Lincoln County Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shoshone, Idaho.
- Location
- 511 East Fourth Street, Shoshone, Idaho 83352
- CMS Provider Number
- 135056
- Inspections on file
- 16
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Lincoln County Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one room, the wall behind a bed had multiple strips of missing paint and numerous holes, and the ceiling near the curtain track had exposed sheetrock. Another room had a damaged windowsill with exposed rebar. In common areas, a dining room vent was covered with a black substance, and a large light fixture above the nurse’s station lacked a cover and had long, thick cobwebs. The Maintenance Supervisor reported difficulty repairing concrete walls, noted that a resident had recently moved into one of the damaged rooms, and stated that housekeeping should have cleaned the cobwebs and vent.
Surveyors identified multiple failures in medication labeling, dating, and storage, including an illegible lorazepam label in the refrigerator, an opened tuberculin vial and a Hepatitis B vaccine syringe improperly stored, and a non–permanently affixed locked box containing insulin and narcotics in the medication refrigerator. In a medication cart, loose unlabeled pills and various identified tablets were found in drawers, and a bottle of glucose test strips in use lacked an open date despite manufacturer instructions. An unattended medication cart was also observed with a pill on the floor nearby, which an LPN later admitted she had dropped and not properly located and destroyed.
The facility did not obtain informed consent before starting antidepressant therapy for two residents. One resident with heart failure and anxiety received Citalopram without any signed informed consent on file. Another resident with a lumbar fracture, depression, and repeated falls received Sertraline before an informed consent form was signed, with the consent only completed several days after the medication was ordered. The RNC confirmed that, per facility policy, informed consent for antidepressant use should have been obtained prior to administration in both cases.
The facility failed to follow its self-administration of medications policy by not obtaining an IDT assessment or documenting approval before allowing a resident to keep and use Calcitonin nasal spray in their room. The policy required that residents may self-administer medications only if the IDT determines it is clinically appropriate and safe, with this decision documented in the medical record and care plan. However, a resident was observed with Calcitonin nasal spray on the overbed table and reported self-administering it as needed, while record review showed no IDT assessment or care plan authorization. A Regional Nurse Consultant confirmed the resident should not have had the medication in the room and had not been assessed for self-administration.
Surveyors found that staff failed to keep call lights within reach for two residents, contrary to facility policy requiring accessible call lights to ensure timely responses to needs. One resident with COPD and dementia was in bed with the call light hanging under the foot of the bed, out of reach. Another resident with a lumbar fracture and history of repeated falls was seated in a recliner while the call light was draped over an overbed table pushed against the bed on the opposite side of the room, also out of reach. A CNA and the RNC both acknowledged that call lights should have been within reach and were not in these cases.
The facility failed to ensure accurate MDS assessments when two residents were incorrectly coded as having daily physical restraints in section P0100, despite observations showing no restraints in their beds or wheelchairs. One resident with epilepsy and dementia was seen in a wheelchair without restraints, while another resident with diabetes and an above-the-knee amputation was observed in bed using only a trapeze bar for repositioning. The DON and MDS coordinator later acknowledged that the restraint coding on both MDS assessments was incorrect.
A resident with COPD, bipolar disorder, PTSD, and other serious mental illnesses was admitted and care planned as meeting PASRR Level II criteria, but the facility did not complete a PASRR Level I screen until more than eight months after admission. That Level I identified multiple major mental illnesses and instructed that the case be forwarded to the state-designated authority for a PASRR Level II evaluation. At the time of survey, there was no documentation of a completed PASRR Level II, and the RNC confirmed that the facility lacked the required Level II evaluation despite policy and federal requirements that such screenings occur prior to admission and be used in assessment and care planning.
The facility did not follow its baseline care plan policy requiring that a written summary of the baseline care plan be given to the resident and/or representative and that this be documented in the medical record. For three newly admitted or readmitted residents with conditions including muscle wasting with respiratory failure, Parkinson’s disease with prostate cancer, and a stable lumbar fracture with repeated falls, there was no documentation that a baseline care plan was provided or discussed. During interview, the RNC acknowledged that there was no record showing these residents or their representatives had received copies of their baseline care plans.
