Ironwood Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coeur D'alene, Idaho.
- Location
- 2200 Ironwood Place, Coeur D'alene, Idaho 83814
- CMS Provider Number
- 135053
- Inspections on file
- 17
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Ironwood Rehabilitation And Care Center during CMS and state inspections, most recent first.
Multiple residents did not receive care according to physician orders and care plans. One resident with complex medical and psychiatric conditions had an ordered weekly skin assessment missed, and later was found with a widespread red, moist, painful rash that the representative had been treating independently with Nystatin powder, which was not on the MAR. Another resident on Sertraline for depression had required every-shift behavior and side-effect monitoring incompletely documented over several months, and multiple doses of the antidepressant were not administered as ordered. A third resident on antipsychotic and antidepressant therapy had required every-shift behavior and side-effect monitoring that was frequently not recorded. Additionally, a resident with Parkinson’s disease and diabetes went five days without a bowel movement, and the ordered stepwise bowel protocol, including PRN laxatives and enemas after three days without a BM, was not implemented.
The facility did not maintain a safe, comfortable, and homelike environment, as evidenced by two residents with dementia and other comorbidities living in rooms with multiple wall holes, chipped drywall, missing paint, and water-stained ceilings, and by extensive uneven flooring in two main halls. Observations showed numerous divots, chipped areas around drainage covers, and partially filled floor defects near the nurses' station and along the East and South halls. A resident reported wheelchairs becoming stuck in these floor ruts, and maintenance staff confirmed both the room damage and the lack of flush flooring around drains, as well as the absence of a current repair plan.
A resident with Down Syndrome and chronic respiratory failure with hypoxia was observed receiving wound care to the buttocks from an RN assisted by a CNA, while another RN cleaned the resident’s penis, without the window curtain being drawn to ensure privacy. The resident was visible to the outside during these intimate cares. When interviewed afterward, the RN providing the wound care stated he had not noticed the curtain was open and acknowledged it should have been closed to provide privacy, resulting in a failure to maintain the resident’s dignity and respect.
Surveyors determined that a resident with multiple complex conditions, including quadriplegia, emphysema, and sleep apnea, was self-administering a prescribed Proventil HFA (albuterol) inhaler kept at the bedside without a documented self-administration of medication assessment. Record review confirmed the absence of the required assessment, and the DON acknowledged that the resident should not have been self-administering medication without it. This failure created the potential for harm if the resident took too much or too little of the inhaled medication or experienced adverse effects such as oral thrush.
A resident with Down Syndrome and chronic respiratory failure with hypoxia experienced involuntary movements and extreme labored breathing, received O2, and was transferred to the hospital by EMS. Review of the medical record showed no documentation that the required written bed-hold notice specifying the duration of the bed-hold policy was provided to the resident or the resident’s representative at the time of transfer, and an RN confirmed she could not locate any such documentation. This deficiency was identified for one of three records reviewed and was determined to create the potential for psychosocial distress if the resident could not return after hospitalization.
A resident with multiple conditions, including a tibia fracture, CVA, unsteadiness, need for assistance with personal care, and generalized muscle weakness, had a physician order for 5 oz of wine daily PRN. Facility policy required the IDT to develop a comprehensive person-centered care plan with measurable objectives and timeframes, including all needs identified in the assessment and necessary healthcare information. Review of the resident's care plan showed that the ordered wine use was not included, and the DON confirmed that this intervention was not care planned despite the existing order.
Medication administration and ordering did not meet professional standards when an LPN incorrectly held an antihypertensive despite the BP parameter, disposed of an unadministered tablet in a resident’s room trash instead of using approved disposal methods, and failed to instruct a resident to rinse their mouth after a Breyna inhaler as ordered. Additionally, two PRN bowel medications for a resident with a colostomy were ordered for rectal administration, even though, according to an RN, this resident could not receive medications rectally.
A resident who was cognitively intact and dependent on staff for part of bathing, with a history of stroke-related hemiplegia/hemiparesis, diabetes, dysphagia, and dysarthria, was care-planned to receive two morning showers per week but reported only receiving one. Review of ADL and bathing flowsheets showed a 14-day gap between documented showers, with multiple scheduled shower days missed and no documentation of refusals. Nursing notes contained no evidence that the resident declined bathing, and the DON confirmed that neither scheduled nor PRN showers were provided on the missed days.
A resident with COPD, chronic bronchitis, nicotine dependence, depression, anxiety, and a mood disorder was identified by the facility as choosing to smoke, yet the only Smoking Assessment on file incorrectly documented the resident as a non-smoker and was not updated after re-admission. Despite this, the care plan stated the resident was safe to smoke independently, and during observation the resident requested access to cigarettes from a locked nursing cart. The DON and an RN later confirmed that no additional smoking assessments had been completed after the initial one, even though an updated assessment should have been done following re-admission.
