one nurse's signature instead of the required two. Both an RN and the Admissions Nurse confirmed that two nurses should have signed the record when accepting or releasing the medication cart. This lapse was identified during a medication cart review and was limited to one cart, but had the potential to affect all residents receiving controlled medications.
Failure to Honor DNR/DNI Orders
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, resulting in a deficiency. The resident, who had multiple diagnoses including a C2 level cervical spinal cord lesion and chronic kidney disease, was found with agonal respirations and subsequently lost her pulse. Despite having a Physician Orders for Scope of Treatment (POST) in her medical record indicating DNR/DNI status, facility staff initiated CPR and connected her to an automated external defibrillator (AED) without verifying her code status. CPR was continued for 13 minutes until EMS arrived, who then intubated the resident without being informed of her DNR/DNI status. The deficiency was further compounded by the lack of communication among facility staff regarding the resident's code status. The Medical Director and Director of Nursing (DON) were unaware of the resident's DNR/DNI status until after she was transferred to the hospital. The hospital emergency department report confirmed that EMS was not notified of the resident's code status until after intubation and transport. The resident's family later confirmed her DNR/DNI status, stating she should have been allowed to pass naturally. The resident ultimately expired at the hospital.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner, as observed during an initial kitchen inspection. In the walk-in refrigerator, eight individual yogurts were found with expired dates, a sandwich was wrapped in cellophane without a clear label, and an open bag of salad was unlabeled. A dietary aide acknowledged that the expired yogurts should have been discarded and was unaware of the sandwich's intended recipient or the reason for the salad's lack of labeling. During a subsequent inspection, the walk-in freezer contained an opened package of chicken breast and a package of chicken tenders, both undated and sealed with a binder clip, which the Food Service Director confirmed should have been dated. Additionally, multiple ants were observed on the food preparation table, under a dish towel, and inside a logbook. The Food Service Director noted that pest control had been conducted a couple of weeks prior, and the Maintenance Director confirmed that pest control services are provided monthly and as needed. The presence of expired and improperly stored food, along with pest issues, posed a risk of food contamination.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for eight residents, leading to potential negative outcomes due to inaccurate assessments. Resident #4, who was admitted with a diagnosis of Cerebral Palsy, had a physician's order indicating nutrition through a feeding tube, but the MDS assessment incorrectly documented that she did not receive nutrition this way. Similarly, Resident #6, diagnosed with schizophrenia, had a PASRR Level II indicating a major mental illness, but the MDS assessment failed to document this condition. Resident #12, admitted with bipolar disorder and PTSD, had a care plan and PASRR I indicating a major mental illness, yet the MDS assessment incorrectly marked 'No' for serious mental illness. Resident #29, with multiple diagnoses including schizoaffective disorder, had a PASRR II in her medical chart, but the MDS assessment did not reflect this. Resident #40's MDS assessment inaccurately documented the presence of a catheter, which was confirmed not to be in place. Resident #54's MDS assessment failed to document a PASRR II despite its presence in her medical chart. Resident #58, diagnosed with bipolar disease, had a PASRR Level II indicating a serious mental illness, but this was not documented in the MDS assessment. Lastly, Resident #65, with a Dobhoff tube for enteral feedings, had an MDS assessment incorrectly marked for parenteral/IV feeding instead of a feeding tube. These inaccuracies in MDS assessments highlight the facility's failure to ensure accurate resident assessments, potentially impacting resident care and monitoring.
