Syringa Chalet Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Blackfoot, Idaho.
- Location
- 700 East Alice Street, Blackfoot, Idaho 83221
- CMS Provider Number
- 135111
- Inspections on file
- 15
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Syringa Chalet Nursing Facility during CMS and state inspections, most recent first.
Surveyors observed that a sharps container in a resident room was filled past the designated full line on multiple occasions, and the flip-top lid was not freely movable. During a joint observation, the DON confirmed the container remained overfilled and acknowledged it should have been changed when full but was not. This failure had the potential for injury and infections.
Surveyors found that the facility did not provide a required bed-hold notice to a resident or the resident’s representative at the time of a hospital transfer. The resident, who had multiple behavioral health diagnoses including paranoid schizophrenia and anxiety, was transferred to the hospital and later returned, but the facility’s bed-hold documentation was not completed for this episode. During interview, the Administrator confirmed that the bed-hold notice was not provided at the time of transfer, despite the requirement to do so.
A resident admitted with major depressive disorder, anxiety disorder, and status post right hip revision had a baseline care plan that did not include key person-centered care information. The facility’s policy required baseline care plans within 48 hours of admission to include physician orders, social services, and PASRR recommendations. However, the resident’s PASRR evaluation, which recommended psychotherapy, community-based rehabilitative services, mental health case management, psychiatric follow-up, and a safety plan for suicidal ideation, was not reflected in the baseline care plan. A physician order for a knee immobilizer to be worn in bed or while sitting was also omitted, and the DON later confirmed these omissions.
A resident with constipation and serious mental illness did not receive bowel management medications as ordered by the physician or as outlined in the facility’s bowel and bladder protocol. The protocol required escalating interventions, including Milk of Magnesia and Bisacodyl, based on the number of hours since the last bowel movement, but documentation showed prolonged periods without bowel movements and no corresponding administration of ordered constipation medications, except for isolated Bisacodyl doses. The Administrator acknowledged that the resident should have received the ordered bowel management medications and did not.
Surveyors found that staff failed to follow and document physician-ordered respiratory services for multiple residents with conditions such as schizophrenia, dementia, COPD, obesity, and bipolar schizoaffective disorder. Several residents had orders for oxygen via nasal cannula with specific SpO2 targets, yet records showed repeated low SpO2 readings, some in the low 80s, without corresponding nursing interventions. One resident was observed with the O2 regulator on but the cannula off, and another reported using oxygen only at night despite an order to maintain certain SpO2 levels. The DON attributed the lack of documented responses to poor and incomplete nursing documentation.
Surveyors found that controlled medications on one medication cart were not properly tracked or secured when narcotic accountability sheets were missing required nurse signatures on multiple days. An RN and the DON both stated that two nurses were expected to sign the narcotic accountability records when accepting or releasing the cart, but this did not occur as required, creating the potential for undetected misuse or diversion of controlled medications affecting all residents receiving these drugs.
Surveyors observed that medication carts for two halls were left unattended outside a dining room during mealtime, with one cart’s drawer containing medications left ajar. Facility policy required all medication areas and cabinets to remain locked when the medication nurse was not present. When an RN returned to the cart and stated it was locked, the surveyor pointed out the open drawer, and the RN was able to open and then properly close and relock it, acknowledging the drawer should have been locked but was not, resulting in unsecured medications accessible to unauthorized individuals.
Surveyors found that in two resident rooms, the bathroom shower call light strings were curled up and did not extend to the floor, making them inaccessible to a resident who might be on the shower floor. The Administrator confirmed that the shower call light strings were expected to extend to the floor area but did not in these bathrooms, creating a situation where a resident could be unable to summon staff for assistance.
Two residents experienced a decline in their ability to perform ADLs due to the facility's failure to provide necessary restorative nursing services. One resident, with schizophrenia and diabetes, did not receive restorative care despite documented needs. Another resident, with schizoaffective disorder and polyneuropathy, experienced increased dependency after physical therapy was discontinued, and restorative services were not consistently provided as ordered.
