Monte Vista Hills Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pocatello, Idaho.
- Location
- 1071 Renee Avenue, Pocatello, Idaho 83201
- CMS Provider Number
- 135018
- Inspections on file
- 21
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Monte Vista Hills Healthcare Center during CMS and state inspections, most recent first.
The facility did not follow standing orders and physician directives for bowel care, resulting in multiple residents with complex medical conditions experiencing extended periods without a bowel movement and no documented administration of prescribed medications or interventions. Nursing staff failed to document or provide required bowel care interventions as ordered, as confirmed by record review and staff interviews.
Staff were observed providing personal care to a resident with multiple complex diagnoses while the resident's door was left open in a high-traffic area. An LPN and the DON confirmed that the door should have been closed to maintain privacy.
A resident with COPD and diabetes was found to have two unsecured portable oxygen cylinders propped in her room, along with a portable oxygen concentrator in use and a liquid oxygen tank on her wheelchair. The DON was unaware of the presence of these cylinders, which were not properly secured or stored as required.
Two residents with physician-ordered oxygen therapy were observed receiving higher oxygen flow rates than prescribed, with concentrators set at 3.5 lpm instead of the ordered 1–2 lpm or 2 lpm to maintain appropriate oxygen saturation levels. The DON confirmed the settings were incorrect.
Controlled medications were not properly tracked and secured when a narcotic accountability sheet for a medication cart was missing a required nurse signature on one date. Staff confirmed that two nurses should have signed the sheet when accepting or releasing the cart, but this was not done as required.
Surveyors found that medications and biologicals were not properly stored or monitored for expiration. A resident had Nystatin cream left at bedside, and expired items, including a fiber supplement, muscle rub, and glucose test solutions, were found on a medication cart. Staff confirmed these expired items should have been removed but were not.
Surveyors found that food items in the kitchen and storage areas were not properly labeled, dated, or stored according to facility policy and the Idaho Food Code. Items such as ranch dressing, milk, diced tomatoes, cucumbers, sliced cheese, and barbeque sauce lacked required date markings, and a case of food was stored directly on the floor. The CDM confirmed these practices did not meet required standards.
Two garbage cans in the kitchen food prep area were observed uncovered and not in use, in violation of FDA Food Code requirements. The CDM confirmed the cans should have been covered when not in use, creating a potential for pest attraction affecting all residents and staff.
The facility failed to employ a qualified director of food and nutrition services, affecting nearly all residents receiving meals. The Dietary Supervisor, with no healthcare experience, had only completed 34% of a certification program and lacked necessary credentials. This was confirmed by the Administrator and RD.
The facility failed to comply with food storage, labeling, and hygiene standards, as observed in the walk-in refrigerator and mini freezer containing improperly labeled and stored food items. The ovens and grease trays were not cleaned daily, and clean kitchen items were covered in residue due to hard water. Staff did not follow proper hand hygiene practices during meal preparation, as confirmed by the RD.
The facility failed to provide necessary health information during hospital transfers for four residents, as required by policy. This included missing documentation of advance directives and care plans. The DON and SSD confirmed the lack of documentation and awareness of requirements.
The facility failed to secure and label unidentified loose pills in a medication cart, as observed during an audit. Several loose pills of various colors and sizes were found in the cart, indicating non-compliance with the facility's medication storage policy. An LPN was unaware of the reason for the loose pills, and the DON acknowledged a lack of documentation for medication cart audits.
A facility failed to assist a resident in exercising their right to formulate an advanced directive, as required by policy. Despite having an advanced directive documented in a Medical Treatment Decisions form, it was not included in the resident's care plan. The DON confirmed the oversight, noting the resident had a POST and a DPOA but lacked documentation of the advanced directive in the care plan.
Two residents in the facility did not receive care according to their care plans, leading to potential health risks. One resident, with a history of surgical amputation, did not have her wound care documented as completed on several occasions. Another resident, with multiple diagnoses including diabetes and respiratory failure, had his urinary catheter tubing unsecured during observations. The DON confirmed these deficiencies.
