Caldwell Care Of Cascadia

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure its Antibiotic Stewardship practices were followed by initiating antibiotic therapy without obtaining culture and sensitivity results to guide appropriate treatment. This was true for 1 of 1 residents (Resident #64) reviewed for antibiotic stewardship. This failure created the potential for inappropriate antibiotic use and development of antibiotic resistant organisms. Findings include:The facility's Antibiotic Stewardship Policy, revised 8/10/25, documented the facility focuses on improving antibiotic use through an Antibiotic Stewardship Program to ensure appropriate antibiotic usage, promote therapeutic and cost effective care, and reduce the likelihood of developing multi drug resistant organisms. The policy also documented the facility utilizes McGeer's Criteria to validate infections and routinely reviews culture and sensitivity reports as part of infection surveillance.The Revised McGeer's Criteria for urinary tract infection (UTI) without an indwelling catheter requires both of the following be present:1. At least one clinical sign or symptom, such as:Fever, rigors, or new onset hypotension (low blood pressure) with no alternate site of infectionAcute change in mental status or functional decline with leukocytosis (extremely high white blood cell counts)New onset suprapubic pain or costovertebral angle tenderness (pain at the angle formed by the 12th rib and spine)Purulent discharge or acute pain/swelling of the testes, epididymis (inflammation of the coiled tube at the back of the testicle that stores and carries sperm) or prostate.AND:2. At least one microbiologic criteria, such as: 10 cfu/mL of no more than two organisms in a voided urine sample 10^2 cfu/mL of any organism in a catheterized specimenResident #64 was readmitted to the facility on [DATE] with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care.Resident #64's care plan revised 3/27/25, directed staff to encourage fluids and monitor for the following symptoms:[urinary] frequency malaisefoul smelling urinedysuria (pain when urinating)fevernauseavomitingflank painsupra-pubic painhematuriacloudy urinealtered mental statusloss of appetitebehavioral changesA progress note dated 3/27/25 at 4:43 PM, documented Resident #64 was observed to be increasingly lethargic with decreased muscle function. As a result, the provider was notified, and the following new orders were given:CBC (complete blood count lab test)CMP (comprehensive metabolic panel blood test)Urine analysis with culture and sensitivityCefdinir (an antibiotic) 300mg by mouth twice daily for 5 days for a diagnosis of urinary tract infection.A review of Resident #64's lab results documented the urine specimen was collected on 3/27/25 at 1:45 PM and the culture and sensitivity were completed on 3/29/25 at 7:54 AM, 3 days after antibiotics were started.On 3/5/26 at 4:12 PM, the DON confirmed Resident #64 did not meet McGeer's criteria for antibiotics for a urinary tract infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure residents receiving anticonvulsant medications were monitored for potential side effects as required by their comprehensive person-centered care plans. This was true for 2 of 5 residents (#34 and #41) whose records were reviewed for unnecessary medications. This failure created the potential for harm if side effects were undetected. Findings include:1. Resident #34 was admitted on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.Resident #34's record included a physician order for Depakote (an anticonvulsant) sprinkles delayed release capsule 250 mg by mouth three times a day for alcohol dependence.Resident #34's care plan revised 8/6/25, directed staff to monitor, notify the provider and document side effects for anticonvulsants such as:Over-sedation or lethargyRestless agitationIncreased confusion or poor concentrationMental status changeVisual disturbanceChange in gaitBehavioral changesWeight changeResident #34's record did not include documentation the facility staff were monitoring for side effects of anticonvulsants.2. Resident #41 was admitted to the facility on [DATE] with multiple diagnosis including borderline personality disorder, Alzheimer's disease, and suicidal ideations.Resident #41's record included a physician order for Depakote sprinkles delayed release capsule 750 mg by mouth two times a day for borderline personality disorder.Resident #41's care plan revised 10/14/24, directed staff to monitor, notify the provider and document side effects for anticonvulsant such as:Over-sedation or lethargyRestless agitationIncreased confusion/poor concentrationMental status changeVisual disturbanceChange in gaitBehavioral changesWeight changeResident #41's record did not include documentation that facility staff were monitoring for side effects of anticonvulsants.On 3/5/26 at 8:32 AM, The DON confirmed Resident #34 and #41's record did not include monitors for anticonvulsants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, it was determined the facility failed to respect the right of residents when they did not provide written notification prior to moving a resident to a new room. This was true for 1 of 1 resident (Resident #13) who was moved prior to receiving written notification. This deficient practice created the potential for psychosocial harm if Resident #13 was not provided an opportunity to see the new location, meet a new roommate, or have questions answered related to the move. Findings include:The facility's Resident Room Changes & Roommate Rights Policy, revised 8/31/25, documented when a resident is being moved at the request of facility staff, the resident, family, and/or representative must receive an explanation in writing of why the move is required. The resident must be provided with the opportunity to see the new location, meet the new roommate, and ask questions.Resident #13 was re-admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.A Quarterly MDS assessment dated [DATE], documented Resident #13 was cognitively intact.A notice of Room-to-Room Transfer form, signed 11/13/25, documented the rational for Resident #13's transfer from room [ROOM NUMBER] to 219 as POA Notified. No further explanation was written.On 3/5/26 at 3:41 PM, the Social Services Manager stated the notification of room change was not filled out correctly and should have identified in writing why Resident #13 was moving from room [ROOM NUMBER] to 219.