A resident with multiple chronic conditions, including emphysema, sleep apnea, and respiratory failure with hypoxia, had physician orders for PRN oxygen and for weekly changes of oxygen tubing, filter cleaning, and water bottle changes. Surveyors observed the resident’s nasal cannula hanging uncovered over the oxygen concentrator, and the resident reported using it the prior night. An LPN stated the cannula should have been stored in a clear bag, and leadership confirmed there were no facility oxygen therapy policies and that staff relied on physician orders. Surveyors also found the resident’s oxygen tubing in use without a date of change, despite documentation that it had been changed, and an LPN acknowledged the tubing should have been dated but was not.
A medication storage deficiency occurred when a medication cart on one nursing unit was left unlocked and unattended. An LPN believed the cart’s timer-based lock had engaged when stepping away, but when attempting to demonstrate that it was locked, a drawer opened, confirming it was unsecured. The LPN reported not knowing the exact timing of the cart’s automatic lock and acknowledged not double-checking its status. The CRN later stated that medication carts are required to be locked whenever staff leave them unattended.
A resident with emphysema, muscle weakness, and a need for assistance with personal care had multiple scheduled medications that were not documented as administered on the MAR over two consecutive days. The MAR entries for midday and bedtime medications on one day and early morning medications on the following day were left blank, with no codes or notations indicating why the medications were not given. The DON later confirmed the resident was in the hospital during this period and stated that nursing staff should have documented this on the MAR and that there should never be blanks on the MAR, resulting in an incomplete and inaccurate medical record.
The facility failed to implement its infection prevention and control program when a nurse provided incontinence and skin care to a resident with chronic conditions without performing hand hygiene between glove changes and while using double gloves, contrary to CDC and facility policy that gloves are not a substitute for hand hygiene. In a separate case, another resident with neurologic deficits and muscle weakness had an IV site with a transparent dressing that remained in place despite visible dried and wet blood beneath it after completion of IV antibiotics, contrary to CDC guidance and facility expectations that soiled IV dressings be changed.
A resident with multiple medical conditions, including a fracture, stroke, unsteadiness, need for assistance with personal care, and generalized muscle weakness, consented to receive a pneumococcal vaccine in accordance with CDC guidance. Despite a facility policy requiring that influenza, pneumococcal, and COVID-19 vaccines be offered and administered to eligible residents after consent, the resident’s record contained no documentation that the pneumococcal vaccine was given. The IP later stated she had misunderstood the information and incorrectly believed the resident was already up to date on pneumococcal vaccination, resulting in the vaccine not being administered and creating a potential for increased risk of pneumococcal pneumonia and severe illness or death.
Two residents experienced abuse and neglect in the facility. One resident, who was deaf, reported a PT threw a soiled bed pan and urinal at her, while another resident was neglected by a NAIT who failed to provide incontinence care despite multiple requests. The facility's investigations confirmed these incidents, highlighting a failure to protect residents' rights.
The facility failed to employ sufficient staff with the necessary competencies and skills in food and nutrition services, impacting resident assessments and care plans. The DM had not completed certification, and the administrator held a food service certificate instead of a degree, potentially affecting all residents needing nutritional therapy.
A facility failed to provide a dignified dining experience for three residents, who received their meals at different times, causing potential psychosocial harm. The delay was due to the facility's meal order process, which did not account for residents' seating arrangements.
The facility did not adhere to its posted mealtime schedule, affecting 69 residents. Lunch service began 35 minutes after residents were seated, and breakfast service started 30 minutes late, with staggered service times for different halls. The DM and RD were unaware of the posted mealtimes, confirming a discrepancy between posted and actual mealtimes, potentially impacting residents' quality of life and medication schedules.
The facility failed to maintain a clean and sanitary kitchen environment, with issues such as undated and unlabeled food items, improper food storage, and significant cleanliness problems. Ice buildup was observed in the freezer, and dirt was found around the AC unit in the refrigerator. The Nutritional Services Director noted that deep cleaning was infrequent, and the maintenance director confirmed that cleaning responsibilities were assigned to kitchen staff. These deficiencies posed a risk to the 69 residents consuming food prepared by the facility.
The facility's Activity Room, used as a Bistro, had inadequate lighting due to missing bulbs and non-functional track lighting. A resident highlighted the issue, and both the Maintenance Director and Activity Director confirmed the problem, noting it affected residents' activities. The Interim DON stated the lighting issue was pending resolution during facility remodeling.
A resident with severe cognitive impairment alleged sexual abuse, but the facility delayed reporting the incident to administration and authorities for almost 14 hours. The facility's policy required immediate reporting, but the delay led to a failure to promptly inform the resident's physician, POA, and the State Agency. A medical examination found no physical evidence of abuse, and the resident later denied being harmed.
A resident with severe cognitive impairment reported an alleged sexual abuse incident, which the facility failed to investigate thoroughly and promptly. The investigation was delayed, and only one staff member was interviewed, while the resident was not assessed for harm until 14 hours later. The facility's Administrator admitted the investigation was incomplete and untimely.