A resident with ESRD and diabetes who received hemodialysis three times weekly had a care plan requiring hemodialysis and administration of medications as ordered, but the facility failed to maintain complete dialysis communication documentation and to update an antihypertensive order per dialysis instructions. Dialysis documentation indicated the resident’s Amlodipine dose should be decreased to 5 mg daily, yet the medical record continued to reflect a 10 mg dose on specific days with hold parameters, and the change was never entered. Dialysis communication forms for two treatment dates were also missing, and both the DON and Regional Nurse Consultant confirmed the Amlodipine dose in the record was incorrect and that the dialysis communication sheets were not present.
The facility did not ensure that daily postings of nurse staffing accurately reflected the actual hours worked by licensed and unlicensed nursing staff. Although facility policy required posting direct care daily staffing numbers for each shift, surveyors found that posted staffing information over several months was not adjusted when scheduled hours differed from actual hours worked. The RNC and DON acknowledged that they did not update the posted staffing with actual hours, only the internal daily assignment sheets, resulting in inaccurate publicly posted staffing information for all shifts.
Surveyors found that meals were not consistently palatable, attractive, or maintained at safe and appetizing temperatures. Residents reported that food was often cold, tasteless, and not nutritious, and that trays, particularly those delivered to rooms, lacked condiments, with dinner described as the worst meal. Observation of a lunch service showed discrepancies between the posted menu and the food actually served, absence of garnishes or condiments, and a test tray with bland scalloped potatoes and gravy, under-temperature green beans, and no beverage. The Dietary Manager stated that frozen foods were used and often lacked flavor, and that only one staff member was scheduled for the dinner meal service each day.
Surveyors found that kitchen staff failed to follow professional standards for food storage, labeling, and distribution, including opened refrigerated and frozen items without proper use-by dates and undated baked goods in the pantry. Dietary trays delivered to resident rooms contained uncovered food items such as gelatin and sliced cake, and the dietary manager acknowledged not being aware that all tray food must be covered. Inspectors also noted that the same daily cleaning log was reused and marked completed for an entire week instead of being replaced, as confirmed by the dietary aide and dietary manager.
Surveyors found that residents were served meals in the dining room without being offered required hand hygiene before eating, despite facility policy mandating handwashing or alcohol-based hand rub use before handling food. A CNA and the DON both acknowledged that residents’ hands should have been sanitized prior to meals. Additional observations showed a housekeeper transporting clean gowns uncovered in a hallway and significant visible buildup of white and grey fuzzy substances on pipes, wires, equipment, and chemical buckets in the laundry area, with the housekeeper stating there was no formal cleaning schedule in place.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, as required by the facility’s Homelike Environment policy revised in February 2021. Observations showed multiple areas of disrepair and uncleanliness in resident rooms and common areas. In one resident room, the wall behind the bed had four strips of missing paint with four holes in each strip, along with multiple additional small holes. The ceiling near the curtain railing in the same room had two areas of missing sheetrock paper measuring approximately 1 x 2 inches and 1 x 3 inches. In another resident room, part of the bottom right corner of the windowsill, approximately 1.5 x 2.5 inches, was missing, exposing the lower part of the rebar. Additional observations in common areas included a dining room vent covered with a black substance and a large light fixture above the nurse’s station that lacked a cover and had two long, thick cobwebs hanging from the light fixture frame. During an interview, the Maintenance Supervisor stated that the walls are concrete and difficult to repair around the window when beds break pieces off, and that the resident in one of the affected rooms had just moved in and he had not yet had time to fix the wall behind the bed. He also stated that housekeeping should have cleaned the cobwebs on the light at the nurse’s station and the vent in the dining room.