Based on observation and staff interview, it was determined the facility failed to ensure resident rights were honored when past survey results were not posted in an area readily accessible to residents and their representatives. This failure created the potential for misinformation about the facility's prior 3 years of survey results and plans of correction. Findings include:On 3/2/26, 3/3/26, 3/4/26, and 3/5/26, a binder labeled State Survey Results was observed in a pocket folder on the wall of a corridor leading to the courtyard. The access to the binder was blocked by a stuffed chair with other large equipment stacked on top of it, two vitals signs towers, and an extra large padded specialized wheelchair. On 3/4/26 at 3:25 PM, during a Resident Council group discussion with surveyors, residents stated they were not aware of the facility's responsibility to make the past 3 years of survey results readily accessible or their right to review the results and plans of correction. The residents stated they did not know where the survey results were posted in the facility. On 3/5/26 at 2:23 PM, the Administrator confirmed the survey results were not accessible because they were blocked by stored equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined resident rights were not honored. This was true for 1 of 16 residents (Resident #9) whose records were reviewed for physician notification. This failure placed Resident #9 at risk for harm when abnormal vital signs were not reported to her physician. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a severe chronic mental health condition), depression, and anxiety. Resident #9's blood pressure record documented four elevated readings the past 90 days:3/1/26: 171/1042/1/26: 164/981/22/26: 171/991/20/26: 173/104Resident #9's record did not document the physician was notified of the elevated blood pressure readings. On 3/6/26 at 9:20 AM, the DON stated the nurses should have notified the physician of Resident #9's elevated blood pressures immediately. The DON was unable to provide documentation the physician was notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview it was determined the facility failed to provide a homelike environment when resident's walls were left unrepaired and/or with visible patch work. This was true for 2 of 16 residents (#13 and #53) whose rooms were observed. This created the potential for psychosocial harm and embarrassment if residents did not have a homelike environment if their walls were not repaired and did not have consistent wall paint covering the white patchwork. Findings include: The facility's Homelike Environment policy, revised 9/17/25, documented the facility supports a residents rights to a safe, clean, comfortable, and homelike environment to promote dignity, independence, and quality of life.1. Resident #13 was re-admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.On 3/2/26 at 9:52 AM it was observed in Resident #13's room there was a jagged vertical damaged line on the wall from floor to ceiling exposing broken drywall. Other areas of the room walls were covered with white patches on top of colored paint. Resident #13 stated the white patches, and damaged wall had been there since she relocated to the room in November 2025.2. Resident #53 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and COPD.On 3/2/26 at 2:35 PM it was observed in Resident #53's room various white patches on painted walls which were both small and large throughout the room. Resident #53 stated the white patches had been on the walls since she could remember.On 3/5/26 at 11:43 AM, the Maintenance Director stated Resident #13 and #53's room walls were patched and primed, ready to be painted; however, they had not been able to paint them yet. He further stated he was unaware Resident #13's room had any damaged walls that needed to be fixed.

