Shaw Mountain Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 909 Reserve Street, Boise, Idaho 83712
- CMS Provider Number
- 135090
- Inspections on file
- 24
- Latest survey
- May 14, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Shaw Mountain Of Cascadia during CMS and state inspections, most recent first.
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.
Three residents did not receive care in accordance with physician orders and professional standards. One resident with CHF and hypertension had multiple episodes of severely elevated BP and increased edema without documented reassessment or provider notification. Another resident with muscle weakness and cognitive deficits had a distended abdomen and absent bowel sounds, but the provider was not notified until the next day. A third resident with abdominal drains had conflicting orders, delays in order implementation, and missing documentation of drain output.
The facility did not maintain adequate nursing staff to meet resident needs, resulting in multiple instances where residents experienced prolonged call light wait times, were left soiled for extended periods, and did not receive timely assistance with daily care. The DON acknowledged ongoing problems with call light response and staffing levels.
A resident admitted for post-sepsis care with multiple liver abscesses had inconsistencies in medical record documentation regarding the number of abdominal drain tubes present. Despite Interventional Radiology notes indicating drain removals, nursing progress notes continued to reflect incorrect drain counts, likely due to staff copying and pasting previous entries. The DON confirmed the records were not accurate.
The facility failed to maintain infection control and sanitation standards, with a CNA using the same gloves to feed two residents, an RN handling medication with bare hands, and an LPN placing feeding supplies on a resident's bed. The laundry room was also found in unsanitary conditions, with water and substances on the floor and surfaces. These deficiencies risked cross-contamination and infection.
The facility did not maintain residents' dignity during dining as a CNA was observed standing while feeding two residents, contrary to the facility's policy requiring staff to sit while assisting with meals. Both an LPN and the DON confirmed this practice was incorrect.
The facility failed to assist two residents in formulating Advance Directives, as their medical records lacked these documents. Both residents, with serious medical conditions, had unsigned admission agreements and incorrect documentation in their care conferences, indicating the facility had copies of their Advance Directives when it did not.
A facility failed to provide the NOMNC form CMS-10123 at least two days prior to discharge for a resident with PTSD and cirrhosis. The resident was discharged from Medicare Part A, and the NOMNC was signed on the same day instead of the required two days prior. The administrator confirmed the oversight.
A resident with dementia and weakness fell out of bed, but their care plan was not updated with new fall prevention interventions. The DON confirmed that the care plan should have included the intervention of keeping the bed in the lowest position, as noted in the Fall Investigation report.
A resident with Spastic Diplegic Cerebral Palsy and anxiety did not receive proper care for their feeding tube. An LPN used an incorrect method to check tube placement, and the feeding formula bottle was not labeled as required. The DON confirmed these lapses, indicating non-compliance with the facility's enteral nutrition policy.
The facility failed to ensure staff completed necessary training and did not adequately monitor a resident's oxygen levels. An RN did not complete required dementia and communication training, and a resident with COPD had multiple instances of low oxygen saturation levels that were not addressed by nursing staff, despite physician orders for continuous oxygen therapy.
The facility failed to ensure controlled medications were properly tracked and secured, leading to potential theft or diversion. An audit revealed missing signatures on the narcotic accountability record for multiple shifts. An RN confirmed that nurses should sign the accountability sheet when handling the medication cart, but this was not consistently done, affecting all residents receiving controlled medications.
A resident with multiple diagnoses, including kidney disease and a right leg amputation, experienced medication administration errors during a medication pass. The nurse failed to prime the insulin pen before administering Glargine insulin and did not wait the required 3-5 minutes between administering two types of eye drops. These actions resulted in a medication error rate of 8.82%, exceeding the acceptable rate of less than 5%.
The facility failed to properly label, date, and store medications, as observed in various medication carts and storage rooms. Issues included expired medications, loose pills, and undated vials, creating potential risks for residents.
