River's Edge Rehabilitation & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Emmett, Idaho.
- Location
- 714 North Butte Avenue, Emmett, Idaho 83617
- CMS Provider Number
- 135020
- Inspections on file
- 20
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at River's Edge Rehabilitation & Living Center during CMS and state inspections, most recent first.
Surveyors found that an ice machine used to produce ice for residents had a black, blackish brown residue along its interior metal plate, indicating inadequate cleaning of this food-contact surface. The Dietary Manager confirmed the residue and stated that maintenance was responsible for cleaning the rented ice machine, while Plant Operations Personnel confirmed the black substance and reported that the rental company performed quarterly cleaning and monthly maintenance. These findings showed that the ice machine was not cleaned often enough to prevent buildup of soil or mold, in violation of FDA Food Code and SOM requirements.
A resident with cognitive communication deficit, muscle weakness, and post-stroke hemiplegia/hemiparesis was housed in a room with visibly damaged closet doors and a sink countertop, including chipped and missing paint, exposed substrate, scuff marks, and scratches. The resident reported the room did not feel homelike due to the condition of the closet and countertop. The Maintenance Director confirmed the need for repairs to the closet doors, sink counter, and nearby wall and stated that, although the closet had been painted months earlier, he did not maintain documentation for painting repairs, only for items such as outlets, lights, and mobility equipment. This resulted in a failure to ensure a safe, clean, and homelike environment.
A resident admitted for end-of-life care with heart failure and chronic kidney disease had a hospice physician’s certification of terminal illness in the record and was admitted with hospice services. However, the Admission MDS assessment inaccurately coded the hospice services item in Section O as not receiving hospice. During interview, the Administrator acknowledged that the resident was on hospice at admission and that the MDS assessment was not accurate.
Nursing staff failed to follow ISMP guidelines requiring medications to be prepared and administered immediately rather than pre-poured. An LPN was observed placing pre-poured medication cups into a medication cart drawer after reporting being behind due to assisting residents, and another unlocked cart was found unattended with three labeled medication cups in the top drawer, including stacked cups containing morphine that had already been signed out on the controlled substance log. These practices involved unsecured, pre-poured medications for multiple residents and increased the risk of medication errors, contamination, diversion, and administration to the wrong residents.
Two residents who required extensive assistance for transfers and repositioning did not receive the level of supervision and staff support specified in their care plans, resulting in falls during care. One resident with quadriplegia, cognitively intact and totally dependent for bed mobility, was being changed in bed by only one CNA instead of the required two-person assist and rolled off the bed to the floor. Another resident with impaired mobility and muscle weakness, care planned for two-person stand-pivot transfers, was transferred by a single CNA without appropriate footwear and experienced leg buckling and an assisted fall to the floor.
A resident with COPD and mild cognitive impairment had physician orders for continuous O2 at 2 L/min via nasal cannula and for O2 tubing, filter, and water to be changed every 7 days. Although the record indicated the orders were followed, surveyors observed the resident resting in bed with an O2 concentrator whose humidifier bottle and cannula storage bag were dated beyond the 7-day change interval. A CNA confirmed that O2 tubing should be changed weekly and acknowledged that the resident’s tubing had not been changed for 14 days, placing the resident at risk for respiratory infections.
A resident with a history of stroke-related hemiplegia, seizure disorder, and dementia continued to receive tamsulosin (Flomax) 0.4 mg at bedtime for kidney stones and prior stent removal, despite no current urological diagnosis. Facility records and the DON’s interview confirmed the resident’s kidney stone treatment and ureteral stent occurred before admission, and there had been no subsequent treatment or active urological condition. National Library of Medicine guidance cited by surveyors indicated tamsulosin for ureteral stones is typically used for a limited duration, yet the medication order remained in place without an appropriate, documented indication, resulting in an unnecessary drug regimen for the resident.
