Quinn Meadows Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pocatello, Idaho.
- Location
- 1033 W Quinn Road, Pocatello, Idaho 83202
- CMS Provider Number
- 135136
- Inspections on file
- 18
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Quinn Meadows Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility failed to electronically submit required 4th quarter Payroll Based Journal (PBJ) staffing data to CMS. A surveyor identified that the 4th quarter PBJ information was missing, and the Executive Director confirmed that the facility had not submitted the required staffing data. This failure created the potential for CMS not to confirm adequate nurse staffing and for residents to experience longer waiting times for needed cares.
Surveyors found that staff did not follow the facility’s call light accessibility policy for a resident with hemiplegia and diabetes. The resident was observed reclining in bed with the call light pinned to the headwall cord and not within reach. An RN and the RSN both acknowledged that call lights are required to be within residents’ reach and that this had not occurred in this case.
A resident with multiple diagnoses, including an open leg wound and muscle weakness, did not receive the required Notice of Medicare Non-Coverage (NOMNC CMS-10123) within the CMS-mandated timeframe. Record review showed the NOMNC was signed only one day before Medicare Part A skilled nursing coverage ended, instead of the required two days’ notice. The Executive Director confirmed that the notice was not provided within the proper timeframe, creating the potential for financial harm or distress due to lack of timely information about the resident’s payment liability.
The facility failed to follow its bowel protocol and PRN constipation orders for two residents who went more than 72 hours without a documented BM. Standing orders required stepwise use of bisacodyl delayed-release tablets, bisacodyl suppositories, and Fleet enemas when no BM occurred in three consecutive days, with provider notification if there was no response. For one resident with a fracture and history of falls, only daily MiraLax was given while ordered bisacodyl tablets, suppositories, and enemas were not administered during multiple 3–4 day gaps without a BM. For another resident with cellulitis and pulmonary fibrosis, only a single bisacodyl tablet dose was given, and the ordered suppository and enema were not used despite prolonged periods without a BM. The DNS acknowledged that these residents had no documented BM for over 72 hours without the required nursing interventions.
A resident with COPD and other comorbidities had a physician order for continuous O2 at 2 L/min via NC with O2 sats to be maintained at or above 88% and checked each shift. On multiple observations, the resident’s oxygen concentrator was found set at 4 L/min while the resident was in bed with the NC in place. An RN confirmed the concentrator should not have been set at 4 L/min and reduced it to the ordered 2 L/min, and a regional support nurse later acknowledged that staff had failed to detect the incorrect O2 flow rate.
A resident with osteomyelitis and sepsis had PRN oxycodone orders specifying one tablet for moderate pain and two tablets for severe pain, based on a standard pain scale. MAR review showed staff repeatedly administered the higher, two-tablet dose when the documented pain scores reflected only mild to moderate pain. The DNS confirmed that the facility uses the standard pain scale and that the opioid should have been given according to the ordered pain levels but was not, resulting in the resident receiving opioid doses inconsistent with the prescribed indications.
The facility failed to maintain kitchen sanitation, with observations of dust, stains, and substances on various kitchen equipment and surfaces. Despite having a cleaning schedule, the kitchen equipment and floor were not cleaned as expected, as confirmed by the DM and Administrator.
A facility failed to maintain accurate documentation of a resident's resuscitation status and did not assist in formulating an advance directive. The resident's records showed conflicting information: a face sheet and care plan indicated DNR, while the POST form indicated CPR. The facility did not document offering assistance for an advance directive, nor the resident's decision on it. The DON and Regional Support Nurse confirmed the discrepancies, acknowledging the POST form as the most current document.
The facility failed to maintain a clean and safe environment for its residents, as evidenced by unclean equipment and inadequate lighting. Observations revealed that a bed rail and bedside table were not cleaned, and a Hoyer lift had a dirty cushion. Additionally, a resident with heart failure and diabetes reported being unable to reach the light switches from his bed, resulting in inadequate lighting. The Administrator acknowledged the issue with light switch accessibility, confirmed by a survey indicating it as a barrier for some residents.
The facility failed to complete a Significant Change of Status Assessment (SCSA) MDS for two residents newly diagnosed with major mental disorders. One resident with primary adrenocortical insufficiency and Alzheimer's was identified with a schizophrenic disorder, but the MDS was not updated. Another resident with a fractured pelvis and anxiety was diagnosed with major depressive disorder, yet the MDS did not reflect this. The DON and RSN acknowledged these oversights, which could lead to unrecognized changes in health status and mental health needs.
