Teton Healthcare Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Idaho Falls, Idaho.
- Location
- 3111 Channing Way, Idaho Falls, Idaho 83404
- CMS Provider Number
- 135138
- Inspections on file
- 20
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Teton Healthcare Of Cascadia during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy and acute respiratory failure with hypoxia was found keeping OTC Refresh eye drops at the bedside and self-using them as needed, despite no documented assessment by the IDT for safe self-administration. Facility policy required the IDT to determine safety, assign responsibility for storage and documentation, and record these decisions in the medical record and care plan before allowing self-administration. Record review showed no such assessment or care plan authorization, and an RN Clinical Resource Nurse confirmed the resident had not been assessed and should not have had the eye drops in the room.
The facility did not follow its call light policy requiring call systems to be within residents' reach. One resident with psychosis and muscle weakness was observed eating at a side table while the call light was tied to a nightstand drawer behind her, out of reach, which a CNA acknowledged was improper. Another resident with hemiplegia and diabetes was found reclining in bed with the call light placed on a bedside table he could not reach after staff provided care, and a CNA confirmed it should have been positioned within his reach. The CNO also stated that call lights are expected to be within residents' reach and were not in these cases.
A resident admitted for post-surgical care following a left femur fracture and muscle weakness did not receive a Notice of Medicare Non-Coverage (NOMNC) within the required timeframe before Medicare Part A skilled services ended. Documentation showed the NOMNC listed the last covered day but was signed by the resident and representative only one day before coverage ended, rather than 48 hours in advance. Social Services noted a phone discussion with the resident’s daughter about the last covered day, and facility leadership acknowledged that the NOMNC was not issued within the required 48-hour window, creating potential financial harm or distress related to unnotified liability for non-covered services.
The facility did not ensure a safe and clean environment in the dining area when surveyors observed two large dining room ceiling vents with brown, hairy-like debris covering part of the inside of each vent and a strip of red, confetti-like paper in one vent, along with brown/black discoloration on the ceiling around other dining room vents. The CEO acknowledged that the vents should have been cleaned and had not been, confirming the lack of appropriate environmental maintenance.
A resident with multiple chronic conditions, including diabetes, heart failure, and cirrhosis, was transferred twice to the ER without documented provision of the required written Notice of Transfer and bed-hold policy. Facility policies required written notice of transfer, with specified exceptions for urgent medical needs, and written information on bed-hold policies prior to and upon transfer for hospitalizations or therapeutic leave. Record review and an RN interview confirmed that no such documentation could be found for these transfers, resulting in a deficiency related to resident rights and notification.
The facility failed to complete baseline care plans within 48 hours of admission for two residents, contrary to its policy requiring a baseline plan of care to be developed within 48 hours to address immediate needs. One resident with ESRD and acute respiratory failure had a baseline care plan initiated but not locked or completed until more than 48 hours after admission, and facility staff confirmed that a plan is not considered complete until it is locked. Another resident with necrotizing fasciitis and diabetes with diabetic polyneuropathy had a baseline care plan completed 5 days after admission. The RN Clinical Resource Nurse acknowledged in both cases that the baseline care plans were not created within the required timeframe.
A resident with acute and chronic respiratory failure and other breathing abnormalities had physician orders for a compression glove and Tubi grip sleeve to be applied to the left upper extremity each day and night for edema, but these interventions were not included in the resident’s care plan. On multiple observations, the resident was noted without the ordered compression glove and sleeve in place. Record review confirmed the active physician order, and the RN Clinical Resource Nurse acknowledged the care plan had not been revised when the new orders were received.
The facility did not accurately post daily nurse staffing information for multiple months. Review of daily staffing sheets covering several months showed that the facility name and LPN hours were missing from all sheets. The CEO later confirmed that both the LPN hours and the facility name should have been included on the daily staffing sheets during this period but were not, affecting the completeness of staffing information available for review.
Surveyors identified that controlled medications were not consistently tracked according to facility policy, as narcotic accountability sheets for two medication carts were missing required dual nurse signatures on multiple occasions. During audits, staff, including an RN and the CNO, acknowledged that two nurses were supposed to sign the narcotic sheets when accepting or releasing the med carts, but this did not always occur, affecting all residents receiving controlled meds.
A resident with lumbar spinal stenosis and neurogenic bladder had a physician order for Gentamicin Sulfate bladder irrigation that lacked a documented indication or diagnosis and specified an indefinite duration. Facility policies required all medication orders to include an indication or diagnosis and duration, and to ensure regimens were free from unnecessary medications. Review of the order and an interview with the ACNO confirmed that these required elements were missing, resulting in noncompliance with the facility’s own medication and unnecessary drug policies.
Surveyors identified expired medications and unsecured drug storage when they observed multiple expired vitamin, supplement, and shampoo products in the medication storage room despite a policy requiring prompt removal and disposal of expired items. They also found a 100 Hall medication cart left unlocked and unattended while several staff members walked by without securing it, until an RN acknowledged it should not have been left open. A later audit of the same cart revealed loose, unidentified pills in two drawers and an expired bottle of multivitamins, and both the RN and CNO confirmed that loose pills should not be present in the cart and should have been destroyed.
Surveyors found that kitchen staff failed to follow FDA Food Code and facility policy for food storage, labeling, and sanitation. Ready-to-eat salads remained in the walk-in refrigerator beyond their intended use date, and chocolate pieces in the walk-in freezer were stored on an uncovered, unlabeled, and undated cookie sheet. Supposedly clean muffin pans on the storage rack were encrusted with buildup on both sides, and the area around the food prep sink, including the drain grate and floor-wall junctions under counters and sinks, was heavily soiled with dirt, food, and grime. These issues affected all residents receiving meals prepared in the kitchen.