Surveyors found a medication cart unlocked and unattended in a resident care hallway, despite facility policy requiring medications to be stored safely, securely, and accessible only to authorized personnel. An LPN later confirmed she had left the cart unlocked and acknowledged it should have been locked, creating a situation in which medications could be accessed by individuals for whom they were not prescribed.
The facility failed to secure protected health information and to maintain accurate behavioral documentation. A medication cart was left unattended with a laptop screen active, displaying the electronic medical record system with resident information visible, and the responsible LPN admitted she had not locked the screen. In a separate issue, a resident with generalized anxiety disorder, mild neurocognitive disorder, and schizoaffective disorder had behavior monitoring records indicating repeated suicidal statements, as required to be monitored by the care plan, but the DON later reported the resident had not made such statements and that the same nurse had inaccurately documented these entries on multiple dates.
Staff failed to consistently follow hand hygiene and PPE requirements for a resident on Enhanced Barrier Precautions (EBP) with an indwelling urinary catheter and PEG-tube. A CNA exited the resident’s room after incontinence care without performing hand hygiene after removing PPE, later handled the resident’s catheter and performed dressing tasks without prior hand hygiene or donning a gown as required by the EBP signage, and entered the room with another CNA for a hoyer lift transfer without either performing hand hygiene upon entry. An LPN performed hand hygiene and donned PPE before medication and nutrition administration via PEG-tube but then touched the sink and water while preparing supplies and did not change gloves or perform hand hygiene before accessing the PEG-tube. These actions did not comply with the facility’s hand hygiene policy and posted EBP instructions and created the potential for infection due to cross contamination.
The facility did not adequately address or document responses to resident concerns raised in Resident Council meetings from June to November 2024. Issues included dietary, housekeeping, call light response times, and staffing. Despite a call light audit indicating room for improvement, no follow-up actions were documented or communicated to residents. Interviews confirmed ongoing issues and lack of written documentation of follow-up actions.
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for four residents, as required by the State Operations Manual. Residents with various diagnoses, including cerebral palsy, TBI, cancer, and heart failure, were transferred to the hospital without the Ombudsman being informed. The facility administrator was unaware of the notification requirement.
The facility did not ensure that full-time NAs were enrolled in or had completed a State-approved training and competency evaluation program within four months of employment. Four NAs were identified as working beyond this period without certification, which could negatively impact the 54 residents in the facility. The HR Manager confirmed the facility's non-compliance.
A facility failed to adhere to infection control practices when a staff member sorted dirty laundry without wearing a gown, as required by standard precautions. This breach was confirmed by the DON, who stated that both gloves and gowns should be worn during such tasks to prevent infection and cross-contamination.
A resident's room was found to have several maintenance issues, including a detached baseboard, improperly placed toilet paper, a grab bar with chipped paint, and a corroded sink. The Maintenance Director was not informed of these issues, as the Housekeeping Supervisor had not submitted work orders. The Housekeeping Supervisor and Administrator acknowledged the problems, noting the sink required replacement.
The facility failed to ensure accurate MDS assessments for three residents. One resident's assessments incorrectly documented an active pneumonia diagnosis, another's inaccurately recorded anticoagulant use, and a third's omitted a completed PASARR level II evaluation. These discrepancies were confirmed by the DON.
A facility failed to refer a resident for a PASARR level II evaluation after diagnosing them with major depressive disorder (MDD). Despite being prescribed antidepressants and having an updated care plan for managing depression and behavioral disturbances, the pre-admission PASARR level I screening was not forwarded for further evaluation. The DON was unaware of the oversight, which could have impacted the resident's mental health care coordination.
The facility failed to administer medications according to professional standards, affecting several residents. A resident with paraplegia received Norco instead of Tramadol due to a card mix-up. Another resident with esophagitis was given rivaroxaban meant for someone else during a training session. Additionally, a resident with respiratory failure was given Anoro Ellipta despite its discontinuation, as staff were unaware of the change. These incidents reflect a failure to follow the six rights of medication administration.