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 Follow Physician Orders and Document Care According to Standards
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for three residents. For one resident with congestive heart failure and hypertension, staff did not document reassessment or provider notification after multiple instances of severely elevated blood pressure and increased edema, despite care plan directives to monitor and report such changes. The Director of Nursing (DON) confirmed that while verbal notifications may have occurred, there was no documentation in the medical record to support this. Another resident with muscle weakness and cognitive communication deficit experienced a distended abdomen with absent bowel sounds, a condition associated with serious complications. Nursing notes showed that the resident had not had a bowel movement in over 72 hours and continued to have abdominal distention. The provider was not notified of the absent bowel sounds until the following day, despite the DON acknowledging that absent bowel sounds are considered an emergency. A third resident, admitted for care following sepsis and multiple liver abscesses, had three abdominal drain tubes. There were conflicting physician orders regarding the amount of sterile saline to flush the drains, and new orders were not implemented on the treatment administration record (TAR) until the day after they were received. Additionally, the record did not document the amount of fluid drained from the collection bags on several dates, and nurses did not follow the physician order to record output as directed.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to ensure sufficient nursing staff were on-site to provide necessary nursing services to residents. Multiple entries in the facility's Grievance Log from July to December 2025 documented repeated incidents where residents experienced long call light wait times, were left soiled for extended periods, or did not receive timely assistance with activities of daily living. Specific incidents included residents waiting up to two and a half hours for restroom assistance, being left in soiled clothing for hours, and not having their call lights answered promptly. In one case, a resident was left in the same clothes all weekend, and another was found soiled with urine and stool in their recliner. Staff interviews confirmed ongoing issues with call light response times. The Director of Nursing acknowledged that call lights were a constant problem and that administrative staff were encouraged to assist when possible. Despite audits and education efforts, the administration continued to struggle with finding a solution to the persistent issue of inadequate staffing and delayed response to resident needs.
Inaccurate Documentation of Resident Drain Tubes
Penalty
Summary
The facility failed to ensure that resident medical records were accurately documented in accordance with professional standards of practice. For one resident admitted for care following sepsis and multiple liver abscesses, there were inconsistencies in the documentation of the number of abdominal drain tubes present. Interventional Radiology notes indicated the removal of specific drains on certain dates, but progress notes from nursing staff continued to document an incorrect number of drains for several days following these procedures. For example, after the removal of drain #1 and later drain #2, progress notes still reflected the presence of three drains, and only later adjusted to two and then one drain as per the actual clinical situation. The Director of Nursing confirmed that multiple progress notes contained inaccurate information regarding the number of drains, attributing the errors to nurses potentially copying and pasting previous notes rather than updating them to reflect the current clinical status. This resulted in inaccurate clinical documentation for the resident, as the medical record did not consistently match the resident's actual condition and the interventions performed.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices in several areas, including meal assistance, medication administration, and laundry room sanitation. During meal service, a CNA was observed assisting two residents with feeding using the same gloved hand without changing gloves or performing hand hygiene between residents. Additionally, the CNA touched a chair without changing gloves or sanitizing hands before continuing to feed the residents. In medication administration, an RN was seen handling a Buprenorphine HCl tablet with bare hands before placing it in a resident's medication cup. Furthermore, an LPN was observed placing feeding tube supplies directly on a resident's bed, which is against proper sanitary procedures. The laundry room was found in unsanitary conditions, with water and a dark green substance on the floor, and a thick layer of gray, fuzzy substance on various surfaces, including pipes and vents. The laundry manager admitted there was no check-off sheet to guide staff on cleaning tasks. These deficiencies in infection control practices and unsanitary conditions in the laundry room posed a risk of cross-contamination and infection to all residents in the facility.
Failure to Maintain Dignity During Dining
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect during dining operations. Observations revealed that a Certified Nursing Assistant (CNA) was standing while spoon-feeding two of the five residents at a dining table during breakfast. This practice is contrary to the facility's Dining Standards policy, which requires staff to sit next to residents while assisting with feeding. Both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that staff should not stand over residents when assisting them with meals.
Failure to Assist Residents in Formulating Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an Advance Directive. This deficiency was identified for two residents whose records were reviewed. Resident #18, who was admitted with diagnoses including Parkinson's disease with dyskinesia and dementia, did not have a copy of his Advance Directives in his medical record. Additionally, the admission agreement, which should have been signed to acknowledge the offering of information regarding Advance Directives, was not signed by the resident or their representatives. Despite documentation in the Multidisciplinary Care Conference indicating that the facility had a copy of the resident's Advance Directives, the Administrator later confirmed that this was incorrect. Similarly, Resident #30, admitted with conditions such as pulmonary embolism and acute respiratory failure with hypoxia, also did not have a copy of his Advance Directives in his medical record. The admission agreement was unsigned, and the Multidisciplinary Care Conference documentation inaccurately stated that the facility had a copy of the resident's Advance Directives. The Administrator acknowledged that the Social Services Director had incorrectly marked the documentation, and the facility had not obtained the necessary documents. This oversight created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 at least two days prior to discharge for one resident reviewed for beneficiary protection notification. This deficiency was identified during a record review and staff interview. The resident in question was initially admitted to the facility with multiple diagnoses, including post-traumatic stress disorder and cirrhosis. The resident was discharged from Medicare Part A on December 16, 2024, and the NOMNC was signed on the same day, rather than the required two days prior. The facility administrator confirmed that the NOMNC had not been completed in accordance with the required timeline.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current needs and interventions, as required by their policy. This deficiency was identified for one resident who had been admitted with multiple diagnoses, including dementia and weakness. The resident experienced a fall from bed, which was documented in their medical record. Despite the fall, the resident's care plan was not updated with new fall prevention interventions. The Director of Nursing confirmed that the care plan should have been updated to include the intervention of keeping the resident's bed in the lowest position, as documented in the Fall Investigation report.