Care Plan Revisions Not Updated for Residents
Penalty
Summary
The facility failed to ensure that residents' care plans were revised to reflect their current needs and interventions, as evidenced by the review of care plans for four residents. Resident #12, who was initially admitted with multiple diagnoses including bipolar disorder and PTSD, had a care plan that inaccurately documented a condition of clostridium difficile, which she no longer had. The Director of Nursing acknowledged that the care plan should have been updated. Resident #23, with diagnoses including heart failure and kidney disease, was observed with Biofreeze at her bedside, but her care plan did not document self-administration of this medication, despite having a physician's order for it. LPN #1 confirmed that the care plan should have included this information. Resident #59, admitted with a history of stroke and benign prostatic hyperplasia, had a physician's order for Calmoseptine Ointment for excoriation, but his care plan did not document this condition or its treatment. LPN #1 stated that the care plan should have included the wounds and treatment orders. Resident #65, with diagnoses including dysphagia and emphysema, had a care plan that inaccurately documented the presence of a Dobhoff tube for enteral feedings, even though it had been discontinued according to a physician's order. The Director of Nursing confirmed that the care plan should have been updated to reflect the discontinuation of the Dobhoff tube.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by several observations of deficiencies in resident rooms and common areas. Specifically, the water temperature in one resident's room was found to be as high as 124 degrees F, exceeding the state regulation range of 105 to 120 degrees F, which poses a risk of burns. Despite rechecks, the temperature remained inconsistent, indicating a failure to maintain safe water temperatures. Additionally, the maintenance director acknowledged that water temperatures should be maintained below 118 degrees F. Further observations revealed multiple issues compromising the cleanliness and homeliness of the environment. These included missing drawer fronts, black substances and hair in showers, missing drywall and baseboards, and light brown splattering on ceilings in resident rooms. In the kitchen, dust and gray substances were found on the ceiling and vents. Similar issues were noted in common areas, with gray fuzzy substances on light fixtures and vents. The maintenance director and administrator acknowledged these issues, indicating a lapse in routine cleaning and maintenance procedures.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to refer residents for further evaluation when diagnosed with major mental illnesses, as required by the Pre-Admission Screening and Resident Review (PASARR) process. This deficiency was identified in four out of seven residents reviewed. Resident #12, diagnosed with bipolar disorder and PTSD, did not have a PASARR Level II evaluation completed despite a positive Level I screen indicating the need for further assessment. Similarly, Resident #51, with a new diagnosis of borderline personality disorder, lacked a PASARR Level II evaluation upon admission and after the new diagnosis. The Director of Nursing (DON) acknowledged these oversights. Resident #60, admitted with Myasthenia Gravis, anxiety, and PTSD, exceeded a 30-day stay without a new Level I PASARR screening or a referral for a Level II evaluation, contrary to the State Operations Manual Appendix PP requirements. Additionally, Resident #219, with schizoaffective disorder, had an incomplete PASARR I that should have triggered a Level II evaluation. The MDS coordinator and DON confirmed the PASARR I was not properly completed or submitted for state review. These failures in the PASARR process could potentially result in residents not receiving necessary specialized mental health services.
Failure to Follow Care Plan for Resident's Bed Mobility
Penalty
Summary
The facility failed to adhere to a comprehensive person-centered care plan for a resident with multiple diagnoses, including hemiplegia, hemiparesis, and seizures. The care plan, dated 11/27/24, specified that the resident required assistance from two staff members for bed mobility due to fragile bones. However, documentation from the resident's medical chart revealed that on multiple occasions, only one CNA or NA assisted the resident with bed mobility. This occurred on several dates, including 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/2/25, 1/5/25, and 1/8/25. On 1/9/25, the Director of Nursing confirmed that the CNAs and NAs should have been following the care plan by using two staff members for assistance.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice, specifically for one resident who was observed during medication administration. The resident, admitted with diagnoses including kidney disease and bladder pain, had a physician's order for a Nicotine Transdermal Patch 14mg to be administered once daily for tobacco use. However, the resident refused the nicotine patch 11 out of 12 times since admission. Despite the facility's policy requiring physician notification after three refusals, there was no documentation that the physician was informed of these refusals. The Director of Nursing confirmed that the physician should have been notified after three refusals, indicating a lapse in following the facility's policy and professional standards of practice.
Deficiencies in Nursing Practice and Documentation
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed for two residents, leading to deficiencies in their care. Resident #12, who was admitted with multiple diagnoses including bipolar disorder and PTSD, was observed with wounds on her left knee. Despite the presence of these wounds, there were no documented physician orders for wound care in her medical record. An LPN observed and treated the wounds without proper orders, acknowledging that there should have been wound care orders documented. Resident #65, admitted with diagnoses including dysphagia and emphysema, was observed using an oxygen concentrator set to 2 liters per minute without wearing his nasal cannula. Although his progress notes indicated continuous oxygen use, there were no documented orders for oxygen in his electronic medical records. Standing orders for oxygen were found in his paper records, but they were not transferred to the electronic system, and nurses failed to document the completion of these orders. An LPN confirmed that the standing orders should have been in the electronic records and documented accordingly.