The facility failed to provide care according to professional standards and residents' care plans. A resident with diabetes had high blood glucose levels without documented physician notification, and another resident requiring two-person assistance was repositioned by one CNA alone. These actions did not comply with the care plans and protocols.
A medication error rate of 6.9% was identified in an LTC facility when a resident with diabetes received insulin without proper priming of the pens, as observed by surveyors. The RN failed to prime the insulin pens before administration, which was confirmed by staff interviews, potentially affecting the resident's blood sugar levels.
Improper Cleaning and Maintenance of Ice Machine
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation when they observed that an ice machine contained visible contamination. On 4/12/26 at 2:58 PM, the interior metal plate of the ice machine was noted to have a black residue. At 3:05 PM, the Dietary Manager confirmed the presence of a blackish brown residue along the interior metal plate and reported that the ice machine was a rented unit for which maintenance staff were responsible for cleaning. Later, at 3:50 PM, Plant Operations Personnel also confirmed a black substance in the ice machine and stated that the rental company provided quarterly cleaning and monthly maintenance of the ice machines. These observations demonstrated that the ice machine, an enclosed food-contact component used to produce ice for residents, was not being cleaned at a frequency necessary to prevent accumulation of soil or mold as required by the FDA Food Code and SOM Appendix PP. No specific residents or their medical histories were mentioned in the report, but the deficiency was cited as having the potential to affect all residents who consumed ice prepared by the facility.
Failure to Maintain Homelike Room Environment and Document Repairs
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when it did not maintain a resident’s room in good repair. One resident, admitted and later re-admitted with multiple diagnoses including cognitive communication deficit, muscle weakness, and hemiplegia and hemiparesis following a stroke, was found to have significant damage to the physical environment of the room. On observation, the resident’s closet doors had large, jagged round and oblong areas with chipped, cracked, and missing paint exposing white and brown patches, along with several long black scuff marks and scratches along the mid to lower closet doors and bottom drawers. Additionally, the sink countertop had a large oblong and jagged damaged area that was missing material and exposing brown wood. When interviewed, the resident indicated the room did not feel homelike, pointing to the damaged closet doors and sink countertop, and stated a desire to have the closet doors painted and the countertop fixed. During a subsequent observation with the Maintenance Director, he confirmed that the closet doors, sink counter, and lower corner wall near the sink needed repair. He stated the closet had been painted approximately three or more months earlier but acknowledged that he did not keep documentation of painting repairs, only of repairs to outlets, lights, wheelchairs, walkers, and similar items. The lack of timely repair and absence of documentation for these environmental issues contributed to the deficiency related to maintaining a homelike environment for the resident.
Inaccurate MDS Hospice Coding for Terminally Ill Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for a resident receiving end-of-life care. The resident was admitted with a diagnosis of heart failure and chronic kidney disease and had a hospice physician’s certification of terminal illness completed prior to admission. Despite this documentation and the resident’s admission to the facility with hospice services, the Admission MDS assessment completed on 3/5/26 inaccurately recorded in Section O, item K1 for hospice services as “no,” indicating the resident was not receiving hospice care. During an interview, the Administrator confirmed that the resident had been admitted with hospice services and that the Admission MDS assessment was not accurate. This inaccuracy in the MDS assessment was identified for 1 of 2 residents whose assessments were reviewed for potential errors, and it was determined that this failure placed the resident at risk for their needs to go unmet due to the inaccuracy.