Failure to Follow Enteral Nutrition Policy for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure adequate care and treatment for a resident with a feeding tube, leading to a potential risk of harm. The facility's Enteral Nutrition policy required staff to verify tube placement by gently tugging on the tube and noting the marking on the tube. However, an LPN was observed checking the resident's feeding tube placement by using a 60cc syringe, a stethoscope, and pushing 10cc of air into the resident's feeding tube while auscultating the abdomen, which was not in accordance with the policy. Additionally, the resident's feeding formula bottle was not labeled with the resident's name, start date, time, and rate of feeding, as required by the facility's policy. The resident involved had multiple diagnoses, including Spastic Diplegic Cerebral Palsy and anxiety, and was admitted to the facility with a physician's order for enteral feeding every shift. The physician's order specified checking the feeding tube placement by observing a change in the external length marked at the entry point before administering formula, medication, or flushing the tube. Despite these orders, the LPN did not follow the correct procedure for verifying tube placement, and the feeding formula bottle was not properly labeled. The Director of Nursing confirmed that the bottle should have been labeled and the feeding pole cleaned, indicating a lapse in adherence to the facility's policies and procedures for enteral nutrition care.
Failure to Ensure Staff Training and Resident Oxygen Management
Penalty
Summary
The facility failed to ensure that its staff completed the necessary annual trainings and competencies required to meet the needs of its residents. Specifically, one registered nurse (RN) hired on 5/29/21 did not complete dementia and communication training, as documented in his personnel file. Despite a Statement of Discussion dated 1/2/25 highlighting the need for this training, the Director of Nursing (DON) confirmed on 3/7/25 that the RN had not completed the required training. This lack of training could potentially impact the quality of care provided to all residents in the facility. Additionally, the facility did not adequately monitor and address the oxygen saturation levels of a resident with chronic obstructive pulmonary disease and depression. The resident's physician ordered continuous oxygen therapy to maintain oxygen saturation levels above 90%. However, multiple recorded instances showed the resident's oxygen saturation levels were below the prescribed threshold, both with and without oxygen. The medical records lacked nursing progress notes addressing these low oxygen levels or the resident's non-compliance with the oxygen order. The DON acknowledged that the oxygen desaturations should have been addressed by the nursing staff but were not.
Controlled Medication Tracking Deficiency
Penalty
Summary
The facility failed to ensure controlled medications were properly tracked and secured, which could lead to potential theft or diversion. During an audit of the medication cart on hall 300, it was observed that the narcotic accountability record had missing signatures from licensed nurses. Specifically, from 11/22/24 to 12/3/24, there were 16 instances where signatures were not documented for each shift, and from 2/9/25 to 3/5/25, there were 2 instances of missing signatures. RN #1 confirmed that nurses are required to sign the narcotic accountability sheet when they accept or release the medication cart. This oversight in documentation created the potential for undetected misuse or diversion of controlled medications, affecting all residents receiving such medications in the facility.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by an observed error rate of 8.82% during a medication pass. This deficiency was identified through the observation of medication administration for a resident with multiple diagnoses, including kidney disease and a right leg amputation. The resident's physician orders included Glargine insulin and two types of eye drops, Dorzolamide and Rednisol acetate. During the medication pass, the nurse did not prime the insulin pen before administering the Glargine insulin, which is a required step to ensure accurate dosing. Additionally, the nurse administered the resident's eye drops without waiting the required 3-5 minutes between applications, as stipulated in the facility's Eye Drop Administration policy. These actions were contrary to the facility's established medication administration policies, which require adherence to physician orders and specific procedures to ensure safe and effective medication delivery. The nurse acknowledged the errors, indicating a lack of awareness of the necessary procedures for insulin pen priming and the required waiting time between eye drop administrations.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled, dated, and stored appropriately, as observed during an inspection of the medication storage areas. In the Hall 100 medication cart, a dairy digestive tablet with an expiration date of July 2024 was found, which should not have been present. Additionally, in the medication storage room, a bottle containing 12 Calcium tablets with an expiration date of October 2023 was discovered, which should have been placed in the medication destruction tote. Furthermore, a loose Losartan tablet was found in the Hall 300 medication cart, which should have been disposed of in the drug buster. In the Friendship house medication cart, several issues were identified, including a loose Remeron tablet, three yellow pills, three white pills, and a multi-dose vial of Lidocaine without an open date. The loose pills should have been destroyed, and the Lidocaine vial should have been dated upon opening. These deficiencies in medication management created the potential for residents to miss doses or receive expired medications with decreased efficacy.
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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