Sunterra Springs Riverview
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 3550 West Americana Terrace, Boise, Idaho 83706
- CMS Provider Number
- 135139
- Inspections on file
- 19
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Sunterra Springs Riverview during CMS and state inspections, most recent first.
A resident with impaired vision and multiple diagnoses was found to be self-administering antacids and Tylenol from a bedside bottle, despite documentation that she did not wish to self-administer medications and without interdisciplinary team approval, as required by facility policy.
The facility did not notify the physician of significant changes in condition for three residents, including substantial weight loss and abnormal vital signs. Two residents experienced notable weight loss without physician notification, despite care plans indicating risk for nutritional deficits. Another resident had abnormal vital signs prior to death, with no evidence that the physician or DON were informed or that appropriate monitoring was documented.
An LPN diverted multiple doses of controlled medications, including oxycodone, that were prescribed for three residents with serious medical conditions such as fractures, dementia, and post-surgical care. The LPN removed the medications, failed to administer them as ordered, provided inconsistent explanations about their whereabouts, and refused a search of personal belongings. The facility's investigation confirmed the misappropriation and exploitation of resident property.
A resident with multiple diagnoses was transferred to a hospital after experiencing severe pain and diaphoresis during a clinic visit, but the facility failed to provide discharge paperwork or document the reason for hospitalization in the medical record. The DON confirmed that documentation of the transfer and hospitalization reason was not completed as required.
A resident with a history of falls and left-sided weakness had their bed moved against the wall by staff after a fall, but this intervention was not added to the care plan. The DON and RNC confirmed the omission when reviewing the care plan and observing the resident's room.
Three residents experienced deficiencies in care, including unclarified medication orders for Parkinson's and antifungal treatment, and missed or undocumented physical and occupational therapy sessions. The facility did not ensure medication orders were clarified with providers or that therapy was delivered and documented as scheduled.
An LPN was found to have worked with residents without completing the required onboarding training, having finished only a small portion of the assigned modules. The Administrator confirmed the incomplete training, and the DON was unaware of the deficiency and had not addressed it.
A pharmacist recommended that an antipsychotic medication be administered with food for a resident, but the physician did not indicate acceptance or rejection of this recommendation on the review form. The medication was scheduled without instructions to give it with food, and nursing leadership confirmed the lack of physician acknowledgment.
A resident with multiple medical conditions was given lorazepam, an anti-anxiety medication, on two occasions without any documented symptoms or behaviors of anxiety. The DON confirmed that the medication was administered without the necessary documentation to support its use as required.
Two residents experienced significant medication errors when one received divided doses of lurasidone against physician orders, and another was given Lyrica and auvelity intended for a different resident. The DON confirmed both incidents after reviewing records and staff reports.
A resident with hypertensive heart disease and heart failure was prescribed Prazosin HCl 1 mg, 2 capsules twice daily, but the pharmacy label instructed administration of only 1 capsule twice daily. An LPN administered the medication according to the incorrect label, and the DON confirmed that the label should have matched the physician's order.
Three residents experienced discomfort due to improper temperature control in their rooms. One resident's room was consistently cold, another's bathroom was particularly cold, and a third faced fluctuating temperatures. Despite thermostat settings indicating compliance, ambient temperature readings showed discrepancies, leading to discomfort and potential health risks. The Maintenance Director acknowledged issues with thermostat accuracy, and the Administrator noted that while regulatory temperature ranges were met, the facility's policy required resident comfort.
The facility did not ensure pharmacy recommendations were addressed by the attending physician for two residents, potentially leading to harm. One resident was prescribed alprazolam without a stop date, and another was prescribed vancomycin without a specified duration. The DON received the recommendations but could not show they were reviewed by the physician due to a rescheduled QAPI meeting.
A resident with a documented allergy to opioid analgesics was administered oxycodone due to an error in transcribing allergy information from hospital documents. The allergy was not listed in the transferring hospital's records, leading to the administration of the medication without complication. The error was confirmed by the DON and went unnoticed during order verification and medication administration.
Failure to Ensure Interdisciplinary Team Approval for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined it was safe for a resident to self-administer medications, as required by facility policy. The policy stated that residents may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely. In this case, a resident with multiple diagnoses, including hypertension and GERD, and who was legally blind, had a care plan and a self-administration evaluation indicating she did not want to self-administer medications while in the facility. Despite this, surveyors observed a bottle labeled antacids on the resident's bedside table containing both antacids and Tylenol. The resident stated she took the antacids and Tylenol whenever she needed them. The DON confirmed the medications at the bedside and acknowledged that the resident should not be self-administering medications, as documented in the assessment.