A resident with severe cognitive impairment and contractures did not have positioning devices in place as ordered by a physician. Despite documentation indicating their use, observations and staff interviews confirmed the devices were not used, and there was no record of the resident refusing them. This oversight could lead to further contractures and pain.
A resident with multiple diagnoses, including a status-post hip fracture, required substantial assistance for transfers. During a transfer from a wheelchair to a recliner, the resident lost balance and was assisted to the floor by a COTA, resulting in a femoral fracture. The COTA did not use a gait belt or a second person, contrary to the care plan and facility policy.
The facility failed to adhere to infection control practices, impacting several residents. Staff did not perform proper hand hygiene, clean equipment like the Hoyer lift and glucometer, or follow insulin administration protocols. Additionally, an oxygen concentrator filter was not maintained as required, placing residents at risk for infection.
Failure to Administer and Document Bowel Care Interventions per Physician Orders
Penalty
Summary
The facility failed to follow its bowel care standing orders and physician directives for administering specific medications when residents did not have a bowel movement within 72 hours. For five residents with various complex medical conditions, including respiratory failure, morbid obesity, schizoaffective disorder, cancer, osteolysis, malnutrition, femur fracture, diabetes, multiple sclerosis, and quadriplegia, there were multiple documented instances where no bowel movement occurred for periods exceeding 72 hours—sometimes up to 240 hours—without any documented nursing intervention or administration of prescribed bowel care medications. The facility's standing orders required timely administration of medications such as Peri Colace, MiraLAX, Milk of Magnesia, Bisacodyl, and Lactulose, and mandated provider notification if symptoms persisted, but these protocols were not followed as documented in the residents' records. Record reviews and staff interviews confirmed that nurses did not document the administration of bowel care medications or interventions as ordered for the affected residents during the periods of constipation. In some cases, physician orders specifically outlined a stepwise approach to bowel management, including escalation to suppositories or enemas if initial interventions were ineffective, but there was no evidence these steps were taken or recorded. The DON acknowledged that the required interventions and documentation were not completed by the nursing staff for the residents identified.
Resident Privacy Not Maintained During Personal Care
Penalty
Summary
Staff failed to maintain a resident's privacy during personal care activities. On the morning of 12/16/25, two staff members were observed assisting a resident with personal cares in the resident's room while the door was left open. The resident's room was located across from the nurse station in a high-traffic area, making the resident visible to passersby. The surveyor observed this from the hallway and confirmed with an LPN at the nurse station that the door should have been closed during such care. The Director of Nursing later confirmed that staff should not have left the door open during personal care. The resident involved had multiple diagnoses, including Ataxic Cerebral Palsy, schizoaffective disorder, and PTSD. The failure to close the door during personal care was directly observed and acknowledged by staff as not following proper privacy protocols.
Unsecured Portable Oxygen Cylinders in Resident Room
Penalty
Summary
The facility failed to ensure that a resident's room was free from accident hazards, as evidenced by the presence of two unsecured portable oxygen cylinders propped up in the corner of the room. The resident, who had multiple diagnoses including COPD and diabetes, stated that she brought the portable oxygen cylinders from home but was not using them at the time. During observation, it was also noted that the resident was using a portable oxygen concentrator and had a portable liquid oxygen tank hanging on her wheelchair. The Director of Nursing was unaware that the resident had portable oxygen cylinders in her room, and acknowledged that they were not properly secured or stored in the designated oxygen room as required.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents. One resident with diagnoses including respiratory failure and morbid obesity was observed on two occasions with their oxygen concentrator set at 3.5 liters per minute (lpm), despite a physician order for oxygen via nasal cannula at 1 to 2 lpm to maintain oxygen saturation at or above 88%. Another resident with osteolysis and malnutrition was observed with their oxygen concentrator set at 3.5 lpm, while the physician order specified 2 lpm via nasal cannula to keep oxygen saturation above 90%. The Director of Nursing confirmed that both residents' oxygen concentrators were set higher than ordered.