The facility failed to treat residents with dignity by administering medications and checking blood sugar in common areas without documented consent. Observations showed residents receiving care in public spaces, and interviews revealed a lack of audits and documentation of resident preferences, leading to a deficiency in maintaining resident dignity.
A facility failed to provide a bed hold notice to a resident or their representative at the time of hospital transfer. The resident, with schizophrenia and traumatic brain injury, was transferred to the hospital, but the bed hold document was completed three days after their return. The DON confirmed the notice should have been completed at the time of transfer.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documented medical conditions. A resident's MDS incorrectly noted a feeding tube, while another's inaccurately documented an enteral feeding tube. Additionally, a third resident's MDS omitted a psychosis diagnosis despite being on antipsychotic medication. These errors were confirmed by the DON and staff.
A facility failed to update a resident's care plan to reflect current physician orders. The resident, with schizoaffective disorder and a rotator cuff tear, had a care plan listing spironolactone, which was not in their active or discontinued medication orders. The DON confirmed the resident was not receiving the medication and the care plan should have been updated.
A resident with schizoaffective disorder and COPD had a care plan requiring oxygen saturation levels to be maintained at 90% and physician notification for decreases. Despite multiple documented instances of levels below 90%, CNAs did not inform licensed nursing staff, and the physician was not notified, potentially affecting the resident's health. The DON acknowledged the failure in communication.
The facility's kitchen staff failed to follow proper food handling and storage protocols, including not washing hands before donning gloves and keeping expired food items in storage. A senior cook was observed not washing hands before putting on new gloves, and expired food items were found in both the walk-in and resident refrigerators, contrary to the facility's policy.
The facility failed to ensure garbage cans in the kitchen and food serving area were properly closed with lids, as required by Idaho Administrative Rules and the FDA Food Code. Five uncovered garbage cans were observed, and the Dietary Manager was unaware of the requirement for closing lids. This oversight could attract pests and rodents, potentially affecting all residents and staff.
Failure to Replace Overfilled Sharps Container in Resident Room
Penalty
Summary
The facility failed to provide a safe and functional environment by not properly managing sharps containers in one of four resident rooms. On two separate observations, the sharps container in room 411 was noted to be filled past the indicated full line, and the flip-top lid was not freely movable. During a subsequent joint observation with the DON, the sharps container in the same room was again observed to be filled past the full line. The DON stated that the sharps container should have been changed when it was full and acknowledged that it had not been. This failure had the potential for injury and infections. No additional information was provided about the specific resident(s) occupying the room, their medical history, or their condition at the time of the deficiency.
Failure to Provide Bed-Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a required bed-hold notice to a resident or the resident’s representative at the time of transfer to the hospital, as identified through record review and staff interview. One resident, admitted with multiple diagnoses including paranoid schizophrenia and anxiety, was transferred to the hospital on 7/19/25 and returned on 8/4/25. Review of this resident’s medical record showed that the facility’s bed-hold document had not been completed for this hospitalization. In an interview on 1/22/26 at 4:03 PM, the Administrator confirmed that the bed-hold notice had not been completed at the time of transfer and acknowledged that it should have been done. This deficiency involved the facility’s failure to ensure residents were informed of their rights related to bed-hold and return to their former bed or room at the time of transfer, as required by policy and regulation, for 1 of 4 residents reviewed for transfers.
Failure to Include PASRR Recommendations and Safety Device in Baseline Care Plan
Penalty
Summary
Surveyors identified that the facility failed to include required person-centered care information on the baseline care plan for one resident. The facility’s Baseline Care Plan policy dated 7/11/24 required that a baseline care plan be developed within 48 hours of admission and include minimum healthcare information necessary to properly care for the resident, such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASRR recommendations when applicable. For the resident in question, who was admitted with multiple diagnoses including major depressive disorder, anxiety disorder, and status post right hip revision, the baseline care plan was created but not dated and did not reflect all required elements. The resident’s PASRR Mental Illness Evaluation dated 1/8/26 documented recommendations for individual psychotherapy, community-based rehabilitative services, mental health case management, weekly or quarterly psychiatrist appointments for psychiatric prescription medication management, and development of a safety plan to address suicidal ideation. Additionally, a physician order dated 1/12/26 directed that the resident wear a knee immobilizer while lying in bed or sitting in a chair. Despite these documented recommendations and orders, the baseline care plan did not include the PASRR recommendations or the physician-ordered knee immobilizer. On 1/21/26 at 5:00 PM, the DON confirmed that these items were not included on the baseline care plan and acknowledged they should have been.