The facility failed to update care plans for two residents, leading to discrepancies between current medical orders and documented care directives. One resident's care plan inaccurately reflected the use of a BiPAP machine, while another's did not include a recent physician's order for regular weight monitoring.
A resident with multiple diagnoses, including diabetes and atrial fibrillation, was observed scratching scabbed sores on her arm, but the facility failed to document a skin assessment or treatment plan. Despite CNAs applying lotion to alleviate itching, the type of lotion was unknown, and there was no record of a skin evaluation or updated care plan, as confirmed by the DON and RCM.
The facility failed to provide podiatry services as ordered for two residents, one with heart disease and cognitive impairment, and another with diabetes and heart disease. Despite physician orders and requests for podiatry care, the facility faced challenges in scheduling appointments due to clinic limitations and insurance issues. Both residents' medical records lacked documentation of podiatry visits, and the facility's policy on podiatry care was not provided during the survey.
A facility failed to document the rationale for continuing PRN alprazolam beyond 14 days for a resident with anxiety. The resident was prescribed Xanax 0.25 mg every 12 hours as needed, but there was no documentation supporting its use beyond the 14-day limit, as required by the State Operations Manual. The facility's Administrator confirmed the absence of a stop date or reason for continuation.
Failure to Follow Physician Orders for Skin, Medication, Behavior, and Bowel Management
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, care plans, and professional standards for multiple residents. One resident with obesity, Parkinson’s disease, cognitive communication deficit, bipolar disorder, and borderline personality disorder had a physician’s order for weekly skin assessments on the evening shift every Tuesday starting 4/21/26. A skin assessment documented no skin issues on 4/21/26, but no skin assessment was completed on 4/28/26 as ordered. On 4/29/26 at 10:35 PM, the resident and representative reported a red rash spreading from under the left lower arm into the abdominal and groin areas, and the representative stated they had been applying Nystatin powder themselves for about three weeks because the facility had not addressed the rash despite multiple requests. On 4/30/26, the surveyor observed a bright red, shiny, moist rash under the arm, in the pannus/apron skinfold, around the back, and into the groin, with the resident reporting itching and pain; the record did not show Nystatin as a current medication, and the DON and RN confirmed the missed weekly skin assessment and that medications are not provided without a physician’s order. Another resident with dementia, cognitive communication deficit, PTSD, and depression had a care plan directing staff to observe for mood changes, behavior changes, social isolation, and fatigue related to antidepressant use and to report signs or symptoms of fatigue related to anemia. Physician orders required staff to monitor antidepressant side effects every shift using a specified numeric scale, monitor episodes of behaviors every shift, and administer Sertraline 100 mg by mouth each morning for depression. Review of the MAR and TAR showed that behavior monitoring was not recorded as ordered on multiple dates across January through April 2026, with numerous missed opportunities each month. The MAR also showed that Sertraline doses were not given on multiple dates in those same months. The CRN stated that staff should have been monitoring and documenting behaviors and medication administration every shift. A third resident with cognitive communication deficit, bipolar disorder, dementia, and depression had a care plan directing staff to observe for mood and behavior changes and fatigue related to antidepressant and antipsychotic use and to report any signs or symptoms. Physician orders required every-shift monitoring of antipsychotic side effects using a numeric scale, every-shift monitoring of antidepressant side effects using another numeric scale, and every-shift monitoring of behavior episodes, along with orders for Aripiprazole 10 mg at bedtime for bipolar disorder and Trazodone 25 mg at bedtime for insomnia. Review of the MAR and TAR showed that behavior monitoring was not recorded as ordered on multiple dates in January through April 2026, with several missed opportunities each month, and the CRN stated staff should have been monitoring and documenting behaviors and medication administration every shift. In addition, another resident with Parkinson’s disease and diabetes had a detailed bowel protocol including daily Polyethylene Glycol and a stepwise PRN regimen of Dulcolax tablets, Milk of Magnesia, Dulcolax suppositories, and Fleet enemas if no bowel movement occurred after three days. The bowel record showed no bowel movement from 4/6/26 through 4/10/26, and review of the MAR showed the resident did not receive the ordered bowel medications during this period; the CRN later confirmed the resident had not received the PRN bowel medications as ordered.
Failure to Maintain Resident Rooms and Hallway Flooring in Safe, Homelike Condition
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment by not maintaining resident rooms in good repair and by allowing uneven flooring in two hallways. One resident with atrial fibrillation and dementia was observed in a room with at least seven holes in the wall over the bed, scattered areas of missing paint on the same wall, and a large area of chipped drywall and missing paint extending approximately 36 inches up from the baseboard next to the bed. Another resident with dementia and a history of stroke was observed in a room with multiple areas of missing paint on the walls by the window and on the east wall, as well as large water stains on the ceiling above the sink. The Maintenance Supervisor confirmed the presence of the holes, missing paint, and water stains in these rooms and acknowledged there were many similar issues and no current plan for repairs or painting. The facility also failed to maintain safe, even flooring in the East and South hallways. Multiple divots were observed throughout these hallways, with drainage covers that were discolored and surrounded by chipped and cracked flooring, creating uneven divots. Additional chipped flooring divots, some partially filled with shellac, were seen near the nurses' station and in both the East and South hallways. A resident reported having seen wheelchairs get stuck in these ruts and unable to move through the hallways. The Maintenance Director confirmed that the flooring was not flush with the drainage covers and that multiple divots were present throughout the East and South hallways.