Failure to Properly Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by a missing licensed nurse signature on the narcotic accountability sheet for one of two medication carts reviewed. Specifically, during an audit of the 200 Hall medication cart, it was observed that the narcotic accountability sheets covering a two-week period had only one nurse's signature documented on a particular date, instead of the required two. Staff interviews confirmed that two nurses were expected to sign the narcotic accountability sheet when accepting or releasing the medication cart, but this procedure was not followed on the identified date.
Failure to Properly Store and Remove Expired Medications and Biologicals
Penalty
Summary
Surveyors identified that medications and biologicals were not properly stored or monitored for expiration in the facility. During observation, two medication cups containing Nystatin cream were found on a resident's nightstand, and the resident was unaware of why they were there or how long they had been present. The Nystatin cream had been left at the bedside, contrary to storage requirements. Additionally, an audit of a medication cart revealed a bottle of fiber supplement with an expiration date of 7/24 and a tube of muscle rub with an unclear expiration date of 12/12, both of which were expired and had not been discarded. Further review of the medication cart uncovered expired biologicals, specifically glucose test solutions with expiration dates of 10/10/25 and 10/12/25, which remained in use. Staff interviews confirmed that these expired medications and biologicals should have been removed but were not. The resident involved had multiple diagnoses, including COPD and diabetes, and was admitted to the facility prior to the observations.
Deficient Food Storage, Labeling, and Distribution Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, labeling, and distribution practices. During observations in the dining room, a squeeze bottle containing a white liquid, identified by the Certified Dietary Manager (CDM) as ranch dressing, was found without a contents label or any dates. Additionally, a container labeled as milk lacked both a date poured and an expiration date, with the CDM stating that milk and ranch dressing are poured out after each meal. In the walk-in refrigerator, surveyors observed a small zip lock bag with diced tomatoes, another with diced cucumbers, a plastic container with sliced cheese, and a plastic container with barbeque sauce, none of which were labeled with dates. Furthermore, a case of food was found stored directly on the ground in the dry food storage room, contrary to facility policy and food code requirements. The facility's Food Storage policy requires that food items be stored on shelves, dated when placed on shelves, stored at least six inches above the floor, and that leftover food be stored in covered containers or wrapped securely, clearly labeled, and dated before refrigeration. The Idaho Food Code also mandates date marking for refrigerated, ready-to-eat, time/temperature control for safety foods held for more than 24 hours. The CDM acknowledged that food in the dry storage area should not be stored on the floor and that all food items should be labeled and dated, which was not being done at the time of the survey.
Uncovered Garbage Cans in Kitchen Area
Penalty
Summary
Surveyors observed that two garbage cans in the kitchen food preparation area were left uncovered and not in continuous use, contrary to the requirements outlined in the U.S. Food and Drug Administration 2022 Food Code, section 5-501.113. The code specifies that receptacles containing food residue must be kept covered when not in continuous use or after being filled. During an interview, the Certified Dietary Manager (CDM) acknowledged that the garbage cans were not in use at the time and should have had their lids on, indicating a failure to ensure proper closure of garbage cans to minimize the attraction of pests and rodents into the kitchen. This practice had the potential to affect all residents and staff in the facility.
Unqualified Dietary Supervisor in Facility
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, which had the potential to affect 61 of 62 residents who received meals prepared in the facility's kitchen. The Dietary Supervisor (DS) had been working as the Dietary Manager since April 2023 but was not certified as a Dietary Manager. The DS had ten years of food service experience in restaurants but none in healthcare. She had completed only 34% of a Dietary Manager certification training program and held only a food handler's certification, without completing other courses in food safety and management. This deficiency was confirmed during interviews with the Administrator and Registered Dietitian (RD), who acknowledged that the DS was currently enrolled in a qualifying course to obtain the necessary credentials.