Failure to Notify Physician of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure timely physician notification of significant changes in condition for three residents. For one resident with multiple diagnoses including a femur fracture, diabetes, and Crohn's Disease, a 14.9% weight loss occurred over 27 days, but there was no documentation that the physician was informed of this significant change. Another resident with a femur fracture, B-12 deficiency anemia, and hyperlipidemia experienced an 11.66% weight loss over 84 days, again without evidence of physician notification. Both residents were identified as being at risk for nutritional deficits and had care plans indicating that untreated weight variances should not occur. A third resident with mild cognitive impairment, sepsis, and Parkinson's disease exhibited a notable decrease in blood pressure and increases in temperature and heart rate, but there was no documentation that the physician or DON were notified of these changes. The resident was later found pulseless and passed away, with conflicting documentation regarding the frequency and nature of monitoring prior to death. Interviews with facility staff confirmed the lack of physician notification and absence of required documentation regarding these significant changes in condition.
Diversion of Controlled Substances by LPN Resulting in Misappropriation and Exploitation
Penalty
Summary
The facility failed to protect residents from misappropriation of property and exploitation, as evidenced by the diversion of controlled medications intended for three residents. The incident involved an LPN who was observed by the DON to mishandle and ultimately divert multiple pills, including oxycodone, which were prescribed for residents with significant medical needs such as fractures, dementia, post-surgical care, and congestive heart failure. The LPN removed several controlled substances into a single medicine cup, signed them out in the controlled medication logbook, and then failed to administer them to the residents as ordered. When questioned, the LPN provided inconsistent explanations regarding the disposal of the medications and refused to allow a search of her personal belongings before leaving the facility. A review of the controlled drug logbook, medication administration records, and resident interviews confirmed that five doses of oxycodone, belonging to three residents, were signed out but not administered. The facility's investigation substantiated that the LPN diverted these medications, constituting misappropriation of resident property and exploitation. The incident was documented in a Facility Reported Incident and confirmed by the Administrator, with evidence showing that the medications were not located and the LPN was responsible for their diversion.
Failure to Provide Resident-Specific Discharge Documentation During Hospital Transfer
Penalty
Summary
The facility failed to provide resident-specific discharge paperwork to the hospital during the transfer of a resident. Record review showed that the resident, who had multiple diagnoses including aftercare following a surgical procedure, was transported to an infectious disease clinic but refused to get out of the vehicle due to severe pain and diaphoresis. The clinic's physician assistant assessed the resident and sent him to the emergency room. However, the nursing notes did not document the reason for the resident's hospitalization, and there was no documentation in the record explaining why the resident was at the hospital. The Director of Nursing confirmed that the best practice would have been to document the resident's transfer and the reason for hospitalization, but this was not done.
Failure to Update Care Plan After Fall Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated as needed following a significant change in the resident's condition. The resident, who had a history of repeated falls, major depressive disorder, and anxiety, was admitted with left-sided weakness and was identified as being at risk for falls. The initial care plan directed staff to encourage the use of the call light and to keep the resident's room free of clutter and tripping hazards. However, after the resident fell out of bed and staff moved the bed against the wall as a fall intervention, this change was not documented or incorporated into the resident's care plan. The Director of Nursing and Registered Nurse Coordinator confirmed that the intervention of placing the bed against the wall was not included in the care plan, despite being implemented after the fall.
Failure to Clarify Medication Orders and Provide Scheduled Therapy
Penalty
Summary
The facility failed to ensure professional standards of care were followed for three residents reviewed for quality of care. For one resident with mild cognitive impairment, dysphagia, sepsis, and Parkinson's disease, there was a lack of clarification regarding the frequency of Carbidopa/Levodopa ODT dosing after the resident's spouse brought in medication and requested a change due to swallowing difficulties. Documentation showed conflicting orders and a possible transcription error, but there was no evidence that the provider clarified the correct dosing frequency. For another resident with chronic lymphocytic leukemia, the medication order for Voriconazole was unclear and inconsistent with the hospital discharge summary, and the DON acknowledged the order should have been clarified with the physician. A third resident, admitted for aftercare following digestive surgery and heart failure, did not receive scheduled physical and occupational therapy sessions as ordered. Progress notes lacked documentation on the number of therapy attempts, whether the resident refused therapy, or reasons for missed sessions. There was also no evidence that missed therapy sessions were made up on the weekend, and a progress note explaining a missed session was entered 14 days after the fact. These deficiencies demonstrate failures in medication order clarification and therapy service delivery according to professional standards and resident care plans.
LPN Provided Care Without Completing Required Training
Penalty
Summary
The facility failed to ensure that a licensed nurse had completed the required onboarding training and demonstrated the necessary competencies before providing care to residents. Personnel record review showed that one LPN, hired on 9/26/25, had only completed 3 out of 24 assigned training modules, with no documentation of full onboarding training in her file. The Administrator confirmed that the LPN had not completed the required training and acknowledged that she should not have been working with residents. The DON stated that all newly hired staff are required to complete assigned training before working with residents but was unaware that this LPN had not fulfilled the requirement and had not addressed the issue.
Physician Failed to Address Pharmacist Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding medication administration were addressed by the physician for one resident. Specifically, a pharmacist reviewed a resident's medication regimen and recommended that lurasidone, an antipsychotic medication, be administered with food as per the manufacturer's instructions for proper absorption. This recommendation was documented on the Interim Medication Regimen Review form, which included a section for the physician to indicate acceptance or rejection of the pharmacist's recommendation. Despite the pharmacist's documented recommendation, the physician signed the form without indicating whether the recommendation was accepted or declined. Further review of the resident's Medication Administration Record (MAR) showed that the medication was scheduled for administration in the afternoon, but there was no indication that it should be given with food. Facility nursing leadership confirmed that the physician should have acknowledged the pharmacist's recommendation, but this was not done.