Failure to Follow Bowel Management Orders and Protocol
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own bowel and bladder protocol for a resident with constipation and multiple diagnoses, including bipolar schizoaffective disorder. The facility’s protocol dated 7/8/20 directed staff to offer prune juice or Milk of Magnesia 24–48 hours after the last bowel movement, Bisacodyl 5 mg PO/PR at 48–72 hours, and to review the resident’s condition with a medical provider at 72 hours if no bowel movement occurred. Physician orders for this resident included Milk of Magnesia 30 ml by mouth, with one repeat dose allowed in 24 hours as needed for constipation, and one-time Bisacodyl 5 mg EC tablet orders on several dates. Record review showed that after a documented bowel movement on 12/14/25, the resident did not have another recorded bowel movement until 12/23/25, a gap of over 192 hours, with no documentation that any ordered constipation medications were administered between 12/15/25 and 12/23/25. After a bowel movement on 12/30/25, the next was not documented until 1/6/26, during which time only one dose of Bisacodyl 5 mg EC tablet was given on 1/5/26, with no other constipation medications documented from 12/31/25 to 1/4/26. Following a bowel movement on 1/6/26, the next was not documented until 1/12/26, with only one Bisacodyl 5 mg EC tablet administered on 1/12/26 and no documentation of constipation medications from 1/7/26 to 1/11/26. The Administrator confirmed that the resident should have received the ordered bowel management medications and had not.
Failure to Provide and Document Ordered Respiratory Services for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services as ordered by physicians and to document nursing interventions in response to low oxygen saturation (SpO2) readings for seven residents. For one resident with disorganized schizophrenia and anorexia, the physician ordered oxygen at 1–2 LPM by nasal cannula as needed to keep SpO2 greater than 90%. The resident’s record showed multiple SpO2 readings of 90% on various dates with no documented nursing interventions. Another resident with anxiety disorder and dementia had an order for PRN oxygen by nasal cannula, titrated 2–5 LPM to keep SpO2 at 90% as allowed. This resident was observed in bed with the O2 regulator set at 2 LPM while the nasal cannula lay on the overbed table, and the record showed several SpO2 readings between 83% and 89% with no timely or documented interventions, except for one instance where an intervention was documented two hours late. Additional residents with dementia, upper respiratory infection, bipolar schizoaffective disorder, hypertension, paranoid schizophrenia, and obesity had physician orders for oxygen titrated by nasal cannula to maintain SpO2 above 90% as tolerated. Their medical records contained multiple low SpO2 readings, ranging from 85% to 90%, without corresponding documentation of nursing interventions. One resident with bipolar schizoaffective disorder and diabetes had an oxygen order of 2–5 LPM to keep SpO2 at 87–90% as allowed, yet was observed at the nurse’s station without supplemental oxygen and later reported using oxygen only at night or when sitting in his room. This resident’s record also showed several low SpO2 readings, including one as low as 80%, with no documented interventions. A resident with COPD and dementia had a physician order for oxygen via nasal cannula at 0.5–5 LPM, titrated to keep SpO2 between 88–92% as allowed. The record showed SpO2 readings of 82%, 84%, and 87%, with one nursing intervention documented five hours late and no other interventions recorded for the other low readings. Across all seven residents reviewed for respiratory services, surveyors identified repeated instances where low SpO2 values were recorded without corresponding nursing actions or documentation, despite existing physician orders specifying oxygen parameters. The DON stated that the low SpO2 documentation without documented nursing intervention was due to poor and lacking nursing intervention documentation.