A nurse failed to follow infection prevention and control practices during medication administration when removing an unwanted medication from a medication cup with an ungloved finger. A resident with COPD and diabetes had fifteen morning medications prepared in a single cup, including a Colace capsule the resident declined. Instead of using a clean device or gloves, the RN used an ungloved finger to remove the capsule before giving the remaining medications to the resident, contrary to facility policy requiring medications be handled without direct contact.
Surveyors observed unclean conditions throughout the facility, including sticky and dried substances on over-bed tables and commodes, soiled briefs and dirty wipes left in trash cans, and resident care items such as wheelchairs and Hoyer lift pads that were visibly dirty. Staff interviews revealed inconsistent cleaning practices and a lack of documentation for required cleaning tasks, resulting in a failure to provide a safe, clean, and homelike environment for all residents.
A resident with multiple medical conditions experienced a fall while reaching for food and drink in a wheelchair. Although the IDT recommended ensuring food and drink were placed closer to the resident to prevent further falls, this intervention was not added to the care plan. The DON confirmed the care plan was not updated to reflect the new intervention.
A medication cup containing a purple substance was found on a resident's bedside table, despite the resident not having an order or care plan documentation to self-administer medications. Staff confirmed that medications should not have been left in the room, indicating improper medication storage.
Staff did not follow enhanced barrier precautions when assisting a resident with multiple medical conditions during transfers and showering, as required by posted instructions. A CNA provided care without donning a gown and gloves, misunderstanding the protocol, while other staff and the DON confirmed that protective equipment was required for these activities.
A resident with dementia and necrosis of the left femur was injured during a Hoyer lift transfer due to improper storage and use of the equipment. The lift tipped over, causing a head laceration and cheek bruising, requiring hospital treatment. The facility's policy required equipment to be stored out of egress areas, but a lift was found stored in a resident's room, creating a fall hazard. The CRN confirmed that CNAs should have been properly trained in safe lift transfers.
The facility failed to ensure CNAs were trained to operate Hoyer lifts, leading to an incident where a resident was injured during a transfer. Additionally, nurses lacked competencies for respiratory equipment, resulting in incorrect AVAP settings for a resident with respiratory failure. The facility had no documented competencies for these skills.
The facility was found to have deficiencies in maintaining a clean kitchen environment and safe food handling practices. Missing temperature and sanitizer log entries, calcified build-up on the ice machine, and a dirty floor were noted. Additionally, expired orange juice was served, and improper hand hygiene was observed during food preparation.
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by disrepair in residents' rooms and an overfilled sharps container. Observations included loose baseboards, damaged walls and doors, and protruding needles from a sharps container. Staff acknowledged these issues, indicating lapses in maintaining a safe environment.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential negative outcomes. A resident with mental health diagnoses had incorrect PASARR Level II documentation, while two residents were inaccurately documented as having active pneumonia despite resolution. The CRN confirmed these coding errors.
The facility failed to develop comprehensive care plans for four residents, leading to potential negative outcomes. A resident with a fractured pelvis did not have oral care documented, while another with dementia had no care plan addressing the condition. A third resident's care plan omitted TED hose use for edema, and a fourth resident's frequent diarrhea was not addressed. The Administrator and CRN acknowledged these omissions.
The facility failed to update care plans for three residents, leading to outdated interventions that did not reflect their current needs. One resident required a two-person assist after a fall, but the care plan was not updated. Another resident's care plan still included hospice services after they were no longer needed. A third resident's care plan was not individualized, remaining a template without specific goals or interventions.
The facility failed to ensure meals were palatable and at correct temperatures, affecting residents' nutritional status. Residents reported cold and unappetizing food, and a tray test showed gravy and scrambled eggs below the required temperature. The Dietary Manager acknowledged the non-compliance.
The facility failed to maintain infection control practices, including inadequate hand hygiene assistance, improper PPE use, and poor storage of medical equipment. Staff did not consistently change gloves or perform hand hygiene during care, and equipment was not cleaned after use. These deficiencies increased the risk of cross-contamination and infection among residents.
The facility failed to provide the required Advance Beneficiary Notice (ABN) to two residents after their Medicare A benefits ended, and a Notice of Medicare Non-Coverage (NOMNC) was signed late by another resident. This oversight could lead to financial harm or distress for the residents involved.
The facility failed to ensure resident privacy and confidentiality, as a computer with resident information was left open on an unlocked medication cart, and a resident did not receive privacy during medical procedures. Additionally, mail was not delivered to residents on Saturdays, despite being received by the facility.
A facility failed to review a resident's hospital discharge instructions upon readmission, resulting in the absence of physician orders for a foley catheter, its care, or removal. The resident, with osteomyelitis and diabetes, had hospital orders for bladder training and catheter discontinuation, but these were not documented in the facility's records. Staff acknowledged the oversight, confirming the resident had a catheter upon readmission.
A facility failed to provide appropriate restorative nursing services to a resident with a history of a tibia fracture and need for personal care assistance. The resident's ability to walk was documented as declining from 150 feet with touch assistance to not attempting 10 feet due to medical or safety concerns. A staff member confirmed the resident was not on a restorative program, which was necessary to maintain or improve his functional ability.