A resident's care plan was not updated following a fall and after lumbar surgery, leading to outdated interventions. The resident, with spinal stenosis and heart failure, fell from a wheelchair, sustaining injuries. Despite this, no new fall interventions were added to the care plan. The DON confirmed the care plan should have been revised to reflect the resident's current needs.
A resident with obstructive sleep apnea did not receive the ordered CPAP therapy for three nights because the facility staff failed to refill the humidifier with distilled water as per the physician's orders. The DON confirmed that the nursing staff should have been maintaining the CPAP machine nightly, but this was not done, potentially affecting the resident's sleep quality and oxygen levels.
The facility failed to ensure controlled medications were properly tracked and secured, as observed in one of the medication carts. The narcotic accountability record lacked a licensed nurse's signature for several days, contrary to the facility's policy. An RN confirmed that nurses should sign the sheet when handling the medication cart.
A resident was administered Risperdal for schizophrenia without a documented diagnosis of the condition in their medical record. The facility's policy requires documentation of the diagnosed condition for which a psychotropic medication is prescribed, but this was not followed. The resident's MDS also indicated 'NO' for schizophrenia, and the DON and RSN confirmed the diagnosis should have been documented prior to medication administration.
The facility failed to ensure garbage cans in the kitchen were properly closed with lids, as required by Idaho Administrative Rules and the FDA 2022 Food Code. A garbage can without a lid was observed next to the clean dish rack, and the cook was unaware of the need for a lid. The RSN confirmed the requirement, highlighting a potential risk of attracting pests and rodents.
A facility failed to maintain infection control practices during IV medication administration for a resident. RN did not disinfect the bedside table or the IV port before connecting syringes, contrary to the facility's policy. The RN acknowledged the oversight, and the RSN confirmed the proper procedure was not followed, risking cross-contamination and infection.
The facility failed to monitor and discard outdated food items and maintain the kitchen in a sanitary manner, affecting 36 residents. Observations revealed inconsistencies in date marking on seasoning containers and expired food items. The kitchen had debris, rust, and food droppings on shelves, and the oven was heavily soiled. The Dietary Manager could not provide documentation of cleaning schedules.
The facility failed to ensure residents and their representatives received assistance to formulate Advanced Directives, affecting six residents with multiple diagnoses. The Social Services Director admitted to incorrect documentation and lack of proper discussions, leading to potential harm if residents' wishes were not followed.
The facility failed to provide baseline care plan summaries to five residents or their representatives within 48 hours of admission, despite their policy requiring it. These residents, who were cognitively intact and had serious medical conditions, did not have documentation indicating that their care plans were discussed with them or their representatives.
The facility failed to update a resident's care plan to include physician-ordered neobladder irrigation twice daily, despite the resident's multiple diagnoses and the facility's policy requiring care plan revisions upon status changes.
The facility failed to provide bathing assistance to a resident with dementia and depression, as documented in the Bath/Shower Flowsheet. The resident did not receive a shower or bath over several weeks, with refusals and 'Not Applicable' entries noted. Observations showed signs of poor hygiene, and the DON acknowledged the resident's refusals should have been documented.
The facility failed to ensure that a resident receiving opioid pain medications was monitored appropriately and offered non-pharmacologic pain interventions. Despite the policy requiring non-drug interventions before administering PRN medications, the resident's record lacked documentation of such interventions. The DON confirmed the oversight.
The facility failed to ensure that a resident receiving psychoactive medications had specific target behaviors identified and monitored. The resident's care plan did not document the use of Trazodone and Aripiprazole or the specific target behaviors for depression, as confirmed by a staff member.
The facility failed to maintain a medication error rate below 5%, with a 6.06% error rate observed. A resident received double the prescribed dose of Amiodarone HCl and was falsely documented as having received Polyethylene Glycol powder, which was not administered.
The facility failed to ensure medications were labeled and dated, as observed in two medication carts. Insulin pens and vials were found without dates, and staff admitted to not knowing the duration for which the insulin was good. This created the potential for residents to receive expired medications with decreased efficacy.
The facility failed to maintain proper infection control practices for three residents, including inadequate use of gowns and gloves, improper catheter and PICC line care, and insufficient hand hygiene during wound care.