Failure to Properly Track and Secure Controlled Medications on Medication Cart
Penalty
Summary
The facility failed to ensure controlled medications were properly tracked and secured from potential theft or diversion for one of two medication carts reviewed. During a medication cart audit conducted on 1/21/26 at 12:46 PM, surveyors observed narcotic accountability sheets dated 1/1/26 to 1/21/26 that were missing three licensed nurse signatures on 1/8/26 and 1/13/26. At 12:48 PM, a registered nurse stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart. At 1:07 PM, the DON confirmed that two nurses were expected to sign the narcotic accountability record when accepting or releasing the medication cart. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medications in the facility. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to the facility’s process for documenting and securing controlled medications on the medication cart.
Unsecured Medication Cart Left Unattended During Mealtime
Penalty
Summary
The deficiency involves the facility’s failure to keep medications secure and inaccessible to unauthorized staff and residents, as required by its own policy and professional standards. The facility’s “Control and Administration of Medications” policy dated 11/13/24 states that all medication areas and cabinets must be kept locked at all times when the medication nurse is not present. During a mealtime observation on 1/20/26 at 12:30 PM, surveyors observed the Sawtooth Hall and Targhee Hall medication carts unattended outside the dining room, and the Sawtooth Hall cart had one drawer containing medications ajar. At 12:33 PM, an RN approached the Sawtooth Hall cart and, when asked, stated the cart was locked; however, the surveyor pointed out the open drawer, and the RN was able to pull the drawer out, push it back in, and then relock the cart. The RN acknowledged that the drawer should have been locked but was not, confirming that medications on that cart were left unattended and unsecured.
Inaccessible Shower Call Light Strings in Resident Bathrooms
Penalty
Summary
Surveyors identified a deficiency in the availability and accessibility of the resident call system in bathroom shower areas. During observations on 1/21/26 at 9:35 AM, the bathroom shower call light strings in resident rooms #303 and #307 were found curled up so they were not accessible to a resident who might be on the floor of the shower. In a subsequent interview on 1/21/26 at 12:50 PM, the Administrator acknowledged that the bathroom shower call light strings should not be curled up and confirmed they should extend to the floor area of the shower but were not. The report states this failure had the potential for harm if residents were not able to summon staff for assistance. No additional resident-specific medical histories or conditions at the time of the deficiency are provided in the report.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain or improve the ability of residents to perform activities of daily living (ADLs), as evidenced by the cases of two residents. Resident #8, with diagnoses including schizophrenia and diabetes, experienced a decline in ADLs without receiving restorative nursing services. Despite documentation showing no initial impairment, later assessments indicated a need for assistance with bed mobility, transfers, and toileting. The Director of Nursing (DON) confirmed the absence of a restorative program and lack of documentation to prevent the decline in Resident #8's ADLs. Resident #18, diagnosed with schizoaffective disorder bipolar type and polyneuropathy, also experienced a decline in ADLs. Initially, there was no impairment, but subsequent assessments showed increased dependency on assistance for mobility. Although a physician ordered restorative nursing for muscle strengthening and range of motion, the resident did not receive these services consistently. The DON acknowledged that Resident #18 had not received the ordered restorative services, contributing to her decline in strength and abilities.
Failure to Ensure Resident Dignity in Medication Administration
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by observations of residents receiving medical care in common areas without documented consent. Specifically, four residents were observed having their blood sugar checked or receiving medications in open areas such as the dining room, hallway, and activity room, where other residents could witness these procedures. The medical records for these residents did not document their preference or consent to receive such care in public spaces, which is a violation of their right to privacy and dignity. Interviews with staff revealed inconsistencies in the facility's practices regarding obtaining and documenting resident consent for receiving medical care in common areas. RN #1 mentioned that audits were conducted to determine residents' preferences, but the Director of Nursing (DON) later confirmed that no such audits were performed, and there were no orders or care plans documenting the residents' consent for public administration of medications or blood sugar checks. This lack of documentation and adherence to the facility's dignity policy resulted in a deficiency that compromised the residents' right to a dignified existence.