Based on observation, record and policy review, and resident and staff interview, it was determined the facility failed to ensure a grievance process was available for residents. This deficient practice created the potential for psychosocial harm if residents' concerns were not identified and addressed in a timely manner. Findings include:The facility's Grievance Process policy, revised 8/29/25, documented the Grievance program addresses the concerns of residents, family members, and visitors and the facility should make prompt efforts to resolve grievances.On 3/2/26 at 8:30 AM, the SA requested a copy of the facility's grievances from September 2025 through March 2026.The facility provided grievances from January 2026 through March 2026. No additional grievances were available.On 3/3/26 at 4:02 PM, the Administrator, with the CRN present, stated there were no grievances available prior to January 2026. The CRN confirmed the facility had identified their grievance process required a performance improvement plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to accurately report which resident was the victim and aggressor in an abuse investigation submitted to the Idaho BFS LTC Reporting System. This was true for 1 of 3 residents (Resident #13) reviewed for abuse. This deficient practice created the potential for psychosocial harm as Resident #13 was identified as the victim on the report and this was reported to Resident #13 and her family member, and to the State of Idaho, contradicting witness statements which identified Resident #13 as the aggressor. Findings include:The facility's Abuse - Reporting & Response: No Crime Suspected policy, dated 8/25/25, documented the report must include sufficient detail to describe the nature of the alleged violation, and new or revised information supplementing the initial report should be included in the follow-up submission to ensure completeness and accuracy.Resident #13 was re-admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.An abuse report, dated 11/13/25, documented Resident #13 was the victim in a resident-to-resident interaction when Resident #17 was heard banging on the restroom door while Resident #13 was using it. Resident #13 exited the bathroom on Resident #17's side, began yelling at her, and Resident #17 reacted by grabbing Resident #13's shirt, without making physical contact. Resident #13 reported she had a hurt arm, which was assessed, and no injury was found. Resident #13 was moved to a new room the same day as the facility believed Resident #13 should not share a bathroom with Resident #17 for their safety.The witness statement, dated 11/13/25, documented Resident #13 was the aggressor as she entering Resident #17's room and yelling at her. Resident #17 reacted to Resident #13 by grabbing her shirt.On 3/5/26 at 10:21 AM, the Administrator stated he filled the report out incorrectly as Resident #13 was the aggressor, not the victim as was documented on the investigation report.

Based on observation and interview, it was determined the facility failed to ensure expired medications were removed from the medication storage room and not available for administration to residents. This was true for 1 of 1 medication room observed. This failed practice created the potential for adverse effects if residents received expired medications with decreased efficacy. Findings include:On 3/4/26 at 1:14 PM, during the inspection of the Medication Storage Room with the ADON, five acetaminophen suppositories which expired on 10/2025 were found inside the refrigerator. The ADON stated the acetaminophen suppositories were expired and should not be kept in the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined the facility failed to ensure required transfer and discharge documentation was included in the resident's medical record to support the communication of essential information to the receiving healthcare provider. This was true for 1 of 2 residents (Resident #1) reviewed for discharge processes. This failure created the potential to result in delayed or inappropriate treatment. Findings Include:Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure, pneumonia, and chronic obstructive pulmonary disease.Resident #1's care plan initiated 6/19/23, documented he had altered respiratory status and directed staff to monitor and report to physician if signs of compromised airway occurred.Resident #1's record included the following:A progress note dated 1/16/26, documented Resident #1 was not responding to an albuterol breathing treatment and continued to have declining oxygen saturation requiring a higher level of care.A Notice of Transfer or discharge date d 1/16/26, documented Resident #1 required immediate transfer due to urgent medical needs.A bed hold agreement signed 1/16/26.Resident #1's record did not include documentation the following required information was sent to the receiving healthcare provider at the time of transfer:Contact information of the practitioner responsible for the care of the resident.Resident representative information including contact information.Advance Directive information.All special instructions or precautions for ongoing care, as appropriate.Comprehensive care plan goals.On 3/5/26 at 9:14 AM, the DON and the CRN confirmed Resident #1's record did not include the required transfer and discharge documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, it was determined the facility failed to ensure Residents' Preadmission Screening and Resident Review (PASRR) accurately reflected the resident's primary diagnosis. This was true for 1 of 3 residents (Resident #34) reviewed for accuracy of PASRR's. This failure resulted in incorrect PASRR Level I determination. Findings include:Resident #34 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.A review of Resident #34's medical diagnoses showed his primary diagnosis was recurrent major depressive disorder.Resident #34's PASRR Level I, dated 9/9/25, documented, Yes in Box 12, indicating the individual had a primary diagnosis of dementia or Alzheimer's disease.On 3/5/26 at 4:45 PM, the Social Worker confirmed Resident #34's PASRR Level I was inaccurately completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interviews it was determined the facility failed to provide quarterly care conferences for 8 of 8 residents (#5, #6, #7, #9, #13, #25, #38 and #47), and for 2 of 16 residents (#5 and #34) whose care plans were not revised. This deficient practice created the potential