Failure to Provide Privacy During Intimate Wound Care
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect by not providing adequate privacy during personal care. Resident #50, who had been admitted and readmitted with multiple diagnoses including Down Syndrome and chronic respiratory failure with hypoxia, was observed on 4/30/26 at 1:23 PM receiving wound care to his bottom from RN #2 assisted by CNA #1. During this care, RN #1 was also observed cleaning the resident’s penis. While these intimate cares were being performed, the window curtain in the resident’s room was not drawn, leaving the resident visible to the outside. At 1:42 PM the same day, RN #2 stated he had not noticed that the curtain was not drawn while providing the wound care and acknowledged that the curtain should have been drawn to provide privacy for the resident. This failure to ensure privacy during personal and wound care constituted a lack of dignity and respect for the resident.
Failure to Assess Resident for Self-Administration of Inhaler Medication
Penalty
Summary
Surveyors found that the facility failed to complete a self-administration of medication assessment for a resident who was self-administering an inhaler. The resident had multiple diagnoses, including quadriplegia, muscle weakness, a stage 4 pressure ulcer of the right buttock, anxiety, depression, emphysema, and sleep apnea, and had been readmitted to the facility with a physician’s order for Proventil HFA (albuterol sulfate) inhalation aerosol, 2 puffs by mouth every 4 hours as needed for shortness of breath, with instructions to rinse the mouth after use. During observation, the resident’s inhaler was seen on the bedside table, indicating self-administration, but review of the medical record showed no documented self-administration of medication assessment. In an interview, the DON confirmed that the resident should not have been self-administering medication without such an assessment and acknowledged that the assessment should have been completed. This deficient practice created the potential for harm if the resident took too much or too little of the inhaled medication, or suffered adverse effects such as oral thrush, due to lack of assessment. The deficiency was cited under the requirement to allow residents to self-administer drugs only when clinically appropriate and after proper assessment, and it was cross-referenced to F761.
Failure to Provide Required Bed-Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a required written bed-hold notice to a resident and/or the resident’s representative at the time of transfer to the hospital. State Operations Manual Appendix PP (issued 7/23/25) requires that at the time of transfer for hospitalization or therapeutic leave, the facility must give written notice specifying the duration of the bed-hold policy. Resident #50, who had multiple diagnoses including Down Syndrome and chronic respiratory failure with hypoxia, was admitted and later readmitted to the facility, and on 3/30/26 nursing notes documented that the resident developed involuntary movements and extreme labored breathing, for which oxygen was administered and EMS was called, resulting in transfer to the hospital. Review of the resident’s record showed no documentation that a bed-hold notice was provided to the resident’s representative at the time of this transfer, and on 5/1/26 at 1:23 PM, RN #1 confirmed she was unable to find documentation that such a notice had been given. This failure was identified for 1 of 3 residents whose records were reviewed (Resident #50) and was determined by surveyors to have created the potential for psychosocial distress if the resident could not return to the facility following hospitalization.
Failure to Include Physician-Ordered Wine Use in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan that included all of a resident's needs, specifically omitting an ordered intervention related to wine use. Facility policy required the IDT to create a comprehensive care plan with measurable objectives and timeframes based on the comprehensive assessment, and to implement a baseline care plan within 48 hours of admission. Resident #6, admitted and later readmitted with multiple diagnoses including left tibia fracture, stroke, unsteadiness on feet, need for assistance with personal care, and generalized muscle weakness, had a physician's order dated 4/9/26 for 5 oz of wine daily as needed every 24 hours. Review of the resident's comprehensive person-centered care plan showed that this wine order was not included, and during an interview on 4/30/26 at 4:30 PM, the DON confirmed that the resident's wine use was not care planned and acknowledged that it should have been. This omission demonstrated that the facility did not fully follow its own Comprehensive Person-Centered Care Planning policy for this resident, as the care plan did not reflect all physician-ordered services identified in the resident's assessment.