Improper Medication Labeling, Dating, and Storage in Medication Room and Cart
Penalty
Summary
The deficiency involves failure to ensure medications and biologicals were properly labeled, dated, and stored in accordance with facility policy and professional standards in both the medication room and a medication cart. In the medication room, surveyors observed a bottle of liquid lorazepam in the refrigerator with an illegible label on both the bottle and box, and the LPN present was unsure whether it should be refrigerated. A vial of tuberculin purified protein derivative was found with an open date of 11/24/25, and the LPN did not know how long it remained usable after opening. A Hepatitis B vaccine syringe with an expiration date of 7/7/25 was also stored in the refrigerator, and the LPN acknowledged it should not have been there. A metal box containing insulin and narcotics from the pharmacy was found in the refrigerator; it was locked but not permanently affixed, and staff stated the narcotics could not be moved to the refrigerator’s lock box due to pharmacy key and assignment issues. The DON later confirmed the narcotics box should have been permanently attached to the refrigerator. In the west hall medication cart, surveyors found multiple loose, unlabeled pills in drawers, including three small round white pills and several identified tablets (duloxetine, Lasix, atorvastatin in multiple strengths, divalproex, pantoprazole, and quetiapine), and the LPN acknowledged these loose pills should not have been in the cart. A bottle of Evencare ProView glucose test strips in use for a resident’s blood sugar check lacked an open date, and the RN using them stated the bottle should have had an open date but was unsure how long the strips were good after opening, despite the operator’s manual specifying dating and discard timeframes. Additionally, an unattended medication cart was observed near the nurses’ station with a round white pill on the floor nearby; the LPN later stated she had dropped the medication earlier, could not find it, and admitted she should have moved the cart to locate and destroy the medication but had not done so.
Failure to Obtain Informed Consent Before Initiating Antidepressant Medications
Penalty
Summary
The facility failed to obtain informed consent prior to initiating psychotropic (antidepressant) medications for two residents reviewed for unnecessary medications. The facility’s Medication Therapy policy required that each resident’s medication regimen include only necessary medications and that medication use be consistent with the individual’s condition, prognosis, values, wishes, and responses to treatment. Resident #1, admitted and later readmitted with multiple diagnoses including heart failure and anxiety, had a physician order dated 3/1/26 for Citalopram Hydrobromide 20 mg by mouth once daily, but the Resident Nurse Coordinator (RNC) confirmed on 4/13/26 that there was no signed Informed Consent for Use of Antidepressant Medications for this order. Resident #35, admitted and later readmitted with multiple diagnoses including a stable lumbar vertebra fracture, depression, and repeated falls, had a physician order dated 4/1/26 for Sertraline HCl 200 mg by mouth at bedtime; the medical record contained an informed consent for use of antidepressant medication signed and dated 4/10/26, and on 4/13/26 the RNC stated that this informed consent should have been signed before the resident received the medication but was not.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that residents were initially assessed by the interdisciplinary team (IDT) to determine if they were safe to self-administer medications, as required by facility policy, for one resident. The facility’s Self-Administration of Medications policy, revised February 2021, stated that residents have the right to self-administer medications only if the IDT determines it is clinically appropriate and safe, and that such determinations must be documented in the medical record and care plan. During observation, a surveyor noted that Resident #35 had Calcitonin nasal spray on her overbed table; the resident reported that she kept it in her room for use when she needed it and that she had used it before coming to the facility. Review of the resident’s medical record and care plan showed no documentation of an IDT assessment or authorization for self-administration of medications. The Regional Nurse Consultant confirmed that the resident should not have had the Calcitonin nasal spray in her room and that no IDT assessment for self-administration had been completed.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents’ call lights were within reach, as required by the facility’s “Answering the Call Light” policy, version 1.3, which states that call lights must be accessible to residents to ensure timely responses to their requests and needs. For one resident with COPD and dementia, the resident was observed lying in bed with the call light plugged into the wall and hanging down the wall under the foot of the bed, not within the resident’s reach. The resident was unable to independently reach the call light. A CNA later confirmed that this resident’s call light should have been within reach and had not been. Another resident, with a history including a stable lumbar vertebra fracture and repeated falls, was observed sitting in a recliner with the call light draped over an overbed table that had been pushed against the bed on the other side of the room, making it inaccessible. This resident reported that staff had pushed the table against the bed after removing the breakfast tray and that the call light could not be reached. The same CNA confirmed that this resident’s call light should have been within reach and was not. The RNC also stated that residents’ call lights should be within reach and acknowledged that they had not been in these instances.