Deficiencies in Food Storage, Labeling, and Hygiene Practices
Penalty
Summary
The facility failed to comply with food storage, labeling, and hygiene standards as outlined in the Idaho and FDA Food Codes. Observations revealed that the walk-in refrigerator contained open containers of salad dressings with expired use-by dates and exposed spouts. Additionally, the mini freezer housed various food items that were loosely wrapped and lacked proper labeling and dating. The Dietary Supervisor (DS) acknowledged these issues but was under the misconception that USDA rules allowed for extended storage times. The Registered Dietitian (RD) confirmed that the items should have been protected from freezer burn and properly labeled. The facility also failed to maintain cleanliness in food-contact surfaces and equipment. The ovens and grease trays were observed to have white dried residue and food drainage, which were not cleaned daily as required. Clean trays, tubs, and silverware were covered in a white residue due to hard water, and the water softener had been down for a week. The DS admitted that the dishes had not been de-limed for over a month. Additionally, the refrigerator in the nutrition room contained undated and expired food items, which the DS confirmed should have been disposed of. Hand hygiene practices were not followed by the staff, as observed during meal preparation. Staff members, including the DS and Dietary Aide, failed to wash their hands between glove changes and after handling potentially contaminated surfaces. The RD stated that the facility should adhere to state food codes, which require secure sealing and labeling of foods and proper handwashing when indicated.
Failure to Provide Pertinent Health Information During Resident Transfers
Penalty
Summary
The facility failed to ensure continuity of care by not providing pertinent health information to the receiving hospital for four residents during their transfers. The facility's policy required specific information to be sent, including contact information for the resident's practitioner, advance directives, comprehensive care plans, and other necessary health information. However, the records for these residents did not include documentation that such information was sent. This lack of documentation was confirmed by the Director of Nursing (DON) and other staff members during interviews. Resident #19 was transferred to the hospital due to lab results indicating hyponatremia and abnormal renal function, but there was no documentation of the advance directive or care plan being sent. Resident #34 was transferred for gastrointestinal bleeding, yet her care plan and advanced directives were not sent. Resident #55 was transferred with a new onset of foul drainage from a foot ulcer, but there was no documentation of the information sent or a physician's order for the transfer. Resident #33 was transferred twice for pneumonia and respiratory failure, with no documentation of the information provided to the hospital. The Social Services Director (SSD) responsible for transfer documentation was unaware of the necessary documentation requirements.
Failure to Secure and Label Medications
Penalty
Summary
The facility failed to secure and label unidentified loose pills in the North side medication cart, as observed during an audit. The audit revealed several loose pills of various colors and sizes in the second drawer of the medication cart. These included four unidentified pink pills, three unidentified blue pills, one unidentified half of a brown tablet, and ten unidentified white pills of different sizes. The presence of these loose pills indicates a failure to adhere to the facility's Medication Access and Storage policy, which requires medications to be stored in containers that meet legal requirements and to be removed if they are outdated, contaminated, or deteriorated. During the audit, an LPN present was unaware of the reason for the loose pills and uncertain about whose responsibility it was to check the medication cart for such issues. The Director of Nursing (DON) later stated that nurses should check the medication cart throughout their shift and destroy loose medication, with narcotics requiring destruction by two nurses. However, the DON also mentioned uncertainty about whether the pharmacy checks the carts and acknowledged that while medication cart audits are conducted, there is no documentation of these audits, including what is being checked or the findings.
Failure to Document Advanced Directive in Care Plan
Penalty
Summary
The facility failed to ensure that a resident and their representative received assistance to exercise their right to formulate an advanced directive. This deficiency was identified for one resident whose records were reviewed for advanced directives. The facility's policy, revised in December 2023, mandates that residents' choices about advance directives be recognized and respected, and that written information be provided to all adult residents regarding their rights to accept or refuse medical treatment and formulate an advanced directive. Despite this policy, the resident in question, who was admitted with multiple diagnoses including stroke and dementia, had an advanced directive documented in a Medical Treatment Decisions form. However, this advanced directive was not included in the resident's care plan. The Director of Nursing confirmed that the resident did not have an advanced directive documented in the care plan, although they had a POST and a DPOA, indicating a failure to adhere to the facility's policy.