Medication Administration and Ordering Did Not Meet Professional Standards
Penalty
Summary
The deficiency involves failures in medication administration and disposal that did not meet professional standards of quality. For one resident with multiple fractures, COPD, and hypertension, an LPN measured the resident’s blood pressure at 108/70 and then incorrectly held the ordered losartan, despite the physician’s order specifying to hold the medication only if the systolic blood pressure was less than 100. The same LPN was observed disposing of an unadministered tablet by dumping it from a medication cup directly into the resident’s room trash can and then discarding the cup in the same trash, contrary to her own statement that unused medications should be placed in a pharmacy-provided return box or a Drug Buster container. In addition, when administering a Breyna (budesonide-formoterol) inhaler to this resident, the LPN assisted with two puffs as ordered but did not instruct the resident to rinse their mouth afterward, nor did she provide education about the need to rinse, despite the physician’s order specifying to rinse the mouth after use. For another resident with emphysema, muscle weakness, a need for assistance with personal care, and a colostomy, the record contained physician orders for Dulcolax (bisacodyl) suppositories and Fleet enemas to be inserted rectally as needed for bowel care. A registered nurse stated that this resident had a colostomy and could not use any medications rectally, indicating that the ordered route for both the suppository and enema was incorrect for this resident’s condition. These findings were identified through observation, record review, and staff interviews, and demonstrate that medication administration and ordering did not consistently follow the five rights of medication administration and proper medication disposal practices.
Failure to Provide Scheduled Bathing Assistance as Care-Planned
Penalty
Summary
The facility failed to ensure a dependent resident received bathing assistance as care-planned and preferred, resulting in missed scheduled showers. A cognitively intact resident with hemiplegia, hemiparesis following a stroke, diabetes, dysphagia, and dysarthria required help with part of the bathing activity and had a care plan initiated on 5/29/25 indicating a preference for two morning showers weekly, on Sundays and Thursdays. The resident reported that she was supposed to receive two showers per week but only received one, and stated she did not refuse when offered a shower or bath. Review of the bathing flowsheets showed the resident received a shower on 4/2/26 and then not again until 4/16/26, a 14-day gap, with no documentation of showers on 4/5/26, 4/9/26, and 4/12/26. Nursing notes did not document any refusals of showers, and the DON confirmed there were no PRN showers provided during this period.
Failure to Complete Updated Smoking Safety Assessment for a Resident Who Smokes
Penalty
Summary
The deficiency involves the facility’s failure to properly assess and document the smoking safety status of a resident who elected to smoke. SOM Appendix PP requires assessment of a resident’s capabilities and deficits to determine if supervision while smoking is necessary. The resident, admitted and later re-admitted with diagnoses including COPD, chronic bronchitis, nicotine dependence, depression, anxiety, and mood disorder, was identified by the facility as a resident who chose to smoke. During observation, the resident asked the surveyor to unlock the nursing cart so she could obtain her cigarettes. However, a Smoking Assessment dated 4/23/26 documented the resident as a non-smoker, and there was no subsequent smoking assessment completed after the resident’s re-admission, despite the facility’s identification of her as a smoker. The resident’s care plan dated 4/27/26 documented that she was safe to smoke independently, but this was not supported by an updated smoking assessment in the record. On 4/30/26, the DON and an RN confirmed there were no additional smoking assessments after 4/23/26 and acknowledged that there should have been one following the resident’s re-admission. This lack of an updated smoking assessment for a resident who chose to smoke constituted the cited deficiency.
Failure to Follow Oxygen Therapy Orders and Equipment Handling Practices
Penalty
Summary
Surveyors identified a failure to provide respiratory care as ordered for a resident receiving oxygen therapy. The resident had multiple diagnoses including quadriplegia, muscle weakness, a stage 4 pressure ulcer of the right buttock, anxiety, depression, emphysema, and sleep apnea, and had a physician's order dated 12/3/25 for oxygen at 0–4 LPM as needed for shortness of breath related to respiratory failure with hypoxia. On 4/27/26 at 3:38 PM, the resident's nasal cannula was observed hanging over the oxygen concentrator without any covering, and the resident reported having used the nasal cannula the previous night. When asked, an LPN stated the nasal cannula should have been stored in a clear bag on the oxygen concentrator. The facility was unable to provide an Oxygen Equipment or Respiratory Therapy policy related to proper nasal cannula storage, and the Clinical Resource Nurse stated the facility did not have any oxygen therapy policies and that staff were instructed to follow physician orders for oxygen services. When asked if a physician's order was needed to store the nasal cannula in a separate bag, the Clinical Resource Nurse answered yes. A separate physician's order dated 12/3/25 directed staff to change the resident's oxygen tubing, clean the filter, and change the oxygen water bottle every night shift on Sundays. On 4/27/26 at 3:38 PM, surveyors observed that the oxygen tubing in use for the resident did not have a date of change marked on it. On 4/28/26 at 9:42 AM, an LPN confirmed there was no date on the tubing, although the April 2026 MAR documented that the tubing had been changed on 4/26/26. The LPN stated the tubing should have been dated when it was changed and acknowledged that it was not.