Failure to Submit Required 4th Quarter PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information for the 2025 4th quarter to CMS through the Payroll Based Journal (PBJ) system as required. On 2/23/26 at 8:00 AM, the surveyor identified that the 2025 4th quarter PBJ data had not been submitted. During an interview on 2/23/26 at 10:33 AM, the Executive Director confirmed that the facility did not submit the required 2025 4th quarter PBJ data to CMS. This failure created the potential for CMS not to confirm adequate nurse staffing and for residents to experience longer waiting times for needed cares.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not ensuring the resident’s call light was within reach, as required by the facility’s “Call Lights: Accessibility and Timely Response” policy dated 12/31/25, which states staff will ensure the call light is within reach of the resident and secured as needed. Resident #47, admitted with multiple diagnoses including hemiplegia and diabetes, was observed on 2/24/26 at 10:11 AM reclining in bed with the call light pinned to the headwall cord and not within her reach. At 10:12 AM, an RN confirmed that the call light should have been within the resident’s reach but was not. Later, at 12:24 PM, the RSN also stated that resident call lights should be within residents’ reach and acknowledged that in this instance it had not been. This deficiency was identified through policy review, observation, record review, and staff interviews, and involved 1 of 14 residents reviewed for resident rights (Resident #47).
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC CMS-10123) within the required timeframe to a resident receiving Medicare Part A skilled nursing services. The resident was admitted on 10/2/25 with multiple diagnoses, including an open wound to the lower left leg and muscle weakness. Record review showed that the NOMNC form was signed on 10/13/25, while the resident’s Medicare coverage for skilled nursing services ended on 10/14/25, giving only one day’s notice instead of the CMS-required minimum of two days. During an interview on 2/24/26 at 11:34 AM, the Executive Director confirmed that the facility did not provide the NOMNC at least two days prior to the end of Medicare coverage and acknowledged that it should have been provided earlier. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended.
Failure to Follow Bowel Protocol and PRN Constipation Orders
Penalty
Summary
The facility failed to follow its bowel care standing orders and physician constipation orders for two residents who went more than 72 hours without a documented bowel movement (BM). The facility’s standing orders and bowel protocol required administration of a bisacodyl delayed-release tablet after no BM in three consecutive days, followed by a bisacodyl suppository if there were no results within 24 hours, and then a Fleet enema if there were still no results, with provider notification if there was no effect after the enema. For one resident with multiple diagnoses including a left arm fracture and repeated falls, the medical record showed a BM on 1/30/26 and not again until 2/4/26 (about 84 hours later), and another BM on 2/16/26 with no further BM until 2/20/26 (about 96 hours later). This resident had a daily MiraLax order that was administered as prescribed, as well as PRN orders for bisacodyl tablet, bisacodyl suppository, and Fleet enema for constipation, but the bisacodyl tablet, suppository, and enema were not administered during these periods without a BM. Another resident, with multiple diagnoses including cellulitis of the right lower limb and pulmonary fibrosis, had documented BMs on 2/10/26 and then not again until 2/15/26 (over 120 hours later), and on 2/18/26 with no further BM until 2/22/26 (over 96 hours later). This resident had PRN orders for bisacodyl delayed-release tablets, bisacodyl suppositories, and Fleet enemas for constipation, to be used sequentially if there was no BM in three consecutive days and no response within 24 hours to each intervention. The record showed only one dose of bisacodyl tablet given on 2/15/26, with no administration of the ordered bisacodyl suppository or Fleet enema during the extended periods without a BM. On 2/24/26 at 10:08 AM, the DNS confirmed that both residents had no documented BM for over 72 hours without nursing intervention using the prescribed medications, despite the standing orders and physician orders in place.
Failure to Follow Ordered Oxygen Flow Rate for Resident on O2 Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for one resident receiving oxygen therapy. The resident, who had multiple diagnoses including diabetes and chronic obstructive pulmonary disease, had a physician’s order dated 2/12/26 for oxygen at 2 L/min via nasal cannula continuously, with instructions to maintain oxygen saturation at or above 88% and to check oxygen saturation every shift. On 2/23/26 at 11:22 AM, the resident was observed asleep in bed with an oxygen concentrator set at 4 L/min and the nasal cannula in place. On 2/24/26 at 10:20 AM, the resident’s oxygen concentrator was again observed set at 4 L/min in the presence of an RN, who stated the concentrator should not have been at 4 L/min and adjusted it back to 2 L/min. Later that day, the Regional Support Nurse acknowledged that someone should have identified the increased oxygen flow rate but had not. This failure to follow the physician’s ordered oxygen flow rate created the potential for residents to experience increased fatigue.