for harm when the care conferences were not conducted, and when their care plans were not revised. Findings include:The facility's Resident Care Plan Revisions policy, revised 9/3/25, documented care plans will be created, reviewed, and revised by an interdisciplinary team (IDT), with family related to the residents' status and care needs, with active involvement from the resident and their representative, when applicable, updates to the care plan will occur as needed based on the residents' response to interventions and changes in condition.1. The following residents records did not have documentation quarterly care conferences were conducted:a. Resident #25 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, depression, anxiety, muscle weakness, and difficulty walking.Resident #25's record documented a quarterly care conference occurred on 7/9/25, attended by the Social Services Manager, the Resident Care Manager, the Culinary Manager, and Resident #25's representative. There was no record of additional quarterly care conferences in or around October 2025 or January 2026.b. Resident #13 was readmitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.A review of Resident #13's care plan documented a care conference on 8/5/25, attended by the Social Services Manager, the Assistant Chief Nursing Officer, and Resident #13's representative. There were no quarterly care conferences found in Resident #13's record related to care conferences for November 2025 or March 2026.c. Resident #5 was admitted to the facility on [DATE]with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.A review of Resident #5's care plan documented a care conference on 6/11/25, attended by the Social Services Manager, the Chief Nursing Officer, and the Culinary Manager, and Resident #5's representative. There were no quarterly care conferences recorded for September and December 2025, or documentation of March 2026's care conference being scheduled for Resident #5. d. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, depression, and anxiety.Resident #9's record documented a quarterly/annual care conference was completed on 9/10/25, attended by the resident, the Social Services Manager, the DON, a Resident Support Services Assistant and the Culinary Manager.Resident #9's record did not include documentation her quarterly care conference was conducted as required in December 2025. e. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, dysphagia (difficulty swallowing) and sleep apnea.Review of Resident #47's record documented a care conference was held on 9/3/25 attended by the Social Services Manager, the DON, the Culinary Manager and Resident #47's representative. There was no other care conference documented on Resident #47's record.f. Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses including dementia, bipolar disorder, and anxiety disorderResident #38's record documented a quarterly care conference occurred on 10/8/25, attended by the Social Services Manager, the Resident Care Manager, the DON, and Resident #38's representative.Resident #38's record did not include documentation of a care conference being conducted after 10/8/25.g. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including dementia, bipolar disorder, and anxiety.Resident #6's record documented a 48 hour/admission care conference occurred on 8/22/25, attended by the Social Services Manager, the DON, and Resident #6's representative. There was no record of any quarterly care conferences for November 2025 or February 2026.h. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including dementia, major depressive disorder, and muscle weakness.Resident #7's record documented a quarterly care conference occurred on 6/24/25, attended the Social Services Manager, the DON, the Culinary Manager, and Resident #7's representative.There was no record of any quarterly care conferences for September 2025 or December 2025.On 3/4/2026 at 10:31 AM, the Administrator and CRN stated if the care conference is not in the residents [electronic health record] the care conference was not completed.2. The following residents did not have their care plans revised:a. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.Resident #5's care plan, dated 8/24/23, documented fall interventions directing staff to provide a variety of fall preventions including a low bed position at night, call light within reach, non-skid socks, and to re-evaluate quarterly and with change of condition or if a fall occurs.On 12/1/25, a fall investigation report documented Resident #5 fell while unattended in the dining room. The IDT directed staff to supervise Resident #5 always while in the dining room.There was no record of this fall intervention being added to Resident #5's care plan until 1/27/26.On 3/4/26 at 2:10 PM, the DON confirmed the care plan related to staff supervision for Resident #5 was not added to the care plan until 1/27/26 when it should have been added in December 2025.Cross reference F689.b. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.A review of Resident #34's care plan, revised 4/6/22, documented the resident was independent with toileting, and staff were directed to provide one person assistance for occasional nighttime incontinence.A review of the Quarterly Minimum Data Set (MDS) dated [DATE], documented Resident #34 was dependent on staff assistance for all toileting needs, which was inconsistent with the toileting status documented in the resident's care plan.On 3/5/26 at 8:40 AM, the DON confirmed Resident #34 was dependent in toileting and stated the care plan should have been revised to reflect the resident's current care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure services provided met accepted professional standards of clinical practice This was true for 2 of 6 residents (#47 and #56) who were observed during medication administration and for 1 of 1 resident (Resident #3) who received hemodialysis services. These failures placed Resident's #47 and #56 at risk for harm when their medications were not administered appropriately, and placed Resident #3 at risk for harm when staff took his blood pressure on the arm with his hemodialysis access. Findings include: 1. Lippincott's Nursing 2026 webpage titled, Protecting a Hemodialysis Fistula; Clinical Do's and Don'ts, accessed 3/4/26, documented, do not take blood pressure readings on the access arm as it could contribute to clotting in the fistula, and do not put any excessive pressure on the access arm.
Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including end stage renal (kidney) disease and dementia.
Resident #3's record documented he was dependent on hemodialysis (a treatment using a machine to replicate kidney function, removing waste from the bloodstream), and his dialysis access site was an AV fistula in his left forearm (an arteriovenous fistula is a surgical connection made between an artery and vein used for hemodialysis).
Resident #3's care plan, dated 11/3/22, documented no blood pressures should be taken on the left arm due to his AV fistula dialysis access site.
On 3/4/26 at 9:16 AM, Resident #3's vital signs records documented he had 18 blood pressure readings taken on the left arm in the past 90 days.
On 3/6/26 at 8:34 AM, the DON confirmed Resident #3's record documented blood pressure readings were taken on his left arm. She added, it was likely the person measuring his blood pressure documented incorrectly as there had not been any adverse outcomes and the resident was aware blood pressures should not be taken on his left arm to protect his dialysis access.
2. The insulin aspart's pen Instruction for Use documented before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing:
Turn the dose selector to select 2 units.
Hold the insulin pen pointing upwards, press the push-button all the way in. The dose selector returns to 0). A drop of insulin should appear at the needle tip.
The Toujeo's insulin pen Instructions for Use documented select 3 units by turning the dose selector until the dose pointer is between 2 and 4. Then press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly.
Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and asthma.
A physician's order documented Resident #56 was to receive the following medications:
Novolog Injection Solution 100 unit/ml (insulin aspart), inject 35 units subcutaneously three times a day related to diabetes, ordered 10/23/25.
Toujeo SoloStar (insulin glargine) 100 unit/ml, inject 64 units subcutaneously two times a day related to diabetes, ordered 2/27/26.
On 3/4/26 at 6:59 AM, RN #1 was observed sanitizing Resident #56's Novolog and Toujeo insulin pens and replaced their needles. RN #1 then dialed the Novolog insulin pen to 35 units and Toujeo insulin pen to 64 units. RN #1 was not observed to prime the insulin pens. RN #1 entered Resident #56's room and administered both insulin injections.
On 3/4/26 at 7:30 AM, RN #1 stated she did not prime Resident #56's insulin pens.
On 3/4/26 at 10:06 AM, the DON stated insulin pens should be primed before dialing the prescribed amount ordered by the physician.
3. The Drugs.com website accessed on 3/10/26, stated to take potassium chloride tablets with food or just after a meal to reduce the risk of stomach irritation. Follow with full glass of water.
Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, dysphagia (difficulty swallowing) and sleep apnea.
A physician's order dated 9/19/24, documented Resident #47 was to receive potassium chloride 20 meq by mouth two times a day for diuretic use.
On 3/3/26 at 3:27 PM, LPN #1 administered Resident #47's 20 meq potassium chloride which was dissolved in small amount of water and mixed it with pudding. Resident #47 answered, no when LPN #1 asked him if he would like to drink water after taking the medication. LPN #1 was not observed educating Resident #47 regarding the importance of drinking water after taking potassium chloride.
On 3/3/26 at 3:30 PM, LPN #1 stated he offered Resident #47 water for his hydration.
On 3/3/26 at 3:36 PM, the DON with the CRN present stated she would advise Resident #47 to drink a full cup of water after taking the potassium chloride. The CRN stated LPN #1 should have educated Resident #47 regarding drinking water after taking the potassium chloride.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, it was determined the facility failed to implement and follow resident centered comprehensive care plan interventions and physician ordered treatments for 3 of 16 residents (Residents #9, #47, and #64) reviewed for quality of care. The facility failed to apply physician ordered interventions for Resident #47, failed to implement fall prevention interventions for Resident #64, and failed to complete reassessment of blood pressures for Resident #9. These failures created the potential for harm when required care plan interventions, treatments, and reassessments were not carried out. Findings include:1. Resident #64 was readmitted to the facility on [DATE] with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care.