Inaccurate MDS Coding of Physical Restraints for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ actual status, resulting in incorrect documentation of physical restraints for two residents. One resident with epilepsy and dementia, observed in a wheelchair on 4/12/26 with no restraints in the wheelchair or bed, had a quarterly MDS that coded in section P0100 “Physical Restraints, Other used daily” for restraint use. Another resident with diabetes and an above-the-knee left leg amputation, observed in bed with a trapeze bar used to assist with repositioning and with no restraints in the bed or wheelchair, had an admission MDS that also coded in section P0100 “Physical Restraints, Other used daily” for restraint use. On 4/13/26, the DON and MDS coordinator stated that these MDS assessments were coded incorrectly and confirmed that neither resident had restraints, indicating that the inaccurate coding stemmed from staff error in completing the MDS.
Failure to Obtain Required PASRR Level II Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to coordinate required PASRR evaluations for a resident with major mental illness in accordance with its own policy and federal guidance. The facility’s Resident Assessments PASRR Screening Coordination policy required that PASRR Level I and Level II screenings, when needed, be conducted prior to admission, and that Level II evaluation reports be used when conducting assessments and developing care plans. The State Operations Manual, Appendix PP, specified that a positive Level I screen requires an in-depth Level II evaluation by the state-designated authority prior to admission. Despite these requirements, the facility did not ensure that the appropriate PASRR process was completed. Resident #4 was admitted with multiple diagnoses, including COPD, Bipolar Disorder, and PTSD. The resident’s care plan documented that the resident met PASRR Level II determination secondary to serious mental illness diagnoses, including anxiety and bipolar disorder, and a long-term care stay. However, the medical record showed that a PASRR Level I screening was not completed until more than eight months after admission, and that this Level I identified major mental illnesses (depressive, anxiety, bipolar, and PTSD) and directed that the screening be forwarded to the state-designated authority for a PASRR Level II evaluation. As of the surveyor’s review, there was no documentation that a PASRR Level II evaluation had been completed, and the RNC confirmed that the facility did not have a PASRR Level II for this resident and should have had one.
Failure to Provide and Document Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to provide baseline care plans to residents or their representatives and to document this provision in the medical record for three of five residents reviewed. Facility policy "Care Plans - Baseline," version 1.2, required that the resident and/or representative be provided a written summary of the baseline care plan in an understandable language and that provision of this summary be documented in the medical record. For a resident admitted with muscle wasting and respiratory failure, there was no documentation that a baseline care plan was provided or discussed with the resident or representative. For a second resident admitted with Parkinson’s disease and malignant neoplasm of the prostate, the medical record likewise lacked documentation that a baseline care plan was provided or discussed. For a third resident, initially admitted and later readmitted with a stable lumbar vertebral fracture and repeated falls, there was also no documentation that a baseline care plan was provided or discussed. On interview, the RNC confirmed there was no documentation that these residents or their representatives had received copies of their baseline care plans. This deficiency centers on the facility’s noncompliance with its own baseline care plan policy and the absence of required documentation in the medical records for multiple residents with significant medical conditions.
Failure to Implement Dialysis Communication and Updated Antihypertensive Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related care and medication management according to professional standards for a resident with end stage renal disease and diabetes who required hemodialysis three times weekly. The resident’s care plan noted the need for hemodialysis and listed interventions such as administering medications as ordered and encouraging attendance at scheduled dialysis sessions. However, review of the medical record showed that dialysis communication forms were missing for two dialysis dates, and the existing dialysis communication form documented a change in the resident’s Amlodipine dosage from 10 mg to 5 mg daily that was not implemented in the medical record. The physician’s order in the chart continued to show Amlodipine 10 mg by mouth on specific days with hold parameters, and there was no documentation of the decreased 5 mg daily dose as communicated by dialysis. The DON and Regional Nurse Consultant acknowledged that the Amlodipine dose in the record was incorrect, that the dose should have been 5 mg every day, and that dialysis communication sheets for two dates were missing.