Failure to Administer PRN Opioid According to Ordered Pain Levels
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s opioid pain regimen was administered according to the ordered indications for use, as required by the facility’s Pain Management policy. The policy, revised on 12/29/25, stated that pharmacological interventions would follow a systematic approach and that evidence-based practice tools would be considered to assist in assessing analgesic therapy. Resident #23, admitted with osteomyelitis and sepsis, had physician orders for oxycodone 5 mg: one tablet by mouth every 4 hours as needed for moderate pain and two tablets by mouth every 4 hours as needed for severe pain. The facility used a standard pain scale where scores of 1–3 indicated mild pain, 4–6 moderate pain, and 7–10 severe pain. Record review of the MAR showed that the resident received two tablets of oxycodone (the dose ordered for severe pain) on multiple occasions when the documented pain level was in the moderate range (pain scores of 4–6) and once when the pain level was documented as 2, which is in the mild range. These administrations occurred on several dates, with pain scores of 4, 5, or 6 documented at the time of administration, and one instance with a pain score of 2. During an interview, the DNS confirmed that the facility uses the standard pain scale and acknowledged that the pain medication should have been administered according to the ordered pain levels but had not been, indicating the resident was not assessed and treated in alignment with the prescribed indications for opioid use.
Facility Fails to Maintain Kitchen Sanitation
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. The inspection revealed multiple areas of concern, including dust accumulation between the handles of the refrigerator and freezer, and a large hard water stain on the ice machine floor drain. Additionally, the drain pipes for the ice machine were covered with a thick, dark gray, dry substance, and the right side of the ice machine had a buildup of a white substance. The inside lip of the ice machine was found with a red, dry substance, and under the handwashing sink, a fuzzy, gray substance was observed on the pipes/tubing along with a hard water stain on the floor. Further observations included a dish rack with a thick, fuzzy, gray, and yellow substance around its base and wheels, and dried chunks of different colors on the poles of the rack. The serving table had a white substance on its lower edge, and the wheels and lower part of the poles of the dish racks were covered with a thick, gray, fuzzy substance. The front of the stove had a brown/orange, thick substance, and the vents in the dish room and above the serving table were covered with a black substance. Inside the refrigerator, a dry, yellow substance was observed in the left corner, and a dry, white substance was noted on the right side of the refrigerator wall. Despite having a daily and weekly cleaning schedule, the kitchen equipment and floor were not maintained as expected, as confirmed by the DM and the Administrator.
Failure to Ensure Accurate Resuscitation Status and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's resuscitation code status was accurately documented and up to date in their medical records, and did not provide assistance to the resident or their representative in formulating an advance directive. This deficiency was identified for one resident who had conflicting documentation regarding their resuscitation status. The resident's face sheet indicated a Do Not Resuscitate (DNR) status, while the Physician Orders for Scope of Treatment (POST) form indicated a preference for CPR and resuscitation. Additionally, the resident's care plan also documented a DNR status, creating inconsistencies in the medical record. The resident's medical record lacked documentation of an advance directive, and there was no evidence that the facility had offered assistance to the resident in formulating one, nor was there documentation that the resident declined to formulate an advance directive. The Director of Nursing (DON) and Regional Support Nurse acknowledged the discrepancies in the documentation and confirmed that the POST form was the most current document, which conflicted with other records. This oversight created the potential for harm or adverse outcomes if the resident's wishes were not accurately followed or documented.
Deficiencies in Cleanliness and Lighting in Resident Rooms
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment for all 37 residents, as evidenced by observations of unclean equipment and inadequate lighting. Direct care staff were responsible for cleaning resident-care equipment, but observations revealed that this was not consistently done. In one instance, a bed rail and bedside table in a resident's room were found with dried substances, indicating they had not been cleaned as required. Additionally, a Hoyer lift was observed with a dirty cushion, and staff interviews revealed a lack of clarity regarding the cleaning schedule for such equipment. Furthermore, the facility did not ensure adequate lighting in resident rooms, which posed a potential safety risk. A resident with heart failure and diabetes reported being unable to reach the light switches from his bed, resulting in the lights being off in his room. The Administrator acknowledged that the location of light switches was a problem for some residents, as confirmed by a survey indicating that four residents identified this as a barrier. These deficiencies highlight the facility's failure to maintain a clean and safe environment for its residents.