Pre-poured and Unsecured Medications, Including Narcotics
Penalty
Summary
The facility failed to ensure medications were prepared and administered safely and in accordance with nationally recognized standards, specifically the ISMP Guidelines for Safe Medication Practices in Long Term Care, which state that medications should be prepared and administered immediately and not pre-poured for later administration. On 4/12/26 at 9:50 AM, a nurse identified as LPN #2 was observed on the 200 hall placing pre-poured medication cups into the top drawer of her medication cart. At 9:57 AM, LPN #2 stated that a CNA had called out sick, she had been assisting residents to get up all morning, and she was behind, so she pre-poured medications to pass them out faster. She confirmed she should not pre-pour medications. On 4/12/26 at 10:39 AM, a medication cart was observed on the 100 hall that was unlocked with no staff present in the area. When the top drawer of the cart was opened, three medication cups were found inside: two cups stacked together and labeled with one resident's name, and a third cup labeled for a different resident. At 10:40 AM, a nurse identified as LPN #1 stated that the top stacked cup contained morphine and confirmed that the narcotic had been signed out on the controlled substance log at 10:09 AM. LPN #1 acknowledged that she should not pre-pour medications and disposed of the medications located in the top drawer. The report notes that these practices increased the risk of medication errors, contamination, diversion, and administration of medications to the wrong residents.
Failure to Follow Care Plans for Supervision and Assistance During Transfers and Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received the level of supervision and assistance required by their care plans to prevent avoidable accidents. For one resident with quadriplegia, anxiety disorder, and total dependence on staff for rolling and repositioning in bed, the MDS documented cognitive intactness and dependence for rolling, and the care plan required assistance from two staff members for turning and repositioning in bed. Despite this, on 4/1/26, the resident was being changed in bed by a single CNA when she rolled off the bed. She was found lying on the floor slightly on her right side, yelling out in pain, and was transported by emergency medical services for further evaluation. The DON later confirmed that two CNAs should have been present to assist with turning this resident at the time of the fall. Another resident, admitted with difficulty in walking, muscle weakness, and the need for assistance with personal care, had an MDS showing a need for substantial/maximal assistance for chair, bed, and toilet transfers. The resident’s care plan directed staff to use two staff members for stand-and-pivot transfers to and from the wheelchair. On 4/8/26, a CNA attempted a stand-and-pivot transfer with this resident using only one staff member, and the resident’s legs buckled, resulting in an assisted fall to the floor. At the time of the transfer, the resident was not wearing appropriate footwear. The DON confirmed that this fall could have been prevented if the care plan, which required two staff members for transfers, had been followed.
Failure to Follow Oxygen Therapy Orders and Change Oxygen Tubing as Scheduled
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for Resident #56. The resident was admitted with multiple diagnoses including mild cognitive impairment, COPD, and a need for assistance with personal care, and had physician orders for continuous oxygen at 2 L/min via nasal cannula and for the tubing, filter, and oxygen water to be changed every 7 days. Record review indicated the orders were documented as being followed as written. However, during an observation on 4/12/26, the resident was seen in bed with a nasal cannula connected to an oxygen concentrator, with the attached humidifier bottle dated 4/5/26 and the cannula storage bag dated 3/29/26. In a subsequent interview, CNA #2 stated that oxygen tubing is to be changed every 7 days and confirmed that the date on the bag reflects when the tubing was last replaced, acknowledging that the resident’s oxygen tubing had not been changed in 14 days. This failure placed the resident at risk for adverse effects, including respiratory infections. The deficiency centers on the discrepancy between the documented adherence to oxygen therapy orders and the actual condition of the resident’s oxygen equipment as observed by surveyors and confirmed by staff, specifically the failure to change the oxygen tubing according to the 7-day schedule ordered by the physician.
Unnecessary Use of Tamsulosin Without Current Urological Indication
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when a resident was maintained on tamsulosin (Flomax) without an adequate clinical indication. Record review showed the resident had multiple diagnoses including right-sided hemiplegia and hemiparesis following a stroke, a seizure disorder, and dementia, and had an order dated 4/26/21 for Flomax 0.4 mg by mouth at bedtime for stent removal and calculus of the kidney. Reference to the National Library of Medicine indicated that tamsulosin for ureteral stones is typically prescribed at 0.4 mg daily for 7 to 42 days or until stone expulsion. The DON reported that the resident had not received treatment for kidney stones or a ureteral stent since admission and that the only documented treatment for kidney stones and a ureteral stent occurred in 2020, prior to admission. The DON further stated the resident did not currently have any urological diagnoses to indicate the ongoing use of Flomax, demonstrating that the medication was being administered without a current, documented indication. This failure resulted in the resident taking a medication for which they did not have a clinical diagnosis, and the report states this placed the resident at risk for harm.