Psychoactive Medication Administered Without Documented Indication
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs when a psychoactive medication was administered without adequate indication for its use. A resident with multiple diagnoses, including depressive disorder, hypertension, and osteoporosis, had a physician's order for lorazepam to be given as needed for anxiety. The medication administration record showed that lorazepam was administered on two occasions, but there was no documentation of anxiety symptoms or behaviors at those times. The Director of Nursing confirmed that the medication was given without documentation of the required symptoms or behaviors, contrary to facility expectations.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by two documented incidents involving medication administration. For one resident with multiple diagnoses, including aftercare for a right femur fracture and psychiatric conditions, the physician's order specified lurasidone 100 mg daily, to be given as 20 mg and 80 mg together. However, the Medication Administration Record (MAR) showed the doses were administered separately at different times over a ten-day period, contrary to the order. The Director of Nursing (DON) reviewed the records and could not explain why the doses were divided during that period. In another case, an LPN administered Lyrica 75 mg and auvelity 45-105 mg, both controlled and antipsychotic medications, to the wrong resident. The medication was intended for a different resident in another room. The error was documented in a medication error report, and both the affected resident and her husband were upset, though no physical harm was noted. The DON confirmed the LPN reported the error and accepted responsibility.
Medication Labeling Discrepancy for Antihypertensive Drug
Penalty
Summary
The facility failed to ensure that the pharmacy label for a resident's medication matched the physician's order. Specifically, a resident with hypertensive heart disease and heart failure had a physician's order for Prazosin HCl 1 mg capsules, instructing administration of 2 capsules by mouth twice daily. However, the pharmacy label on the medication card directed staff to give only 1 capsule by mouth twice daily. During medication administration, an LPN prepared and administered the medication according to the label, not the updated physician's order. Upon review, the LPN confirmed the discrepancy between the label and the order, and the Director of Nursing acknowledged that the pharmacy label should match the physician's order.
Temperature Control Issues in Resident Rooms
Penalty
Summary
The facility failed to maintain comfortable bedroom temperatures for three residents, leading to discomfort and potential health risks. Resident #10 reported his room was consistently too cold, despite the thermostat being set to 78 degrees Fahrenheit. Observations confirmed the room felt drafty and cold, with the ambient temperature measured at 71 degrees Fahrenheit, indicating a discrepancy with the thermostat reading. The Maintenance Director acknowledged the issue, suggesting the thermostat might need repair. Resident #127 also experienced discomfort due to cold temperatures, particularly in her bathroom, which she described as feeling like the North Pole. Despite the thermostat being set to 76 degrees Fahrenheit, the ambient temperature in her bedroom was 70 degrees Fahrenheit, and the bathroom was even colder at 68 degrees Fahrenheit. The Maintenance Director was unaware of her complaints, and the discrepancy between the thermostat and ambient temperature readings was noted. Resident #144 faced fluctuating temperatures, with her room being too cold in the mornings and too hot in the evenings. The thermostat settings and readings varied, with the ambient temperature measured at 71 degrees Fahrenheit, despite the thermostat reading 77 degrees Fahrenheit. The Maintenance Director attributed the temperature fluctuations to the large windows in her room. The Administrator noted that the Maintenance Director's computer showed all rooms within the regulatory temperature range, but the facility's policy required temperatures to be comfortable for residents.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed or addressed by the attending physician for two residents, which could potentially lead to harm if medications were administered without a clinical rationale. The facility's policy required the pharmacist to send monthly medication reviews to the Director of Nursing (DON) or designee, who would then print the recommendations and provide them to the medical provider for review and signature. However, this process was not completed for two residents, as the physician did not sign off on the pharmacy consultation reports. One resident was prescribed alprazolam for depression without a stop date, and the pharmacy recommended re-evaluation after 14 days, as per regulations for PRN psychotropic medications. Another resident was prescribed vancomycin for osteomyelitis, but the order lacked a specified duration of therapy, with the pharmacy recommending a duration of at least six weeks. The DON acknowledged receiving the pharmacy recommendations but could not provide evidence that the physician had addressed them, as the review was delayed due to a rescheduled Quality Assurance and Performance Improvement (QAPI) meeting.
Medication Error Due to Inaccurate Allergy Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, which led to the administration of a medication listed on the resident's allergy list. The resident, admitted for care following a lumbar fracture, had an allergy to opioid analgesics documented in his medical record. Despite this, the resident was prescribed and received oxycodone, an opioid analgesic, since mid-December. The Director of Nursing (DON) confirmed that the allergy was incorrectly transcribed from the transferring hospital's documents, which did not list an opioid allergy. This error went unnoticed during the verification of physician orders and each administration of the opioid medication.
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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