A review of Resident #64's care plan, revised 3/19/26, documented she required one person assistance for ambulation and transfers. The care plan also directed staff to monitor Resident #64's position in bed and in her wheelchair for safety.
A progress note dated 3/19/26 at 1:16 PM documented that CNA #1 was assisting Resident #64 with dressing. After completing the task, CNA #1 walked to the wardrobe closet to put away clothing. CNA #1 looked back and observed Resident #64 fall forward from the bed and strike her face on the floor. Nursing staff were notified, assessed the resident, and assisted her to stand. The note documented no injuries.
During an interview on 3/5/26 at 11:15 AM, CNA #1 stated Resident #64 had been sitting on the edge of the bed when she stepped away to put the resident's shoes in the closet. CNA #1 stated she saw Resident #64 stand up and fall forward and attempted to stop her but was unable to reach her in time.
A progress note dated 3/21/25 at 12:17 PM documented the Interdisciplinary Team determined that, due to the fall, an appropriate intervention would be to monitor Resident #64 for orthostatic blood pressures.
On 3/5/26 at 3:40 PM, a request was made for documentation of orthostatic blood pressures, and none was provided.
On 3/5/26 at 4:12 PM, the Director of Nursing (DON) confirmed the facility did not have records of any orthostatic blood pressures being obtained for Resident #64.
2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including muscle weakness, dementia, and protein calorie malnutrition.
A review of Resident #2's care plan, revised 1/7/25, directed staff to apply pressure relieving boots bilaterally at all times.
A physician order dated 5/2/25 documented: Pressure relief/reducing boots to bilateral feet when in bed and up in wheelchair.
Resident #2 was observed in the common area watching television without his pressure relieving boots on the following dates and times:
3/2/26 at 1:58 PM
3/3/26 at 9:35 AM
3/3/26 at 11:20 AM
3/4/26 at 7:25 AM
3/6/26 at 9:16 AM
During both observations, the boots were seen in his room on the bedside nightstand, not on the resident.
During an interview on 3/6/26 at 9:17 AM, LPN #1 confirmed Resident #2 was not wearing his boots and stated he only wears them when he's in bed.
During an interview on 3/6/26 at 9:32 AM, the DON confirmed Resident #2 should have the boots on at all times.
3. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, depression, and anxiety.
Resident #9's vital signs records documented a blood pressure reading on 3/1/26 of 171/104.
Resident #9's record did not include documentation her blood pressure was reassessed on 3/1/26, or she was assessed for other symptoms related to the elevated blood pressure.
On 3/6/26 at 9:20 AM, the DON stated, the nurses should have notified the provider of the elevated blood pressure and re-assessed the resident. The DON was unable to provide documentation the nurses reassessed Resident #9's blood pressure.
4. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, dysphagia (difficulty swallowing) and sleep apnea.
Resident #47's Skin Evaluation dated 3/2/26, documented he had pressure areas to his palm but no open areas.
A physician's order dated 2/2/26, directed staff to apply a carrot splint to Resident #47's right hand as tolerated and monitor him for skin alteration two times a day.
Resident #47 was observed with both his hands closed in a fist on 3/2/26 at 10:26 AM, 3/3/26 at 10:05 AM and 10:29 AM, and 3/4/26 at 9:30 AM, with no carrot splint to his right hand.
On 3/4/26 at 9:34 AM RNA #1 helped Resident #47 to open his right hand. Resident #47's right hand was noted to have pressure marks from his fingertips, with no open areas on his right palm.
On 3/4/26 at 9:54 AM, the DON reviewed Resident #47's care plan and physician's order, and stated the carrot splint should be applied to his right hand.