The facility failed to notify the physician of significant weight loss in three residents, each with multiple diagnoses including dementia and kidney failure. Despite care plans directing staff to inform the physician of weight changes, there was no documentation of such notifications. A CRN confirmed that the physician should have been notified, highlighting a lapse in following care plan directives.
The facility failed to provide the required 12 hours of in-service education for a CNA and did not conduct annual performance evaluations for two CNAs. One CNA had only 6 hours of training for 2022-2023 and none for 2023-2024, while both CNAs lacked documentation of annual evaluations. The HR/Payroll coordinator and Administrator acknowledged these oversights, which increased the risk for harm to residents.
The facility did not update the nurse staffing information daily as required. On a morning observation, the Daily Staffing form was found to be two days old, and the Administrator confirmed it should have been updated every morning.
A resident was prescribed Risperdal without a documented medical necessity, contrary to the facility's policy that psychoactive drugs should only be used for specific conditions. The resident's care plan noted the use of antipsychotic medications for dementia with agitation and distress, but behavioral episodes were resolved with reassurances. A CRN later indicated that dementia was not an appropriate diagnosis for Risperdal, suggesting the medication should have been discontinued or properly justified.
The facility failed to ensure proper storage and labeling of medications, affecting three residents and a medication cart. Medications were found in residents' rooms without proper orders or assessments, and the medication cart contained improperly labeled and loose tablets. These issues indicate non-compliance with the facility's Medication Management policy.
A resident with lactose intolerance and gluten sensitivity was not provided with appropriate meals, leading her family to bring food from outside. The facility served meals containing gluten and lactose, and when the resident complained, she was given a grilled cheese sandwich, which was unsuitable. The culinary manager admitted that dietary notes were not properly monitored.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was initially assessed by the interdisciplinary team to determine if it was safe for the resident to self-administer medications before doing so, as required by the facility’s Self-Administration of Medications policy dated 11/28/17. That policy specified that the interdisciplinary team must determine safety for self-administration, decide who is responsible for storage and documentation of drug administration and the location of administration, and document these determinations in the medical record and care plan. Surveyors found that these required assessments and documentation steps were not completed. The resident involved had been admitted with multiple diagnoses, including metabolic encephalopathy and acute respiratory failure with hypoxia. During observation, the resident was noted to have OTC Refresh eye drops on the overbed table and stated that the drops were kept in the room for use when needed. Review of the medical record and care plan showed no assessment for self-administration of medications and no documentation authorizing self-administration. In an interview, the RN Clinical Resource Nurse confirmed that the resident should not have Refresh eye drops in the room and had not been assessed for self-administration of that medication.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure residents' call lights were within reach as required by its "Call Light Response Time" policy, revised 10/15/22, which states that call light systems are expected to be available and within reach at the bedside and in toileting and bathing areas. For one resident with multiple diagnoses including unspecified psychosis and muscle weakness, surveyors observed her sitting at her side table in the middle of her room eating breakfast while her call light was tied around the nightstand drawer handle behind her next to the bed, out of her independent reach. A CNA confirmed that this resident's call light should have been within reach and was not. Another resident, admitted with multiple diagnoses including hemiplegia and diabetes, was observed reclining in bed with his call light placed on the bedside table to the left side of the bed, which he stated he could not reach after staff had assisted him with cares. A CNA confirmed that this resident's call light also should have been within reach and was not. The CNO further stated that resident call lights should be within residents' reach and acknowledged that in these instances they had not been.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a timely Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) to a resident receiving Medicare Part A skilled services. Record review showed the NOMNC for Resident #81 stated that coverage for current SNF services would end on 11/18/25, but the form was signed by both the resident and the resident’s representative on 11/17/25, not 48 hours prior to the end of covered services as required. Social Services documentation on 11/17/25 indicated that the resident’s daughter was informed via telephone about the NOMNC and the last covered day of 11/18/25. The CEO confirmed that the NOMNC should have been signed 48 hours before the end of skilled nursing coverage and acknowledged that this did not occur. Resident #81 had been admitted with multiple diagnoses, including post-surgical repair of a left femur fracture and muscle weakness, and was receiving skilled nursing facility services under Medicare Part A at the time the deficient notification occurred. The surveyors determined that this failure to provide timely NOMNC had the potential to cause financial harm or distress to residents by not informing them of their potential liability for payment when Medicare Part A benefits ended.
Failure to Maintain Clean and Safe Dining Room Ceiling Vents
Penalty
Summary
The facility failed to honor residents' right to a safe, clean, comfortable, and homelike environment by not maintaining clean dining room ceiling vents. On 3/2/26 at 12:22 PM, surveyors observed two large dining room ceiling vents with brown, hairy-like debris covering approximately one-third of the inside of each vent, and a small strip of red, confetti-like paper in one of the vents. On 3/2/26 at 12:23 PM, surveyors also observed brown/black discoloration on the ceiling around other dining room ceiling vents. At 12:34 PM on the same day, the CEO acknowledged that the vents should have been cleaned and confirmed that they had not been cleaned, supporting the finding that the facility did not ensure a safe and clean environment in the dining area.
Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to a resident or the resident's representative when the resident was transferred to the hospital. Policy review showed the facility's "Discharge or Transfer" policy, revised 8/30/25, required that the resident, the resident's representative (if any), and the State Long-Term Care Ombudsman receive written notice at least 30 days before a transfer or discharge, except when urgent medical needs require an immediate transfer. The facility's "Bed-Hold" policy, revised 9/9/25, required that written information about bed-hold policies be provided to residents prior to and upon transfer for absences such as hospitalization or therapeutic leave. Record review and staff interview revealed that a resident admitted with multiple diagnoses including diabetes, heart failure, and cirrhosis was transferred to the ER on 9/22/25 and again on 2/8/26, and on both occasions the medical record lacked documentation that a written Notice of Transfer or bed-hold policy was provided. The RN Clinical Resource Nurse confirmed on 3/3/26 at 4:00 PM that they could not locate the Notice of Transfer or bed-hold documentation for either ER transfer. The deficient practice was identified for 1 of 2 residents reviewed for transfers and was determined to have the potential to create psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure baseline care plans were developed and completed within 48 hours of admission, as required by facility policy. The facility’s Baseline Care Plans policy, revised 10/15/22, states that a baseline plan of care is to be developed within 48 hours of admission to address the immediate needs of residents and used/updated until a comprehensive care plan is implemented. For one resident with end stage renal disease and acute respiratory failure with hypoxia, the baseline care plan was initiated on 2/2/26 but was not locked or completed until 2/3/26, which exceeded the 48-hour requirement. The RN Clinical Resource Nurse and the CNO both stated that a baseline care plan is not considered completed until it is locked, and the RN Clinical Resource Nurse acknowledged that this resident’s baseline care plan had not been completed within 48 hours and should have been. A second resident, who had diagnoses including necrotizing fasciitis and diabetes with diabetic polyneuropathy, was also found to have a baseline care plan completed outside the required timeframe. A closed record review showed that this resident’s baseline care plan was not completed until 12/29/25, which was 5 days after admission. The RN Clinical Resource Nurse stated that the baseline care plan for this resident should have been created within 48 hours of admission and had not been. These findings demonstrate that for 2 of 3 residents reviewed for baseline care plans, the facility did not complete the baseline care plans within the 48-hour timeframe specified in its own policy, resulting in care plans that did not provide timely direction for care.
Care Plan Not Updated to Reflect Physician-Ordered Edema Interventions
Penalty
Summary
The facility failed to ensure an existing care plan was revised to reflect current physician-ordered interventions for a resident with acute and chronic respiratory failure and other breathing abnormalities. The resident, who reported that his left arm had been swollen "for a while," had a physician order dated 9/16/25 for a compression glove to the left hand and a Tubi grip sleeve to the left arm from wrist to shoulder to be applied every day and night shift for edema. On multiple observations, the resident was seen sitting in his room without the ordered compression glove and Tubi grip sleeve in place. Review of the resident’s care plan showed no documentation regarding the compression glove or Tubi grip sleeve, despite the active physician order. The RN Clinical Resource Nurse acknowledged that the care plan should have been updated when the physician orders for these edema interventions were received and that it had not been updated.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurate and posted daily for each shift. During an observation on 3/3/26 at 1:50 PM, the surveyor reviewed the Daily Staffing sheets for the period from February 2025 through July 2025 and noted that the name of the facility and the LPN hours were not listed on any of these sheets. On 3/4/26 at 10:35 AM, the CEO confirmed that the LPN hours and the facility name should have been included on the daily staffing sheets for that entire period but were not. This deficiency affected the accuracy and completeness of the posted staffing information available for review by residents, their representatives, visitors, and others.
Failure to Maintain Dual Nurse Signatures on Narcotic Accountability Sheets
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications by not completing required dual nurse signatures on narcotic accountability sheets for two medication carts. On the 400 Hall medication cart audit conducted on 3/3/26 at 8:52 AM, the narcotic accountability sheet dated 3/2/26 to 3/3/26 was missing one licensed nurse signature for 3/3/26, and the RN interviewed confirmed that two nurses should have signed the sheet. On 3/4/26 at 8:44 AM, during the 100 Hall medication cart audit, narcotic accountability sheets dated 2/6/26 to 2/12/26, 2/13/26 to 2/20/26, and 3/1/26 to 3/3/26 were found to be missing one licensed nurse signature on multiple dates (2/11/26, 2/12/26, 2/13/26, 2/19/26, and 3/3/26). An RN and the CNO both stated that two nurses were required to sign the narcotic accountability sheets when accepting or releasing the medication cart, but this had not occurred as required, creating the potential for undetected misuse and/or diversion of controlled medications for all residents receiving these medications. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency pertained to the facility’s medication accountability process for controlled substances affecting all residents who received controlled medications.
Lack of Indication and Duration for Antibiotic Bladder Irrigation Order
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when reviewing facility policies, medical records, and staff interviews. The facility’s Physician/Providers Orders Policy required each medication order to include the resident’s name, drug name and strength, indication or diagnosis, dosage, frequency, route, duration, and any required monitoring parameters. The Unnecessary Medications Policy required that each resident’s medication regimen be free from unnecessary medications, including those prescribed without adequate indications for use or without appropriate monitoring. For one resident admitted with multiple diagnoses including lumbar spinal stenosis and neurogenic bladder, a physician order dated 9/22/25 prescribed Gentamicin Sulfate irrigation, 400 mg every day and night shift, with instructions to inject 60 cc of solution into the bladder via Foley catheter, clamp for 30 minutes, then unclamp. This order did not document an adequate indication or diagnosis for the Gentamicin use and listed the duration as indefinite. During an interview on 3/3/26 at 1:37 PM, the ACNO acknowledged that the Gentamicin order should have included an indication for use and a duration but did not, confirming noncompliance with the facility’s own policies. The report stated this failure had the potential to cause significant harm if the resident were to develop antimicrobial resistance or toxicity.