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurate and posted daily for each shift, as required by its own policy. The facility’s “Staffing, Sufficient and Competent Nursing” policy, revised April 2025, stated that direct care daily staffing numbers for each shift must be posted in the facility. On 4/13/26, surveyors reviewed the daily postings of licensed and unlicensed nurse staffing for the period 11/1/25 through 4/11/26 and found there were no adjustments made to the posted staffing when the scheduled hours did not match the actual hours worked. During an interview on 4/13/26 at 11:37 AM, the RNC and DON confirmed that the facility does not update the daily posted staffing with actual hours worked and instead only adjusts the time on the daily assignment sheets. This practice resulted in posted staffing information that did not reflect the actual direct care nursing personnel responsible for resident care for each shift, affecting all residents, their representatives, visitors, and others who might review the facility’s staffing levels.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were palatable, attractive, and maintained at safe and appetizing temperatures for residents consuming food prepared in the kitchen. During a Resident Council meeting, all 6 residents present reported that food was often cold, tasteless, and not nutritious, and that meal trays, especially those delivered to rooms, lacked condiments. They also stated that the dinner meal was usually the worst meal of the day. The 2022 FDA Food Code standard that hot food be maintained at 135°F or above and cold food at 41°F or below was cited as the applicable guideline. During observation of a lunch meal service, the posted menu listed roast beef with gravy, scalloped potatoes, seasoned green beans, a roll with margarine, coconut cake, and a beverage, but the meal actually served was roasted pork with gravy, scalloped potatoes, green beans, a roll with margarine, white cake, and a beverage, with no garnishes or condiments provided. When the last tray from the meal cart was tested, the scalloped potatoes were 135°F but tasted bland, the gravy was bland and tasteless, and the green beans were 128°F instead of the expected 135°F, and were described as bland and mushy; no beverage was present on the tray. The Dietary Manager stated that the facility used frozen food that often lacked flavor, confirmed the green beans should have been at 135°F, and reported that only one staff member was scheduled for the dinner meal service each day.
Improper Food Storage, Labeling, Tray Coverage, and Cleaning Log Documentation
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and distribution of food, as well as incomplete documentation of cleaning activities. Based on the FDA Food Code 2022, they observed in the walk-in refrigerator a large opened package of provolone cheese without a use-by date. In the pantry, they found three bags of cookies dated 4/8/26 with a use-by date of 4/11/26 and one bag of sliced cake that was not dated. In the walk-in freezer, they observed an opened box of enchiladas dated 3/24/26 with no use-by date. These items were not clearly marked in accordance with date-marking requirements for refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours. Surveyors also observed that food on dietary trays delivered to resident rooms was not consistently covered. At one time, trays included an uncovered bowl of gelatin dessert, and at another time, trays included an uncovered plate of sliced cake. When interviewed, the dietary manager stated she was not aware that all food on dietary trays delivered to resident rooms must be covered. Additionally, the daily cleaning log was observed to be marked as completed for every day of the week, and the dietary aide reported she did not have a new cleaning log and therefore continued to use the same one. The dietary manager confirmed that the daily cleaning log should have been replaced with a new log for the current week and that it had not been replaced.
Inadequate Hand Hygiene and Environmental Cleaning in Infection Control Program
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to hand hygiene and maintaining a clean, sanitary environment. The facility’s Handwashing/Hand Hygiene Policy, revised March 2022, required use of alcohol-based hand rub or soap and water before and after eating or handling food. During a meal service observed at 12:04 PM on 4/12/26, 14 residents were served meals in the dining room without being offered hand hygiene before eating. At 12:12 PM, a CNA acknowledged that residents’ hands should have been sanitized before they started eating, and on 4/13/26 at 2:44 PM, the DON confirmed that residents in the dining room should have been offered hand hygiene using hand sanitizer from a bottle before meals. Additional infection control concerns were observed regarding environmental cleanliness and handling of clean items. On 4/14/26 at 6:53 AM, a housekeeper was seen carrying clean gowns down the hallway uncovered, and at 6:56 AM the housekeeper stated the gowns should have been covered. Later that morning at 8:36 AM, with the housekeeper present, surveyors observed multiple areas of visible buildup and residue in the laundry room, including a white hard substance and grey fuzzy substance on pipes behind a small washing machine, a tube of wires covered with grey fuzzy substance near the entrance, teal-colored and grey fuzzy substances on water pipes behind a large washing machine, a layer of white substance on the chemical dispenser cover, and grey fuzzy buildup on chemical buckets and nearby walls. At 8:41 AM, the housekeeper reported there was no cleaning schedule for the laundry room, although sweeping was done daily.
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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