Failure to Complete SCSA MDS for Residents with New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS) for two residents who were newly diagnosed with major mental disorders. Resident #27, who was initially admitted with primary adrenocortical insufficiency and Alzheimer's disease, was identified to have a schizophrenic disorder on a PASARR dated 8/21/24. However, the quarterly MDS did not reflect this diagnosis, and the Director of Nursing (DON) and the Registered Staff Nurse (RSN) acknowledged that the MDS should have been updated within 14 days of the diagnosis. Similarly, Resident #33, admitted with a fractured pelvis, anxiety disorder, and depression, was later diagnosed with major depressive disorder by her physician. Despite this diagnosis, the Admission MDS did not document her as having a serious mental illness. The DON and RSN confirmed that a SCSA MDS was not completed following the new diagnosis. These oversights in updating the MDS records for both residents could potentially lead to unrecognized changes in their health status and mental health needs.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that a resident's care plans were revised to reflect current needs and interventions, as evidenced by the case of a resident who experienced a fall and had undergone lumbar spinal fusion surgery. The resident, who was initially admitted with multiple diagnoses including spinal stenosis and heart failure, fell from his wheelchair, resulting in injuries. Despite this incident, the resident's care plan was not updated with new fall interventions, as confirmed by the Director of Nursing (DON). Additionally, the resident's care plan contained outdated information regarding his lumbar surgery, which had occurred some time ago. The care plan included interventions related to surgical site monitoring and pain management, which were no longer relevant as the resident did not have any current wound issues. The DON acknowledged that the care plan should have been updated to reflect the resident's current condition and needs.
Failure to Provide Ordered Respiratory Services
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for a resident with obstructive sleep apnea. The resident, who was initially admitted with multiple diagnoses including diabetes and obstructive sleep apnea, reported not using her CPAP machine for three nights because the humidifier water had run dry and had not been refilled by the staff. The physician's orders specified that the CPAP humidifier should be filled with distilled water every night and as needed during the night shift. Observations and interviews revealed that the nursing staff did not adhere to the physician's orders regarding the maintenance of the CPAP machine. The Director of Nursing confirmed that the nursing staff should have been filling the humidifier each night and as needed, but this was not done. This oversight created the potential for the resident to experience increased fatigue, poor sleep quality, and low oxygen levels.
Controlled Medication Tracking and Security Lapse
Penalty
Summary
The facility failed to ensure controlled medications were properly tracked and secured, which could lead to potential theft or diversion. This issue was identified during a review of one of the two medication carts. The facility's policy on Controlled Substance Administration & Accountability, dated 12/16/24, mandates safeguards to prevent loss or diversion of controlled substances. However, during an audit of hall 100's medication cart, it was observed that the narcotic accountability record, covering the period from 1/1/25 to 2/4/25, lacked a licensed nurse's signature for 11 out of 35 days. RN #1 confirmed that nurses are required to sign the sheet when they accept or release the medication cart.
Psychotropic Medication Prescribed Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure that psychotropic medications were prescribed based on a documented and specific diagnosed condition in the resident's medical records. This deficiency was identified for one resident who was administered Risperdal, an antipsychotic medication, without a documented diagnosis of schizophrenia, which was the condition for which the medication was prescribed. The facility's policy on unnecessary drugs requires documentation in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed. However, this was not adhered to in the case of the resident in question. The resident, who had multiple diagnoses including primary adrenocortical insufficiency and Alzheimer's disease, did not have schizophrenia documented as a medical diagnosis in their medical record. Despite this, the resident's physician's order included Risperdal for schizophrenia. The Minimum Data Set (MDS) for the resident also indicated 'NO' for schizophrenia. During an interview, the Director of Nursing (DON) and the Registered Staff Nurse (RSN) acknowledged that the diagnosis should have been documented before the medication was ordered and administered, but it was not.
Improper Garbage Disposal in Kitchen
Penalty
Summary
The facility failed to ensure that garbage cans in the kitchen were properly closed with lids, which is a violation of Idaho Administrative Rules and the U.S. Food and Drug Administration 2022 Food Code. During an observation on February 3, 2025, at 8:10 AM, a large garbage can without a lid was noted next to the clean dish rack in the kitchen. On February 5, 2025, at 1:13 PM, the cook stated that they had never had a lid on their garbage can and were unaware of the requirement for one. Later that day, at 2:54 PM, the RSN confirmed that the garbage can should have had a lid. This deficient practice had the potential to affect all residents and staff in the facility by attracting pests and rodents into the kitchen.