Expired and Unsecured Medications Found in Storage Room and Medication Cart
Penalty
Summary
The deficiency involves failure to ensure medications were not expired and were stored securely and inaccessible to unauthorized staff and residents. Surveyors reviewed the facility’s Medication Storage & Labeling policy, which required medications to be stored in locked compartments, maintained in clean and sanitary conditions, and for expired or discontinued medications to be promptly removed and disposed of per facility policy and DEA guidelines. During an observation in the medication storage room with an LPN present, surveyors found multiple expired items, including three bottles of Rena Vite 100 tablets, two bottles of Melatonin 1 mg, one bottle of Multi Vitamin 1000 tablets, one bottle of Pro Stat Liquid Protein 30 ounces, and two bottles of anti-dandruff shampoo with Selenium Sulfide 1%, all with manufacturer expiration dates that had passed. The CNO acknowledged that these expired medications should have been removed from the medication storage room and had not been. Additional observations showed that a medication cart on the 100 Hall was left unlocked and unattended, with multiple staff members walking by without addressing the unsecured cart. An RN later approached the cart and stated it should not have been left unlocked when unattended, and the CNO confirmed the cart should not have been left unlocked when the nurse left it. A subsequent audit of the same medication cart with the RN present revealed loose, unidentified pills in the bottom of two drawers, including various capsules and tablets, as well as a bottle of Multi Vitamin with an expired manufacturer date. Both the RN and the CNO stated that pills should not have been loose in the medication cart, that the drawers should have been cleaned to remove loose pills, and that the loose pills should have been destroyed.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
Surveyors identified a deficiency in food storage, labeling, and equipment cleanliness in the facility’s kitchen based on the FDA Food Code, facility policy, observation, and interview. Ready-to-eat, time/temperature control for safety foods were required by the FDA Food Code and the facility’s Food Safety & Storage policy to be clearly labeled with preparation and use-by dates when held longer than 24 hours. During observation of the walk-in refrigerator, surveyors found 11 individual salads dated for the previous day that remained in storage beyond their intended use date. In the walk-in freezer, chocolate pieces were observed on a cookie sheet that was not covered, labeled, or dated, contrary to policy requirements that opened or repackaged food and food removed from original packaging be labeled with contents and use-by or expiration dates. Surveyors also found deficiencies related to equipment and environmental cleanliness. The clean pots and pans storage rack contained muffin pans with encrusted buildup on both the front and back surfaces, in violation of FDA Food Code requirements that food-contact surfaces of cooking equipment and pans be kept free of encrusted grease deposits and other soil accumulations. Additionally, the drain hole under the food prep sink had a split grate covered in black dirt and grime-like substance extending onto the surrounding floor tiles, and the floor areas underneath the counters, handwashing sink, and food prep sink where the floor and wall met had a thick layer of dirt, food, and grime. These conditions were confirmed by the Certified Food Manager (CFM) and Dietician during interviews.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control practices during medication administration, contrary to the facility’s Medication Administration policy that requires staff to remove medications from storage without directly touching them. Resident #60, admitted with diagnoses including COPD and diabetes, had physician orders for fifteen morning medications, including Colace 100 mg by mouth. During a medication pass observed on 3/4/26 at 8:30 AM, RN #3 placed all fifteen medications into a medication cup and brought them into the resident’s room. When Resident #60 stated she did not want the Colace, RN #3 removed the Colace capsule from the medication cup using her ungloved finger before handing the remaining medications to the resident. During an interview at 8:37 AM the same day, RN #3 acknowledged she should have used a spoon or donned gloves to remove the Colace from the medication cup and had not done so. Later that afternoon, the CNO confirmed that RN #3 should not have used her ungloved finger to remove the medication from the cup. These observations and interviews demonstrated that the facility failed to maintain infection control practices as required by its own policy during medication administration for Resident #60.
Failure to Maintain Clean and Homelike Environment and Properly Clean Shared Equipment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment for all residents, particularly those transferred with Hoyer lift equipment. Multiple observations revealed unclean conditions, including sticky substances on over-bed tables, dried black and brown substances on commodes, and trash cans containing soiled briefs and dirty wipes left in resident rooms. Additionally, resident care items such as wheelchairs were found with dried substances and odors, and supplies like briefs were stored on the floor. Staff interviews confirmed that cleaning protocols, such as removing trash after each brief change and cleaning wheelchairs twice weekly, were not consistently followed, and there was no documentation to verify that these tasks were completed. Further observations showed that shared equipment, specifically Hoyer lift crossbeam pads, were visibly dirty with whitish, brown, and black marks. Staff members, including CNAs and LPNs, were unsure about the cleaning schedules or procedures for these items. The Director of Nursing and other staff acknowledged that cleaning and storage practices were not in line with facility policy, which requires proper cleaning and disinfection of multiple-use resident care items between each use. These lapses in cleaning and maintenance created the potential for cross-contamination and did not meet the standards for a safe and homelike environment.
Care Plan Not Updated After Fall Incident
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current needs and interventions following a fall incident. Specifically, after a resident with multiple diagnoses, including acute osteomyelitis and adult failure to thrive, experienced a fall while leaning forward in a wheelchair to reach food and drink, the interdisciplinary team (IDT) assessed the situation and recommended that staff ensure the resident's food and drink be placed closer to him in the dining room. However, this recommendation was not incorporated into the resident's care plan fall prevention interventions. Record review, policy review, and staff interview confirmed that the care plan was not updated to include the IDT's recommendations after the fall. The facility's policy required that a person-centered plan of care be developed and revised by the interdisciplinary team to address falls and prevent future occurrences. The Director of Nursing acknowledged that the care plan had not been updated as required.