Failure to Follow Care Plans for Wound and Catheter Management
Penalty
Summary
The facility failed to adhere to professional standards of practice and comprehensive care plans for two residents, leading to potential health risks. Resident #17, who had multiple diagnoses including orthopedic aftercare following a surgical amputation and morbid obesity, did not receive wound care as directed by her care plan. The wound care interventions, such as monitoring the wound vac and changing dressings, were not documented as completed on several specified dates. The Director of Nursing (DON) confirmed that the wound care was not performed as ordered, and there was no documentation explaining the omissions. Resident #41, with diagnoses including traumatic subdural hemorrhage, diabetes, malnutrition, and respiratory failure, was also not provided care according to his care plan. His physician's order required that his urinary catheter tubing be secured every shift to prevent kinking and accidental removal. However, observations on two separate occasions revealed that the catheter tubing was not secured. The DON acknowledged that the catheter should have been secured to prevent it from being pulled out.
Failure to Use Positioning Devices for Contracture Prevention
Penalty
Summary
The facility failed to ensure that positioning devices were in place for a resident with severe cognitive impairment and multiple diagnoses, including traumatic brain dysfunction, quadriplegia, and contractures. The resident had a physician's order to use positioning devices, such as carrots or rolled-up washcloths, to prevent further contractures. However, observations over several days revealed that the resident did not have these devices in her hands, despite documentation in the Treatment Administration Record (TAR) indicating otherwise. Interviews with staff, including an LPN, RNA, and CNA, confirmed that the positioning devices were not in use, and there was no documentation of the resident refusing the devices. The Director of Nursing (DON) was unaware of the discrepancy between the TAR and the actual use of positioning devices. The Physical Therapy Assistant (PTA) mentioned that the devices had been provided to the resident about two months prior and should have been in use. The lack of positioning devices could lead to further contractures and pain for the resident, as the facility did not adhere to the care plan and physician's orders, and failed to document any refusals by the resident.
Failure to Use Gait Belt and Two-Person Assist During Transfer
Penalty
Summary
The facility failed to ensure staff used a gait belt during a transfer, as per policy, which resulted in a potential for more than minimal harm for a resident. The resident, who was admitted with multiple diagnoses including a status-post left hip fracture, osteoporosis, Parkinson's disease, and arthritis, required substantial assistance with transfers. The care plan indicated the need for a two-person mechanical lift for transfers. However, during a transfer from a wheelchair to a recliner, the resident lost balance and was assisted to the floor by a COTA, resulting in a complaint of pain and a skin tear. The resident was subsequently transferred to the hospital, where a left femoral fracture was diagnosed, requiring surgical repair. The investigation revealed that the COTA did not use a gait belt during the transfer and did not utilize a second person, despite the resident being a two-person transfer for CNAs. The COTA stated she normally used a gait belt but could not recall if it was used during the incident. The PTA confirmed that the policy required a gait belt and a two-person transfer, which was not followed. The facility's administrator stated that all staff, including therapy staff, are expected to follow the care plan and use a gait belt for transfers.
Infection Control and Equipment Cleaning Deficiencies
Penalty
Summary
The facility failed to adhere to infection control and prevention practices, impacting several residents. Staff did not perform proper hand hygiene, as observed when CNAs failed to offer handwashing to residents before meals. Additionally, a CNA did not change gloves or perform hand hygiene after providing catheter care and before handling a clean brief for a resident. These actions were contrary to the facility's hand hygiene policy and CDC guidelines, which require hand cleaning when moving from a contaminated to a clean body site. The facility also did not ensure the cleanliness of resident equipment. A Hoyer lift used for transferring a resident was not cleaned after use, and staff were unsure of the cleaning protocol. Furthermore, the glucometer used for checking blood sugar levels was not disinfected according to the manufacturer's instructions, as staff did not allow the disinfectant to remain wet for the required time. Insulin administration procedures were also not followed correctly, as staff did not clean the rubber cap of the insulin pen before use. Additional deficiencies were noted in the maintenance of medical equipment. The oxygen concentrator filter for a resident was observed to have a thick layer of dust, indicating it had not been cleaned as per the facility's policy. These lapses in protocol and hygiene practices placed residents at risk for cross-contamination and infection, as the facility did not adhere to its own policies and CDC guidelines.
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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