On 3/4/26 at 3:07 PM, the Director of Rehabilitation stated Resident #47 was on PT/OT/RNA program for his upper extremities and the carrot splint was ordered as skin intervention for his right hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to prevent a fall when a fall intervention was not updated in the resident's care plan. This was true for 1 of 5 residents (Resident #5) reviewed for accident prevention. This deficient practice created the potential for harm when Resident #5 fell from her wheelchair when she was left unsupervised in the dining room. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.On 12/1/25, a fall investigation report documented Resident #5 fell from her wheelchair while unattended in the dining room. The IDT investigation documented, to avoid future falls, Resident #5 was always to be supervised while in the dining room.On 1/26/26, a fall investigation report documented Resident #5 fell from her wheelchair on 1/23/26 when a staff member left her in the dining room unsupervised.A review of Resident #5's care plan, revised 1/27/26, documented Resident #5 should have constant supervision while in the dining room.There was no record of Resident #5's care plan being updated on 12/1/25 when the intervention was first identified as a fall prevention measure by the IDT.On 3/4/26 at 2:10 PM, the DON confirmed the care plan related to staff supervision for Resident #5 was not added to the care plan until 1/27/26 when it should have been added in December 2025. When asked if the fall on 1/23/26 could have been prevented if Resident #5's care plan had been updated in December 2025, the DON declined to answer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, pharmacy review, and staff interview, it was determined the facility failed to ensure recommended monitoring for adverse effects of antipsychotic medication was completed for 1 of 5 residents (Resident #38) reviewed for psychoactive medication monitoring. This created the potential for side effects to go undetected when the facility did not complete a current AIMS (an abnormal involuntary movement scale) or DISCUS (dyskinesia identification system condensed user scale) assessment as recommended by the consulting pharmacist. Findings include:Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses, including bipolar disorder, anxiety disorder, and traumatic brain injury.Resident #38's care plan directed staff to monitor and report side effects and adverse reactions related to psychoactive medications.A physician order dated 7/22/25 documented:Seroquel (an antipsychotic medication) 300 mg by mouth once daily for traumatic brain injury.A pharmacy review dated 1/26/26 documented antipsychotic medications have the capacity to cause tardive dyskinesia and other movement disorders, and recommended that a movement disorder assessment, such as an AIMS or DISCUS test, be completed at least every six months while the resident remained on antipsychotic therapy.A review of Resident #38's medical record showed the last AIMS assessment was completed on 8/18/25, more than six months prior to the pharmacy recommendation and outside the recommended monitoring interval.On 3/4/26 at 9:55 AM, the DON confirmed the pharmacy recommendation had not been acted upon and Resident #38's record did not contain a current AIMS assessment.

Based on observation, review of FDA Food Code, and staff interview, it was determined the facility failed to ensure employees were not wearing jewelry during food preparation and service, and cutting boards were not cleaned properly. These deficiencies had the potential to affect the 59 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include:1. The FDA Food Code Section 2-303.11 documented items of jewelry such as rings, bracelets, and watches may collect soil, and the construction of the jewelry may hinder routine cleaning. As a result, jewelry may act as a reservoir of pathogenic (disease causing) organisms transmissible through food.On 3/4/26 from 6:30 AM to 7:35 AM, [NAME] #1 and [NAME] Trainee #1 were observed preparing and serving food while wearing rings on their fingers, [NAME] Trainee #1 had additional bracelets on her right and left wrist. Hand hygiene was performed with the jewelry on.On 3/4/26 at 7:40 AM, the Dietary Manager stated jewelry should not be worn while preparing or serving food, and if the jewelry was permanent gloves should be worn to cover.2. The FDA Food Code Section 4-501.12 Cutting Surfaces documented cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.On 3/5/26 at 2:35 PM, it was observed the cutting boards in the kitchen had dark colored stains within the grains of the plastic.On 3/5/26 at 2:37 PM, the Culinary Manager stated the cutting boards should be replaced when they are not able to get clean or have the stains removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and American Health Care Association (AHCA)/National Center for Assisted Living (NCAL) and CDC guidance, the facility failed to ensure an infection control prevention and practices were implemented during medication administration and cleaning of a urine spill. These deficient practices created the potential for the spread of infectious diseases which could harm the residents in the facility. Findings include:1. The American Health Care Association website accessed on 3/10/26, stated to place a clean and dry paper towel under blood glucose meter before placing on resident's table or on top of medication cart.
Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and asthma.
On 3/4/26 at 6:59 AM, RN #1 entered Resident #56's room with the glucometer with the test strip inserted into it, two insulin pens, lancet and alcohol wipes. RN #1 placed the glucometer and insulin pens on the foot of Resident #56's bed, performed hand hygiene and donned gloves. RN #1 then took the glucometer and placed it above the pillow where Resident #56's arm was resting and checked her blood glucose. RN #1 was not observed to place a barrier when she placed the glucometer and insulin pens on two different surfaces on Resident #56's bed.