Medications Improperly Stored in Resident Room
Penalty
Summary
A deficiency occurred when a medication cup containing a purple substance with multi-colored specks and a spoon was observed on the bedside table of a resident who had been admitted with chronic obstructive pulmonary disease and hypertension. The resident did not have an order to self-administer medications, nor was self-administration documented in the care plan. During staff interviews, an RN confirmed that the resident should not have had medications left in the room, and the Director of Nursing stated that residents should not have medications left in their rooms. This indicates that medications were not stored appropriately as required.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to enhanced barrier precautions (EBP) protocols when providing care to a resident with multiple diagnoses, including acute cystitis and dysphagia. During observation, a CNA assisted the resident with a transfer from bed to wheelchair and then to the shower room, as well as with showering, without donning the required gown and gloves, despite an EBP sign on the resident's door instructing staff to wear this personal protective equipment during such activities. The CNA stated she believed gown and gloves were only necessary when assisting with catheter care. Another CNA confirmed that the EBP sign indicated staff should wear gown and gloves for bathing, transferring, and catheter care. The DON also stated that staff were expected to wear gloves and gowns when providing care to residents with EBP signage.
Improper Storage and Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper storage and use of Hoyer lift equipment, resulting in harm to a resident. The Space and Equipment policy, revised on 12/4/19, required that resident care equipment be stored out of egress areas while maintaining availability. However, on 12/17/24, a Hoyer lift was observed being stored in a resident's room, creating a potential fall hazard. The CRN confirmed that Hoyer lifts should not be stored in residents' rooms. This improper storage practice contributed to an incident involving a resident. The resident, who had multiple diagnoses including necrosis of the left femur and dementia, was injured during a Hoyer lift transfer on 6/26/24. The incident report documented that the lift tipped over, causing a laceration to the resident's head and bruising on the cheek. A nursing note indicated that CNA #2 used an improper technique during the transfer, leading to the accident. The resident required hospital treatment, receiving three staples to close the scalp laceration. The CRN stated that all CNAs should have been properly trained and had competencies completed on safe Hoyer lift transfers before use.
Deficiencies in CNA and Nurse Competencies for Equipment Use
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) were trained and had documented competencies to operate the facility's Hoyer lifts. This deficiency was highlighted when a Hoyer lift tipped over during a transfer of a resident with multiple diagnoses, including necrosis of the left femur and dementia, resulting in a laceration to the head and bruising on the cheek. Interviews with CNAs revealed that they had not been competency tested on the Hoyer lift at the facility, despite some having received training elsewhere. The facility's Competency Verification of Nursing Staff policy required completed competencies to be documented, but this was not adhered to prior to a specified date. Additionally, the facility did not ensure that licensed nurses had the appropriate competencies and skills to provide respiratory-related services. A resident with heart failure and respiratory failure reported issues with their AVAP machine, including difficulty breathing and discomfort due to cold air. Observations confirmed incorrect AVAP settings and an inactive humidifier. An LPN admitted to only being trained to turn the AVAP on and off and assist with the mask, lacking knowledge on operating the humidifier. The facility had no documented competencies or training for the AVAP machine for nursing staff.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by several observations during a kitchen inspection. The temperature log for the dish machine and the sanitizer log were missing recorded entries for specific dates, and the Culinary Manager (CM) was unaware of the reason for these omissions. Additionally, the ice machine had a significant amount of calcified water build-up, and the CM did not know the cleaning schedule for the machine, indicating a lack of proper maintenance. The floor between the kitchen and dishwashing area was observed to have a layer of dirt and grime, and the CM attributed this to a loose threshold, while the Administrator acknowledged the need for cleaning but cited the need for appropriate cleaning chemicals. Food handling practices were also found to be deficient. An RNA was observed pouring expired orange juice into cups for residents and admitted that the kitchen should not have sent out expired juice. The RNA also inadvertently placed her fingers inside the cups while serving, which was acknowledged as inappropriate by both the RNA and the CM. Furthermore, a cook was seen cracking raw eggs on a grill with both gloved and non-gloved hands, sometimes failing to wash hands before handling ready-to-eat foods. The cook and CM both recognized the need for handwashing after handling raw foods to prevent cross-contamination.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by several observations of disrepair and unsafe conditions. In one instance, a loose baseboard was observed in a resident's room, and the resident confirmed that it had been in that condition for some time. Additionally, multiple rooms were found with significant damage to walls and doors, including holes and deep gouge marks with missing paint. These issues were acknowledged by the Maintenance Director and the Administrator, who stated that repairs should be made when reported or when a resident moves out. Furthermore, a sharps container in a resident's bathroom was found to be overfilled, with needles protruding from the top. An LPN and the CRN both acknowledged that the sharps container should have been changed sooner, indicating a lapse in maintaining a safe environment. These observations highlight the facility's failure to adhere to its policy of maintaining a sanitary, orderly, and comfortable interior, potentially compromising the dignity and safety of its residents.