Improper Use of Power Strip for Medical Device
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards, as observed in the case of a resident with atrial fibrillation who was using sequential compression devices for lymphedema management. A power strip was found in the resident's room, with the compressor for the compression device plugged into it. This practice was against the guidelines documented in the State Operations Manual, which states that power strips should not be used as a substitute for adequate electrical outlets and are not designed for use with medical devices in patient care areas. The Maintenance Director confirmed that the medical device should not have been plugged into a power strip, indicating a lapse in adherence to safety protocols.
Failure to Follow Oxygen Administration Standing Orders
Penalty
Summary
The facility failed to ensure that licensed nurses performed tasks for which they had the necessary knowledge, skills, and competencies, as evidenced by the failure to follow standing orders for oxygen administration. This deficiency was observed in three out of four licensed nurses. The facility's standing orders required that supplemental oxygen be titrated for oxygen saturations below 88%. However, for Resident #41, who had multiple diagnoses including hemiplegia, hemiparesis, and seizures, there were multiple instances of low SpO2 readings (ranging from 85% to 86%) recorded over several days without any documented follow-up or intervention by the nursing staff. Interviews with LPN #1 and the DON confirmed that the nursing staff did not follow the standing orders or notify the physician regarding the low SpO2 levels.
Medication and Supply Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately for two residents, leading to potential risks. Resident #51, who has multiple diagnoses including diabetes and post-traumatic stress disorder, was observed with medication cups containing tablets left on her bedside table. The resident stated that the nurse left the medication for her to take later. However, there was no documentation of a self-administration assessment or care plan allowing for self-administration of medications. The Director of Nursing confirmed that medications should not have been left at the bedside without proper assessment and care planning. Resident #58, diagnosed with paraplegia, malnutrition, and bipolar disease, was found with stoma powder, ostomy/wound supplies, and wound scissors left out in the room. The resident mentioned that nurses regularly leave these items out. The wound nurse acknowledged that these supplies should not have been left in the resident's room. These observations indicate a failure to adhere to the facility's policy on medication and supply storage, potentially compromising resident safety.
Unqualified Food Service Director in Facility
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as required by the State Operations Manual Appendix PP. The manual specifies that the director must meet certain qualifications, such as being a Certified Dietary Manager, a Certified Food Service Manager, or having similar national certification. Alternatively, the director could have an associate's or higher degree in food service management or hospitality, or have two or more years of experience in the position within a nursing facility setting, along with a completed course of study in food safety and management by a specified date. On January 9, 2024, it was confirmed through interviews with the Food Service Director and the Registered Dietician that the current Food Service Director did not meet these regulatory requirements. This deficiency had the potential to affect all residents receiving meals prepared in the facility's kitchen.
Infection Control Deficiencies in Equipment and Catheter Management
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by several observations. For oxygen and respiratory equipment, Resident #51's oxygen concentrator was found with a white substance and fuzz on the filter, and Resident #22's nebulizer mouthpiece and tubing were left uncovered on a bedside table. These observations were contrary to the facility's policy, which requires oxygen supplies to be stored in a labeled bag when not in use and concentrators to be cleaned weekly. Additionally, the external filter should be checked daily and cleaned weekly, which was not adhered to in these cases. Further deficiencies were noted in the management of indwelling urinary catheters and glucometer cleaning. Resident #59 and Resident #222 had catheter bags resting on the floor, violating the facility's policy that prohibits such practice. In terms of glucometer cleaning, LPN #3 and RN #2 did not follow the proper cleaning protocol, which requires using two towelettes for cleaning and disinfecting, ensuring the surface remains wet for the recommended contact time. Both staff members used only one towelette and did not adhere to the required cleaning procedure, as confirmed by their statements and the Director of Nursing's acknowledgment.
Inconsistent Glucometer Calibration
Penalty
Summary
The facility failed to ensure the proper calibration of glucometers, which is essential for maintaining the accuracy of blood glucose test results. Specifically, the glucometer solution tests were not consistently performed for two medication carts, Hall 300 and Hall 400, as required by the Assure Prism Blood Glucose Monitoring System manual. The manual specifies that control solution tests should be conducted under various circumstances, including when using the meter for the first time, when opening a new bottle or box of test strips, if the meter or test strips do not function properly, if the resident's symptoms are inconsistent with test results, or if the meter is dropped or damaged. Upon review on January 8, 2025, it was found that the Hall 400 glucometer solution test was not consistently done from December 2024 to January 2025, and the Hall 300 glucometer solution test was not consistently done for January 2025. An LPN confirmed that these tests should have been conducted daily by the night shift.
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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