Unattended, Unlocked Medication Cart in Resident Care Hallway
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security when a medication cart was observed unlocked and unattended in the 100-hall. The facility’s Medication Storage policy, revised April 2025, required that medications be stored safely, securely, and properly in accordance with manufacturer or supplier recommendations and applicable federal and state regulations, and that the medication supply be accessible only to authorized personnel. On 4/12/26 at 10:39 AM, a medication cart was found unlocked with no staff present in the area, contrary to this policy. At 10:41 AM the same day, a licensed practical nurse (LPN #1) confirmed she had left the medication cart unlocked and acknowledged that it should have been locked. The report states that this failure to secure medications had the potential to affect all residents in the facility, as unsecured medications could be accessed by individuals for whom they were not prescribed, creating a risk for harm.
Failure to Secure PHI and Maintain Accurate Behavioral Documentation
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain accurate medical records in accordance with its confidentiality policy and accepted professional standards. The facility’s Resident/Patient Confidentiality policy stated that HIPAA requires appropriate safeguards to protect personal health information and limits use and disclosure without authorization. Despite this, a medication cart on the 100-hall was observed with a laptop attached, displaying the electronic medical record system with resident information visible, while no staff were present at the cart. When interviewed, the LPN responsible for the cart acknowledged she had forgotten to lock the screen. The facility also failed to ensure accurate documentation of a resident’s medical record. One resident, admitted with generalized anxiety disorder, mild neurocognitive disorder, and schizoaffective disorder, had a care plan directing staff to monitor the resident every shift and notify the physician if the resident verbalized suicidal thoughts. Behavior monitoring records for this resident documented suicidal thoughts on multiple dates between early March and early April. When surveyors requested documentation of physician notification for these reported suicidal statements, the DON stated that the resident had not verbalized suicidal thoughts and that the behavior monitoring records had been inaccurately documented by the same nurse on each of the listed dates.
Failure to Follow Hand Hygiene and PPE Requirements for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently followed infection prevention and control practices, including hand hygiene and use of PPE, for a resident on Enhanced Barrier Precautions (EBP). The facility’s hand hygiene policy, revised 12/2023, required staff to perform hand hygiene before and after direct resident contact, after removing gloves and PPE, after contact with objects in the resident’s immediate vicinity, and before and after entering isolation precaution settings. Resident #1, admitted with quadriplegia, Friedreich’s ataxia, and neuromuscular bladder dysfunction, had physician orders dated 3/3/25 for EBP related to an indwelling urinary catheter and PEG-tube, with posted signage directing hand sanitizing before entering and after leaving the room and use of gown and gloves for high-contact care activities such as changing linens, providing hygiene, changing briefs, device care, and dressing tasks. On multiple observations, staff did not adhere to these requirements. On 4/14/26, CNA #1 provided incontinence care and changed the resident’s brief, then removed PPE and exited the room to obtain supplies without performing hand hygiene after removing PPE or upon exiting. Later, CNA #1 returned, performed hand hygiene, donned PPE, and completed incontinence care, but during dressing tasks, CNA #1 obtained clothing from the closet, applied socks, then donned gloves to handle the resident’s catheter without performing hand hygiene beforehand or donning a gown, despite the EBP sign listing dressing as a task requiring PPE. Subsequently, CNA #1 and CNA #3 entered the resident’s room with a hoyer lift and did not perform hand hygiene upon entry before donning gowns and, for CNA #3, gloves to transfer the resident. On 4/16/26, LPN #3 entered the resident’s room, performed hand hygiene, donned PPE, then handled a graduated cylinder and syringe at the sink, turned on the water, and filled the cylinder before mixing and administering medications and nutrition via the PEG-tube without changing gloves or performing hand hygiene between touching the sink and accessing the PEG-tube. The facility stated this practice should have included changing gloves and hand hygiene before accessing the PEG-tube. This failed practice created the potential for adverse outcomes including infection due to cross contamination.