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could lead to negative outcomes due to inaccurate assessments. Resident #27, who was diagnosed with depression, bipolar disease, and schizophrenia, had a PASARR Level II completed on 10/12/18. However, the MDS assessments dated 2/20/23, 1/4/24, and 11/11/24 incorrectly documented that there was no completed PASARR Level II. The Clinical Resource Nurse (CRN) confirmed that these sections were coded incorrectly and should have been marked as 'yes'. Additionally, Resident #41, with diagnoses including heart failure and diabetes, was incorrectly documented as having an active diagnosis of pneumonia in the MDS assessments dated 7/24/24, 8/19/24, and 11/4/24, despite the pneumonia having resolved. Similarly, Resident #52, who had chronic venous insufficiency and other conditions, was also incorrectly documented as having an active diagnosis of pneumonia in the MDS assessments dated 8/21/24 and 11/6/24, even though the pneumonia had resolved. The CRN confirmed these inaccuracies in the MDS coding for both residents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to potential negative outcomes. Resident #33, admitted with a fractured pelvis and requiring assistance with personal care, did not have oral care documented in her care plan, and there was no record of her receiving oral care or seeing a dentist. Resident #34, diagnosed with dementia and kidney failure, had no care plan addressing dementia, and the multidisciplinary care conference did not document any reference to this condition. Resident #220, with a right tibia fracture and end-stage renal disease, had physician's orders for TED hose to manage edema, but this was not included in the care plan. Resident #226, suffering from irritable bowel syndrome with diarrhea and polyneuropathy, reported frequent diarrhea, yet his care plan did not address these issues. The facility's failure to include these critical aspects in the residents' care plans was acknowledged by the Administrator and CRN, indicating a lack of comprehensive planning for the residents' needs.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were revised to reflect their current needs and interventions, as evidenced by the cases of three residents. Resident #1, who was initially admitted with a fracture of the lower end of the left tibia and required assistance with personal care, experienced a fall and subsequently required a two-person assist when toileting. However, the care plan, dated several months prior, still documented the need for extensive assistance with one to two staff, and was not updated to reflect the change in assistance required. Similarly, Resident #33, who was admitted with a fracture of the pelvis and required assistance with personal care, had a care plan that included hospice staff providing a shower or bed bath once a week. After coming off hospice, the care plan was not updated to reflect this change. Resident #226, admitted with irritable bowel syndrome with diarrhea and polyneuropathy, had a care plan initiated that did not document any individualized focus, goals, or interventions. The care plan was left as a template and not tailored to the resident's specific needs. The facility's policy required care plans to be revised quarterly, annually, with significant changes, or more frequently as needed, but this was not adhered to, placing residents at risk of adverse outcomes due to outdated care plans.
Failure to Maintain Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that resident meals were palatable and maintained at the correct temperatures, as required by the 2022 FDA Food Code. This deficiency was identified through observations and interviews with residents and staff. Three residents reported that their meals were often cold, with one resident describing the cream of wheat as a lump and another stating the food was soggy. A tray from the last meal cart delivered on the 200 hall was tested, revealing that the gravy was at 120 degrees F and scrambled eggs were at 115 degrees F, both below the required 135 degrees F. The Dietary Manager confirmed that these temperatures were not in compliance with the standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by several observations. Staff did not consistently assist residents with hand hygiene before meals, as seen when a resident was served a meal without being offered hand hygiene. Additionally, during incontinent care, CNAs did not change gloves or perform hand hygiene between tasks, increasing the risk of cross-contamination. Enhanced Barrier Precautions were not adhered to, with staff entering rooms without donning appropriate PPE, despite signage indicating the need for gowns and gloves. Improper storage of medical equipment was also noted, with oxygen supplies and bed pans being stored on the floor, contrary to infection control policies. Equipment such as a sit-to-stand device was not cleaned after use, and medication administration practices were compromised when a nurse used her bare finger to handle a resident's medication. These lapses in infection control practices had the potential to impact all residents by increasing the risk of cross-contamination and infection.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the required Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) to residents, which are essential for informing them of their potential financial liability when Medicare Part A benefits end. Specifically, two residents, one with a left femur fracture and traumatic brain injury, and another with dementia and kidney failure, did not receive the ABN after their Medicare A benefits ended, despite continuing their stay in the facility. This oversight was identified through a Skilled Nursing Facility Beneficiary Notification Review, which documented the end of their Medicare A benefits. Additionally, another resident with a urinary tract infection and chronic obstructive pulmonary disease signed the NOMNC after their Medicare A benefits had already ended, rather than 48 hours prior to the end of covered skilled nursing services as required. The facility administrator confirmed the absence of the ABNs for the two residents and acknowledged the timing error in the NOMNC for the third resident. These deficiencies in providing timely and appropriate beneficiary notifications could lead to financial harm or distress for the residents involved.
Failure to Maintain Resident Privacy and Timely Mail Delivery
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information. During an observation on hall 400, a computer on top of a medication cart was left open with resident information visible, and the medication cart was unlocked with keys left in the lock. RN #1 acknowledged that she should have closed the computer screen, locked the cart, and taken the keys with her. Additionally, RN #1 did not provide privacy for Resident #53 during a lab draw and insulin administration, as she left the door open while performing these tasks. Resident #53 had multiple diagnoses, including osteomyelitis and diabetes. Furthermore, the facility did not ensure timely delivery of mail to residents. During a Resident Council meeting, residents reported that mail was not delivered on Saturdays. The Administrator confirmed that while mail was delivered to the facility on Saturdays, it was not distributed to the residents. This failure to deliver mail in a timely manner affected all residents who receive mail at the facility.