Failure to Provide Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives at the time of transfer to a hospital, as required. This deficiency was identified during a review of records and staff interviews, specifically affecting one resident who was transferred to the hospital. The resident, who had multiple diagnoses including schizophrenia and traumatic brain injury, was admitted to the facility and later transferred to the hospital. The bed hold document, which should have been completed at the time of transfer, was not completed until three days after the resident returned to the facility. The Director of Nursing acknowledged that the bed hold should have been completed at the time of the hospital transfer.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could lead to negative outcomes due to inaccurate assessments. Resident #2 was admitted with multiple diagnoses, including bipolar disorder and hypertension. Her Quarterly MDS inaccurately documented the presence of a feeding tube, which was confirmed as an error by the Director of Nursing (DON) and a registered nurse (RN). Similarly, Resident #14's MDS incorrectly noted an enteral feeding tube, which the resident and the DON confirmed was never in place. Resident #33, diagnosed with dementia and major depressive disorder, was on Risperidone for psychosis, as documented in her pharmacy Drug Regimen Review report and care plan. However, her Quarterly MDS failed to document her psychiatric disorder, including dementia with behavioral disturbances and psychosis. The DON acknowledged that the physician had not updated the medication list, resulting in the omission of the psychosis diagnosis on the MDS.
Care Plan Not Updated to Reflect Current Orders
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current physician orders. This deficiency was identified for one resident who was admitted with multiple diagnoses, including schizoaffective disorder depressive type and a rotator cuff tear. The resident's care plan, initiated in September, incorrectly documented that the resident was to receive spironolactone, an anti-hypertensive medication, which was neither listed in the resident's active nor discontinued medication orders. This discrepancy was noted during a review in December, and the Director of Nursing confirmed that the resident was not receiving spironolactone and acknowledged that the care plan should have been updated to remove the medication.
Failure to Follow Care Plan for Oxygen Saturation Monitoring
Penalty
Summary
The facility failed to ensure that care plans were followed for a resident with schizoaffective disorder bipolar type and chronic obstructive pulmonary disease. The resident's care plan required CNAs and licensed nursing staff to maintain oxygen saturations at 90% and to notify the physician if levels decreased. However, multiple instances of oxygen saturation levels below 90% were documented by various CNAs over a period of time, with no evidence that the licensed nursing staff were informed or that the physician was notified. This oversight had the potential for adverse effects on the resident's medical and physical status. The Director of Nursing confirmed that the CNAs documented the low oxygen levels but failed to notify the licensed nursing staff as required.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The kitchen staff at the facility failed to adhere to proper food handling and storage protocols as outlined in the U.S. Food and Drug Administration 2022 Food Code. Specifically, a senior cook was observed not washing her hands before donning new gloves after removing the old ones, which is a violation of the food safety code that requires handwashing before putting on gloves. This lapse in hygiene practice was confirmed by the Dietary Manager, who acknowledged that the cook should have washed her hands before putting on new gloves. Additionally, the facility was found to have expired food items in both the walk-in refrigerator and the resident refrigerator. Observations revealed expired cut-up lettuce, ranch dressing, and pineapple juice in the walk-in refrigerator, as well as opened salsa, mayonnaise, French Onion Dip, and Watermelon Minute Maid in the resident refrigerator, all past their use-by dates. The Dietary Manager and the Director of Nursing confirmed that these items should have been discarded according to the facility's policy on refrigerated food storage.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that garbage cans in the kitchen and food serving area were properly closed with lids, as required by the Department of Health and Welfare - Idaho Administrative Rules and the U.S. Food and Drug Administration 2022 Food Code. This deficiency was observed on two separate occasions, with five uncovered garbage cans noted in the kitchen and food serving area. The Dietary Manager was interviewed and stated she was not aware that the garbage cans needed to have closing lids. This oversight had the potential to attract pests and rodents, affecting all residents and staff in the facility.
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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