Infection Control Lapse in IV Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices during the administration of IV medication to Resident #28. The facility's Intravenous Therapy policy requires the disinfection of needleless connectors and IV ports with an appropriate antiseptic agent before and after connecting syringes. However, during an observation, RN #1 did not disinfect the bedside table before placing IV push antibiotics and flush syringes on it, nor did she use a protective barrier. Additionally, RN #1 failed to clean the second IV port with an alcohol pad before connecting the antibiotic syringe, which is a deviation from the established protocol. During an interview, RN #1 acknowledged the oversight, admitting that she should have disinfected both the bedside table and the IV port before connecting each syringe. The RSN also confirmed that the proper procedure was not followed, as the bedside table and IV port should have been cleaned prior to each connection. This lapse in protocol had the potential to place residents at risk for cross-contamination and infection.
Failure to Monitor and Discard Outdated Food Items and Maintain Kitchen Sanitation
Penalty
Summary
The facility failed to monitor and discard outdated food items and maintain the kitchen in a sanitary manner, which had the potential to affect the 36 residents consuming food prepared by the facility. Observations revealed that several seasoning containers had handwritten use-by dates that were one or two years from the date on the sticker, with some containers having two different use-by dates. Additionally, some seasonings and food items had no date on the sticker but had use-by dates written on them. The Chef and Dietary Manager (DM) confirmed that expired food items should not be in the kitchen and that some containers were refilled, leading to inconsistencies in date marking. During a kitchen tour, it was observed that the metal shelf where the oven was located had a collection of dark debris, rusted areas, and food droppings. The oven door had whitish dried splatters, and the inside of the oven was heavily soiled with grease. The can opener also had white splatter on its side. The DM stated that the shelves were cleaned every three months and the oven every week but was unable to provide documentation to support this. These deficiencies placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.
Failure to Assist Residents with Advanced Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an Advanced Directive. This deficiency was identified for six residents whose records were reviewed for advanced directives. The facility's policy required that on admission, the facility would determine if the resident had an advanced directive and, if not, assist in formulating one. However, the records for these residents did not include an advanced directive or documentation that information about an advanced directive was provided and discussed with the residents or their representatives. Specific examples include residents with multiple diagnoses such as respiratory failure, hypertension, cerebral infarction, and diabetes, whose records lacked the necessary documentation regarding advanced directives. The Social Services Director (SSD) admitted that the social services assessments incorrectly documented that copies of the residents' advanced directives were received. The SSD also acknowledged that she did not document discussions or offers to assist residents or their representatives with completing an advanced directive. This oversight was confirmed through staff interviews and record reviews, highlighting a significant lapse in following the facility's policy on advanced directives, potentially leading to harm or adverse outcomes if residents' wishes were not followed or documented.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a summary of residents' baseline care plans to residents or their representatives within 48 hours of admission, as required by their policy. This deficiency was identified for five residents who were admitted with various serious medical conditions, including respiratory failure, hypertension, cerebral infarction, Type 2 diabetes, cervical vertebra fracture, sepsis, and urinary tract infection. Despite being cognitively intact, these residents did not have documentation in their records indicating that their baseline care plans were provided and discussed with them or their representatives. The facility's policy required that a written summary of the baseline care plan be provided to the resident or their representative, with a signature obtained to verify receipt. If the summary was provided verbally by telephone, the nurse was to document the discussion, sign the summary, and mail it to the resident's representative. However, staff interviews confirmed that there was no documentation showing that the baseline care plans were reviewed or signed by the residents or their representatives, indicating a systemic failure to comply with the policy.
Failure to Update Care Plan for Neobladder Irrigation
Penalty
Summary
The facility failed to ensure that residents' care plans were revised and updated as necessary. This was evidenced by the case of a resident admitted with multiple diagnoses, including bladder cancer and muscle weakness. A physician's order directed staff to irrigate the resident's neobladder twice daily with saline. However, the care plan did not include this critical information. The Clinical Resource Nurse confirmed that the care plan was not updated to reflect the required neobladder irrigation, despite the facility's policy that care plans should be reviewed and revised upon a resident's status change.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to ensure residents received bathing assistance consistent with their needs, specifically for one resident with multiple diagnoses including dementia and depression. The Resident Showers policy directed staff to assist residents with bathing to maintain proper hygiene. However, the Bath/Shower Flowsheet for the resident documented multiple instances where the resident did not receive a shower or bath over a period of several weeks, with refusals and 'Not Applicable' entries noted. Observations of the resident showed signs of poor hygiene, such as wearing a gown with a shirt over it and having small white hairs on his chin. The Director of Nursing acknowledged that the resident refused many of his cares and that these refusals should have been documented in his record.