Failure to Review Hospital Discharge Instructions for Foley Catheter
Penalty
Summary
The facility failed to ensure that a resident's hospital discharge instructions were reviewed upon readmission to assure physician orders were in place to meet their medical needs. This deficiency involved a resident with multiple diagnoses, including osteomyelitis of the right ankle and foot and diabetes, who was readmitted to the facility. The hospital discharge orders included instructions for bladder training and discontinuation of a foley catheter when able. However, upon review, the facility's physician orders did not document an order for the foley catheter, its care, or its removal. Additionally, the resident's progress notes and care plan lacked documentation regarding foley catheter care or removal. A CRN acknowledged the absence of the foley catheter order in the facility's records, and the MDS Coordinator confirmed the resident had a catheter upon readmission.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the ability of a resident to carry out activities of daily living. This deficiency was identified for one resident who was not included in a restorative nursing program despite having a medical history that included a fracture of the lower end of the left tibia and a need for assistance with personal care. The resident's Annual MDS indicated he could walk 150 feet with touch assistance, but the Quarterly MDS later documented that walking 10 feet had not been attempted due to medical condition or safety concerns. A staff member confirmed that the resident was not on a restorative program, although he should have been, which placed him at risk for decreased range of motion and functional ability.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss in three residents, which is a deficiency in care. Resident #34, who was admitted with diagnoses including dementia and kidney failure, experienced a weight loss of 9.58% over a 15-day period. Despite the care plan's directive to notify the physician of weight changes, there was no documentation that this was done. Similarly, Resident #59, with diagnoses of kidney failure and nutritional deficiency, lost 11.14% of his weight over approximately two months. The care plan required notification of the physician and registered dietitian for significant weight changes, but the medical record lacked evidence of physician notification. Resident #62, also diagnosed with dementia and kidney failure, experienced a 12.99% weight loss over a period of about six weeks. Again, there was no documentation that the physician was informed of this significant weight loss. In all three cases, the Certified Registered Nurse (CRN) confirmed that the physician should have been notified of the residents' significant weight losses, indicating a lapse in following the care plan directives and ensuring proper medical oversight.
Deficiency in CNA Training and Evaluation
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of in-service education per year for one of two Certified Nursing Assistants (CNAs) reviewed, specifically CNA #1. CNA #1, hired on February 1, 2022, had only completed 6 hours of in-service training for the 2022-2023 period and had no documented training hours for 2023-2024. Additionally, the facility did not ensure that each CNA's performance was evaluated at least once every 12 months. Both CNA #1 and CNA #4, whose personnel records were reviewed, lacked documentation of annual performance evaluations. CNA #4 was hired on June 17, 2023, and also did not have an annual evaluation completed. The HR/Payroll coordinator and the Administrator acknowledged these oversights, indicating that the training and evaluations should have been completed. This deficiency created the potential for incompetent CNAs providing care and increased the risk for harm to all residents living in the facility.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurate and posted daily for each shift. This deficiency was identified through observation and staff interviews. On the morning of December 16, 2024, it was observed that the Daily Staffing form displayed was dated December 14, 2024, indicating that the staffing information had not been updated for two days. During an interview, the Administrator acknowledged that the Daily Staffing form should have been updated every morning.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure the medical necessity for the administration of psychotropic medication for a resident. The facility's policy on psychoactive drug use, revised on 10/15/22, states that such drugs should only be used when necessary to treat a specific condition. However, a resident was prescribed Risperdal, an antipsychotic medication, without a documented medical symptom or basis for its use. The resident's Acknowledgement of Psychoactive Medication Use form for Risperdal did not specify the medical symptom being treated. A Pharmacy Medication Regimen Review form later documented the prescription of Risperdal for major depressive disorder, while a physician order dated 4/3/24 indicated its use for dementia with agitation and distress. The resident's care plan noted the use of antipsychotic medications for dementia with agitation and distress, demonstrated by delusions and yelling out. Behavioral documentation from June to December 2024 recorded episodes of delusions, all of which were resolved with reassurances or allowing the resident to rest. On 12/19/24, a CRN stated that dementia was not an appropriate diagnosis for the use of Risperdal, suggesting that the medication should have been discontinued or a proper diagnosis should have been provided. This oversight created the potential for negative side effects from unnecessary psychotropic medication use.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored appropriately and properly labeled, affecting three residents and one medication cart. In one instance, a tube of Calcipotriene ointment belonging to a discharged resident was found in another resident's bathroom. Another resident had a bottle of Tums on her bedside table without a documented order or self-administration assessment. Additionally, a tube of generic brand hemorrhoid ointment was found on a third resident's bedside table without an order. The facility's policy requires a self-administration assessment, an order, and care planning for medications at the bedside, which was not followed in these cases. In the medication cart, deficiencies included a bottle labeled in black marker as Sodium bicarb, which was shared between carts instead of having separate, properly labeled bottles. Loose tablets, including a Tylenol tablet and half a Metoprolol 25 mg tablet, were found on the bottom of the cart drawers. The LPN acknowledged that the tablets should not have been there and that the sodium bicarbonate should have been in a properly labeled bottle. These observations indicate a failure to adhere to the facility's Medication Management policy and proper medication storage protocols.
Failure to Accommodate Dietary Needs for Resident with Intolerances
Penalty
Summary
The facility failed to accommodate the dietary needs of a resident with lactose intolerance and gluten sensitivity. The resident, who was admitted with multiple diagnoses including surgical aftercare, lactose intolerance, and gluten sensitivity, reported that her family had to bring her food because the facility served her meals containing gluten and lactose. On one occasion, when she complained, the facility provided her with a grilled cheese sandwich, which was inappropriate for her dietary restrictions. The menu for the days in question included items such as coffee cake, cheese croissant sandwiches, and cheese enchiladas, none of which were suitable for a gluten and lactose-free diet. The culinary manager acknowledged that the cooks should have been monitoring dietary notes and that the substitute meal provided was not appropriate for the resident's needs.
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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