Unattended Unlocked Medication Cart on Nursing Unit
Penalty
Summary
The facility failed to ensure medications were stored securely when a medication cart on the North Hall was found unlocked and unattended. On 4/30/26 at 8:59 AM, surveyors observed the North Hall medication cart unattended with its drawers accessible. At 9:03 AM, an LPN returned to the cart, stated that it was locked, and attempted to demonstrate this by pulling on a drawer handle, which opened, showing the cart was not locked. The LPN explained that the cart was supposed to lock on a timer and believed it had locked when stepping away, and also stated not knowing how long the timer took to engage and acknowledged she should have double-checked it. Later that morning, the Clinical Resource Nurse confirmed that medication carts must be locked when staff leave them unattended. This failure was identified for 1 of 3 medication carts observed (the North Hall Med Cart) and was determined to have created the potential for harm related to unmonitored use of medications.
Incomplete MAR Documentation for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident, specifically on the medication administration record (MAR). Resident #11, admitted with emphysema, muscle weakness, and a need for assistance with personal care, had multiple scheduled medications that were not documented as administered on specific dates. On 4/16/26, the resident’s midday and bedtime medications were not recorded as given, and on 4/17/26, the early morning medications were not recorded as given. The MAR contained blank spaces with no code or notation explaining why the medications were not administered. During an interview on 4/30/26 at 4:52 PM, the DON stated that Resident #11 was in the hospital on 4/16 and 4/17 and that the nurses administering medications should have documented this on the MAR, adding that there should never be blanks on the MAR. This failure to document the reason for non-administration of medications on the MAR for Resident #11, who was hospitalized during the relevant time, resulted in an incomplete and inaccurate medical record, as identified through record review and staff interview.
Failure to Follow Hand Hygiene and IV Dressing Change Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene and IV site management. For one resident with Down Syndrome and chronic respiratory failure, a nurse performed incontinence and skin care without following CDC and facility hand hygiene guidance. During wound care to the buttocks and genital area, the nurse removed contaminated gloves and donned new gloves multiple times without performing hand hygiene in between, and also used double gloving. These actions occurred despite CDC guidance and facility policy stating that gloves are not a substitute for hand hygiene and that hand hygiene must be performed before donning and after removing gloves. The deficiency also includes improper management of an IV site for another resident with hemiplegia, hemiparesis, dysphagia, and muscle weakness following a stroke. The resident had an IV access site on the right wrist covered with a transparent dressing, under which dried blood and a wet, gel-like dark brown material were observed. The resident reported the IV had been used for antibiotics that were completed several days earlier. When the dressing was removed, the dried blood adhered to the dressing and a wet, gel-like substance was visible above the insertion site. CDC guidance states that transparent dressings on short-term catheters should be replaced at least every 7 days and whenever the dressing is damp, loosened, soiled, or when inspection is necessary, and both the infection preventionist and DON acknowledged that a soiled IV dressing should be changed when blood is present.
Failure to Administer Requested Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure a resident who requested pneumococcal vaccination actually received it, as required by its immunization policy. The written policy dated 1/26 stated that the facility would offer and administer influenza, pneumococcal, and COVID-19 immunizations to eligible residents after providing education and obtaining consent. Record review for Resident #6, who had multiple diagnoses including left tibia fracture, stroke, unsteadiness on feet, need for assistance with personal care, and generalized muscle weakness, showed that on 9/27/25 she consented to receive the pneumococcal vaccine per CDC guidance. However, there was no documentation in her medical record that the pneumococcal vaccine was ever administered. During interview, the IP reported she had misunderstood the information, believed the resident was up to date on pneumococcal vaccination, and was mistaken, resulting in the resident not receiving the requested vaccine. This failure created the potential for the resident to have an increased risk of pneumococcal pneumonia, a serious bacterial lung infection, and the potential for severe illness or death.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving two residents. One resident, who was deaf and required a whiteboard for communication, reported that a physical therapist (PT) threw a soiled bed pan and urinal at her, causing urine to splash onto her arm. The incident occurred when the resident declined to attend a therapy session due to preparing to move rooms. The PT did not use the whiteboard to communicate and was reportedly yelling at the resident. A nursing assistant in training (NAIT) present during the incident confirmed the PT's actions and noted the resident was left with feces and urine on her. Another resident, who was cognitively intact and required extensive assistance with personal hygiene, experienced neglect when she used her call light multiple times to request help with incontinence care. A NAIT responded to her call light but failed to return with assistance, leaving the resident without the necessary care. Despite being informed by a registered nurse (RN) to assist the resident, the NAIT falsely claimed to have provided the care and informed another CNA that the resident had been helped. The resident reported the neglect, and the facility's investigation confirmed the NAIT's failure to provide care. These incidents highlight the facility's failure to ensure residents' rights to be free from abuse and neglect, placing all residents at risk of harm. The facility's investigations substantiated the allegations of abuse and neglect, confirming the inappropriate actions of the PT and the neglectful behavior of the NAIT.
Removal Plan
- PT #1 was suspended during the investigation, then terminated from employment at the facility.
- The State Licensure Board was notified of the abuse allegations and investigative findings related to PT #1's involvement in the incident.