Failure to Address Resident Concerns
Penalty
Summary
The facility failed to address and resolve concerns raised by residents during Resident Council meetings from June 2024 through November 2024. The Resident Council minutes documented various issues such as dietary concerns, housekeeping, offsite activities, call light response times, staff behavior, and laundry problems. Despite these concerns being consistently raised in meetings, the minutes did not document any actions taken to address or resolve them. A call light audit conducted in October 2024 identified the need for improvement, but no follow-up actions were documented or communicated to the residents. Interviews with residents and staff revealed ongoing issues with housekeeping, staffing, heating, and call light response times. The Social Services Designee (SSD) and the Activities Director (AD) confirmed that concerns from Resident Council meetings were supposed to be addressed in staff meetings, but there was no written documentation of follow-up actions or responses provided to the residents. The Administrator acknowledged that while concerns were discussed in team meetings, they were not consistently documented or communicated back to the residents in writing.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for four out of five residents reviewed. This deficiency was identified through a review of the State Operations Manual, Appendix PP, which mandates that facilities must notify the resident, their representative, and the Ombudsman before any transfer or discharge. The facility did not comply with this requirement, as evidenced by the lack of documentation in the medical records of Residents #19, #30, #32, and #33, who were transferred to the hospital without the Ombudsman being informed. Resident #19, who had multiple diagnoses including spastic quadriplegic cerebral palsy and aphasia, was transferred to the hospital for possible gastrointestinal bleeding without Ombudsman notification. Similarly, Resident #30, with diagnoses including TBI, anxiety, and diabetes, and Resident #32, with cancer, anemia, and heart failure, were transferred without the required notification. Resident #33, with a fracture, anemia, and congestive heart failure, also experienced a facility-initiated hospital stay without Ombudsman notification. The facility administrator admitted to being unaware of the requirement to notify the Ombudsman of such transfers.
Non-Compliance with Nurse Aide Certification Requirements
Penalty
Summary
The facility failed to ensure that full-time nurse aides (NAs) were either enrolled in a State-approved training and competency evaluation program or had completed such a program within four months of employment. This deficiency was identified for four out of eleven NAs whose personnel files were reviewed. Specifically, NA #1, hired on November 21, 2023, NA #2, hired on April 11, 2024, who completed the class but had not tested, NA #3, hired on June 5, 2024, and NA #4, hired on June 13, 2024, were all working beyond the four-month period without obtaining their nurse aide certification. The HR Manager acknowledged the facility's non-compliance with the requirement for NAs to be certified within four months of their hire date. This oversight had the potential to negatively impact the 54 residents living in the facility.
Infection Control Breach in Laundry Handling
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as observed during a survey. A staff member in the laundry department was seen folding clean laundry and later admitted to sorting dirty laundry without wearing a gown, which is against the standard precautions outlined in the State Operation Manual Appendix PP. The manual specifies that gowns and gloves should be worn when handling potentially contaminated laundry to prevent infection and cross-contamination. The Director of Nursing confirmed that the correct procedure involves wearing both gloves and gowns during the sorting of dirty laundry.