Failure to Monitor and Offer Non-Pharmacologic Pain Interventions
Penalty
Summary
The facility failed to ensure that residents receiving opioid pain medications were monitored appropriately and offered non-pharmacologic pain interventions. This was identified for one resident who was reviewed for unnecessary medications. The facility's PRN Medications policy required staff to offer non-drug interventions before administering PRN medications. However, the resident's Medication Administration Record (MAR) did not include documentation that non-pharmacologic interventions were offered prior to administering the as-needed pain medications. Resident #15, who had multiple diagnoses including bladder cancer and muscle weakness, was given oxycodone 10 mg one time a day for 27 days and two times a day for 9 days. The resident's pain level ranged from 3 to 5 on the pain scale during this period. Despite the physician's order to attempt non-medication interventions before administering pain medications, there was no documentation in the resident's record that these interventions were offered. The Director of Nursing (DON) confirmed that non-pharmacologic interventions should have been offered and documented, but they were not.
Failure to Document Target Behaviors for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychoactive medications had resident-specific target behaviors identified and monitored. This was evident for one resident who was prescribed Trazodone and Aripiprazole for depression. The resident's care plan did not document the use of these psychoactive medications or the specific target behaviors for depression. A staff member reviewed the resident's record and confirmed the absence of documented target behaviors.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, as evidenced by a 6.06% error rate observed during the survey. This deficiency affected one resident, who was prescribed multiple medications. Specifically, Resident #27, who had been admitted with diagnoses including sepsis and respiratory failure, was involved in two medication errors. On one occasion, RN #1 administered 400 mg of Amiodarone HCl instead of the prescribed 200 mg. The nurse admitted to not realizing she had already placed the medication in the cup, resulting in the resident receiving double the prescribed dose. In another instance, RN #1 documented that Resident #27 received 17 grams of Polyethylene Glycol powder, as per the physician's order. However, the nurse later admitted that she had not administered the medication because the resident usually refuses it. Despite this, she documented the administration in the Medication Administration Record (MAR). These actions led to the facility failing to meet the required medication error rate, placing residents at risk of not receiving their prescribed medications or dosages.
Failure to Label and Date Medications
Penalty
Summary
The facility failed to ensure medications available for residents were labeled and dated, as observed in two medication carts inspected. Specifically, two insulin pens and two opened multi-use insulin vials were found without dates, and a Lispro insulin vial was dated 2/2/24 in the top drawer of the 100-hall medication cart. RN #1 admitted to not knowing the duration for which the insulin pen or vial was good and acknowledged that the insulin vial and pen should have been dated when opened. Additionally, five insulin pens and one opened vial of insulin were found without dates in the top drawer of the 300-hall medication cart. LPN #1 confirmed that the insulin pens and vials should have been dated when opened and are good for 28 days from the opened date. LPN #1 also stated that the insulin pens and vials should have been discarded when expired and replaced with new ones. This failure created the potential for residents to receive expired medications with decreased efficacy.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, impacting three residents observed for infection control. Resident #19, who had a Foley catheter and gastric tube, was not provided with appropriate isolation signage, and staff did not follow proper procedures for catheter irrigation, including disinfecting the port and wearing a gown. RN #1 was unaware of the need for these precautions and did not clean the catheter port before use or wear a gown during the procedure. Resident #27, who had a PICC line and was receiving IV antibiotics, was also not provided with proper infection control measures. RN #1 did not disinfect the PICC IV tubing port before administering the antibiotic and did not wear a gown during the procedure. The nurse was unaware of the need to clean the port and the requirement for Enhanced Barrier Precautions. Resident #2, who had a right knee infection and was on Enhanced Barrier Precautions, did not receive proper wound care. The Wound Nurse failed to change gloves and perform hand hygiene between steps of the wound dressing change and did not wear a gown during the procedure. The nurse acknowledged the mistakes after the procedure, indicating a lack of adherence to infection control protocols.
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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