- All staff were educated on abuse/neglect and identifying burnout.
- Staff were offered counseling services for burnout.
- NAIT #1 was suspended immediately during the investigation.
- The facility provided retraining to all nursing staff regarding abuse, neglect, and how to manage burnout.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility was found to have deficiencies in employing sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services. This includes the failure to adequately perform resident assessments, develop individual plans of care, and consider the number, acuity, and diagnoses of the resident population. The deficiency was identified through documentation and staff interviews, revealing that the facility's part-time dietitian and the director of food and nutrition services (DM) did not meet the required qualifications as outlined in the State Operations Manual, Appendix PP. The DM, who had been in the position for five years, had completed food services manager training but had not yet taken the certification exam. Additionally, the facility's administrator, an LPN, held a food service certificate rather than a degree. These staffing inadequacies had the potential to affect all residents requiring medical nutrition therapy, nutritional assessments, and appropriate dietary interventions, as the facility did not have a full-time qualified dietitian or a properly certified director of food and nutrition services.
Failure to Provide Timely and Dignified Dining Experience
Penalty
Summary
The facility failed to treat each resident with respect and dignity, which affected their quality of life and dining experience. This deficiency was observed in the dining room, where three residents did not receive their meals in a timely manner or at the same time as others at their table. Specifically, Resident #1 was observed eating her meal at 12:40 PM, while Resident #17 received his meal at 12:45 PM and required assistance from a feeding aide. Resident #28 initially received the wrong meal type at 12:49 PM, which was then corrected to a mechanical chopped meal at 12:53 PM, and she began eating with assistance at 12:55 PM. The delay in meal service was attributed to the facility's process of filling meal orders based on meal tickets received, without prior knowledge of residents' seating arrangements. The Dietary Manager (DM) explained that staff attempt to serve residents together, but this does not always occur as planned. This inconsistency in meal service timing created the potential for psychosocial harm, as residents may feel excluded from the dining experience.
Failure to Adhere to Posted Mealtime Schedule
Penalty
Summary
The facility failed to provide meal service according to the posted mealtime schedule, potentially affecting 69 residents. Observations revealed that during lunch, residents were seated at 12:00 PM, but the first tray was not delivered until 12:35 PM, with the last meal served at 12:53 PM. Similarly, during breakfast, residents were seated at 7:30 AM, but meal service did not begin until 8:00 AM, with staggered service times for different halls. The Dining Manager (DM) and Registered Dietitian (RD) were unaware of the posted mealtimes and confirmed that the actual mealtimes differed from those posted. This discrepancy could lead to poor quality of life, nutritional issues, and complications with medications that need to be taken with meals.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during inspections. During the initial inspection, several issues were noted, including undated and unlabeled food items such as noodle soup, shredded carrots, and a container of noodle/macaroni spiral salad in the refrigerator. Additionally, a fully cooked ham was improperly stored on top of liquid eggs. The kitchen also had significant cleanliness issues, with a brown layer of dirt around the AC unit and across the ceiling, directly above open and undated bags of shredded lettuce and an open container of dry, grated parmesan cheese. Ice buildup was observed in the freezer, with ice growing from a cardboard food box and from the ceiling, and two large ice cream containers were left unsealed under the freezer ceiling. A follow-up inspection revealed persistent issues, including ice buildup in the freezer and dirt around the AC unit in the refrigerator. The facility's cleaning schedule indicated that the freezer floor was not cleaned on several dates, and the maintenance director confirmed that while equipment was checked, the cleaning of refrigerators and freezers was the responsibility of the kitchen staff. The Nutritional Services Director acknowledged that deep cleaning was done monthly or quarterly, and the ice buildup was attributed to a freezer door that did not close properly. These deficiencies had the potential to affect the 69 residents who consumed food prepared by the facility, placing them at risk for potential contamination and adverse health outcomes.
Inadequate Lighting in Activity Room
Penalty
Summary
The facility failed to ensure that the Activity Room, which was being used as the facility's Bistro, had adequate and comfortable lighting for residents to enjoy their activities. This deficiency was observed when a resident requested the surveyor to visit the Activity Room, where it was noted that the lighting was dim due to missing light bulbs and multiple lights being out on the track lighting. The Maintenance Director acknowledged the issue, stating that the light tracks could not be replaced because they were no longer available in the area and that the previous administrator had planned to address it during the facility's remodeling. The Activity Director confirmed that residents had expressed concerns about the inadequate lighting, which affected their ability to perform activities such as working on jigsaw puzzles and applying nail polish. The Interim DON also stated that the track lighting had not been replaced due to the pending remodeling of the facility.