Deficiency in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including dementia, malnutrition, and hypertension, was found to have a room with several issues. Observations included a six-inch section of baseboard near the bathroom that was not attached to the wall and a corner of the baseboard broken off. Additionally, a roll of toilet paper was improperly placed on the grab bar instead of the toilet paper holder. The grab bar itself had large sections of chipped and peeling paint. Furthermore, the hand washing sink was corroded with rust and chipped around the drain. The Maintenance Director was unaware of these issues, as the Housekeeping Supervisor was responsible for submitting work orders, which had not been done. The Housekeeping Supervisor acknowledged the improper placement of the toilet paper and, along with the Administrator, stated that the sink could not be cleaned and would need replacement.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For one resident, the quarterly and significant change MDS assessments incorrectly documented an active diagnosis of pneumonia, despite the condition having resolved months earlier. This discrepancy was confirmed by the Director of Nursing (DON) during an interview. Another resident's admission MDS assessment inaccurately recorded the use of an anticoagulant, which was not supported by the physician's orders. The DON confirmed the error after consulting with the MDS Coordinator. Additionally, a third resident's admission MDS assessment failed to document a completed PASARR level II evaluation, despite the medical record indicating it had been completed. The DON acknowledged this oversight during the review.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for a PASARR level II evaluation after the resident was diagnosed with a major mental illness, specifically major depressive disorder (MDD). The resident was admitted with multiple diagnoses, including MDD and dementia, and was prescribed antidepressant medication. The care plan was updated to include directions for managing the resident's depression and behavioral disturbances. However, the pre-admission PASARR level I screening identified the resident's MDD but was not forwarded to the appropriate state-designated authority for a level II evaluation. The deficiency was identified during a review of the resident's records and staff interviews. The Director of Nursing (DON) was unaware that the PASARR level I form was filled out incorrectly and that a level II evaluation should have been completed. This oversight had the potential to cause harm by not ensuring the resident's specialized mental health needs were evaluated and coordinated by the appropriate authority.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice, affecting multiple residents. Resident #18, who has diagnoses including paraplegia and chronic pain, was mistakenly given Norco instead of the prescribed Tramadol due to a mix-up with medication cards. Resident #25, with a diagnosis of esophagitis, was incorrectly administered rivaroxaban intended for another resident during a training session between LPN #1 and RN #1. These errors were documented in Medication Error Reports. Additionally, Resident #27, who suffers from chronic respiratory failure, was administered Anoro Ellipta despite the physician's order for ipratropium-Albuterol and the discontinuation of Anoro Ellipta. The medication technician and LPN involved were unaware of the discontinuation, leading to the administration of the wrong medication. These incidents highlight the facility's failure to adhere to the six rights of medication administration, creating potential adverse effects for the residents involved.
Failure to Follow Care Plans and Notify Physician
Penalty
Summary
The facility failed to provide resident-centered care in accordance with professional standards of nursing practice and residents' comprehensive care plans for two residents. Resident #6, who was admitted with multiple diagnoses including metabolic encephalopathy, diabetes, and hypoglycemia, had a physician's order to notify the provider if blood glucose levels were less than 70 mg/dl or greater than 400 mg/dl. However, on two occasions, Resident #6's blood glucose levels exceeded 400 mg/dl, and there was no documentation in the medical record that the physician was notified, despite the Director of Nursing stating that the nurse had informed the nurse practitioner. Resident #19, diagnosed with spastic quadriplegia, cerebral palsy, and aphasia, required two-person assistance for repositioning in bed as per his care plan. On one occasion, CNA #1 was observed repositioning and turning Resident #19 alone while changing his bed sheet, despite the care plan's requirement for two-person assistance. CNA #1 admitted to frequently performing the task alone, and the Unit Manager confirmed that the care plan required two staff members for bed mobility, indicating a failure to adhere to the resident's care plan.
Medication Error Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.9% error rate observed during the administration of insulin to a resident with diabetes. The resident was prescribed Insulin Glargine and Insulin Lispro, with specific instructions for administration based on blood glucose levels. On the day of observation, the resident's blood glucose was recorded at 256 mg/dl, requiring 15 units of Insulin Lispro according to the sliding scale. However, the RN administering the insulin did not prime the insulin pens before injecting the prescribed doses, which is a necessary step to ensure the full dose is delivered. The failure to prime the insulin pens was confirmed through staff interviews, where the RN admitted to not priming the pens, and the Unit Manager acknowledged that priming is required to ensure the resident receives the correct dose. This oversight in medication administration created the potential for the resident to experience fluctuations in blood sugar levels, as the full prescribed dose may not have been delivered. The deficiency was identified during a survey, highlighting a lapse in following proper medication administration protocols.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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