Delayed Reporting of Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment in a timely manner. The resident, who had a history of dementia with agitation and anxiety, made a statement about being raped, which was initially reported by a CNA. However, the nursing staff did not report this allegation to the facility's administration until the following morning, resulting in a delay of almost 14 hours before notifying the police and other relevant authorities. The facility's policy required such allegations to be reported immediately, but not later than two hours after the allegation was made. The delay in reporting led to a failure to promptly inform the resident's physician, POA, and the State Agency. The resident's initial complaint was followed by a medical examination that found no physical evidence of abuse, and the resident later denied being harmed. Despite this, the facility's failure to adhere to its abuse reporting policy created a potential for psychosocial harm to the resident. The incident report section for notifying agencies was left blank, indicating a lack of proper documentation and communication regarding the incident.
Inadequate Investigation of Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged sexual abuse incident involving a resident with severe cognitive impairment. The resident, who had multiple diagnoses including dementia and anxiety, reported an incident of sexual abuse, which was not promptly or comprehensively investigated. The initial allegation was made on the evening of May 13, 2024, but the investigation was not initiated until the following day, May 14, 2024. The investigation report documented that only one staff member was interviewed, and the nursing staff who received the initial allegation was unavailable for interview as she was a travel nurse no longer working at the facility. Furthermore, the investigation did not include interviews with additional staff or residents who might have had relevant information. The resident was not assessed for physical or psychosocial harm until nearly 14 hours after the initial allegation. The facility's Administrator, who also served as the Abuse Coordinator, acknowledged that the investigation lacked thoroughness and timeliness, as it did not include necessary assessments and statements from other potential witnesses or involved parties.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions, as evidenced by the cases of two residents. Resident #42, who was admitted with multiple diagnoses including diabetes and obstructive sleep apnea, reported that she was supposed to be tested for a BiPAP machine but had not been able to use it due to the facility's requirement for a hospital evaluation. Her care plan, initiated in May 2024, still documented the use of the BiPAP machine despite the order being discontinued in July 2024. The facility's staff confirmed that the care plan was not updated to reflect the discontinuation and the new order for a sleep study. Resident #32, admitted with a diagnosis of anxiety, had a physician's order to be weighed every Monday morning. However, the care plan did not reflect this current order, instead directing staff to notify the physician of significant weight gain. The Interim DON acknowledged that the care plan should have been updated with the current physician's order. These oversights in updating care plans placed residents at risk of adverse outcomes due to the lack of accurate and current care directives.
Failure to Conduct Skin Assessment for Resident
Penalty
Summary
The facility failed to follow professional standards of practice for a resident who was not evaluated for a skin condition. The resident, who had multiple diagnoses including diabetes, atrial fibrillation, anemia, and obstructive sleep apnea, was observed scratching at scabbed sores on her upper right arm. Despite the resident's report of being a picker/scratcher and suspecting medication as a cause, there was no documentation of a skin assessment or treatment plan for the arm sores or itching in the resident's medical record. Staff interviews revealed that while CNAs applied lotion to the resident's arms to alleviate itching, the type of lotion used was unknown, and there was no record of a skin assessment being completed. The Director of Nursing (DON) and Resident Care Manager (RCM) confirmed the absence of necessary documentation and acknowledged that a skin evaluation or dermatology review should have been conducted. Additionally, there were no progress notes indicating the application of lotion to the resident's arms, and the care plan had not been updated to address the skin condition.
Failure to Provide Podiatry Services as Ordered
Penalty
Summary
The facility failed to provide podiatry services as ordered for two residents, leading to a deficiency in care. Resident #13, who was severely cognitively impaired and diagnosed with heart disease, had a physician's order for a podiatry referral due to an ingrown toenail. Despite the POA's request for podiatry care, the facility faced challenges in scheduling an appointment because the podiatry clinic was not accepting new patients for nail or callus care. The facility attempted to find alternative podiatry services, but Resident #13's electronic medical record did not document any podiatry visit as per the physician's orders. Resident #61, with diagnoses including diabetes and heart disease, also required podiatry care. The resident expressed a need to see a podiatrist, but was informed that the service was not covered by insurance. A physician's order indicated the resident may see a podiatrist as needed, and a progress note suggested a referral for podiatry related to diabetes. However, there was no documentation of a referral or podiatry visit in the resident's medical record. The facility's administration confirmed the lack of follow-up and scheduling for both residents' podiatry appointments, and the facility's policy on podiatry care was not provided to the survey team during the survey.
Failure to Document PRN Alprazolam Use Beyond 14 Days
Penalty
Summary
The facility failed to ensure that a resident receiving PRN alprazolam, an anti-anxiety medication, had a clear indication for its use and a clinical rationale for its continued use beyond 14 days. This deficiency was identified during a record review and staff interview, which revealed that the resident was prescribed Xanax (alprazolam) 0.25 mg every 12 hours as needed for anxiety, without documentation supporting its continuation beyond the 14-day limit. The State Operations Manual requires that PRN orders for anti-psychotropic drugs be limited to 14 days unless the attending physician documents a rationale for extending the order. The absence of such documentation for the resident's medication order was confirmed by the facility's Administrator, who acknowledged that the order lacked a stop date or reason for continuation beyond the specified period.
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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