On 3/4/26 at 10:06 AM, the DON stated insulin pens and glucometer should be placed on top of a paper towel before placing them on any surface in residents' room.
2. The CDC web page titled Environmental Cleaning Procedures accessed on 3/12/26, under This is the general processes for cleaning of spills of blood or body fluids:
Wear appropriate PPE.
Confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or absorbent granules (if available) that are spread over the spill to solidify the blood or body fluid (all should then be disposed as infectious waste).
Clean thoroughly, using neutral detergent and warm water solution.
Disinfect by using a facility-approved intermediate-level disinfectant.
Immediately send all reusable supplies and equipment (e.g., cleaning cloths, mops) for reprocessing (i.e., cleaning and disinfection) after the spill is cleaned up.
On 3/4/26 at 9:57 AM, CNA #2 was observed assisting CNA #3 with a urine spill from a leaking urinary catheter collection bag in the [NAME] Wing common area. CNA #2 was observed placing a dry white towel over top of a small puddle of urine. CNA #2 donned gloves and wiped the urine spill with the dry white towel and left the [NAME] Wing common area.
On 3/4/26 at 2:25 PM, when asked what the process was for cleaning soiled areas, CNA #2 stated the process was to wear gloves, wipe up the soiled area, and to use alcohol wipes or disinfectant wipes on the soiled area. When asked if CNA #2 used any alcohol wipes or disinfectants on the urine spill she cleaned that morning, CNA #2 stated she did not use any disinfectant and stated she should have sanitized the area and notified housekeeping of the spill.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure a bed-hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 1 of 4 residents (Resident #110) reviewed for hospitalizations. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed at the facility within a specified time. Findings include:
Resident #110 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including schizoaffective disorder, borderline personality disorder, COPD (lung diseases that block airflow and make it difficult to breathe), and diabetes.
Resident #110's record included documentation she was transferred to the hospital on 1/21/24, for evaluation and treatment of worsening respiratory symptoms. Her record did not include documentation she was provided with a bed-hold notice.
During an interview on 10/11/24 at 10:24 AM, the DON confirmed there was no documentation Resident #110 received a bed-hold notice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility failed to ensure residents received a written notice prior to a change in their room for 1 of 1 resident (Resident #110) who was reviewed for a room change. This resulted in a lack of information being provided to a resident necessary to make an informed decision. Findings include:
Resident #110 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including schizoaffective disorder, borderline personality disorder, COPD (lung diseases that block airflow and make it difficult to breathe), and diabetes.
Resident #110's record included documentation that on 1/3/24, she was transferred from her single-bed room to a 4-bed room. Resident #110's record did not include documentation she was provided with written notice prior to the room change.
During an interview on 10/11/24 at 9:30 AM, the CRN reviewed Resident #110's record and confirmed there was no documentation to confirm Resident #110 had been notified in advance of her room change.

Based on observation and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment. This was true for 1 of 3 shower rooms observed. This deficient practice created the potential for diminished quality of life for all residents that use the east shower room. Findings include:
On 10/8/24 at 9:22 AM, observed paint peeling away from the ceiling in various areas in the east shower room.
On 10/8/24 at 9:25 AM, CNA #2 stated she noticed the paint had started peeling a few months ago.
The facility maintenance work orders were reviewed for the last 6 months. There was no work order for the peeling paint found.
On 10/8/24 at 3:30 PM, the Maintenance Director stated he was not aware of the paint peeling in the east hall shower room and that it needed to be fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the State Survey Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure residents' rights were protected to be free from abuse. This was true for 1 of 6 residents (Resident #32) reviewed for abuse. This failure placed all residents at risk of ongoing abuse, potential physical, and psychosocial harm. Findings include:
Resident #32 was admitted to the facility on [DATE] with multiple diagnoses including, hemiplegia (paralysis of one side of the body) and end stage renal disease (a chronic kidney disease that has reached its final, permanent stage).
Resident #111 was admitted to the facility on [DATE] with multiple diagnoses including dementia and hypertension.
A facility reported incident investigation, initiated 3/9/24, documented Resident #111 walked up behind Resident #32 and put him in a choke hold, stating he was going to kill him. Resident #111 was pulled away from Resident #32 by nursing staff. Resident #32 stated he did not suffer any injuries and refused to be assessed.
The facility administrator documented in the 3/9/24 incident investigation that it was his opinion that Resident #111's intent was to harm Resident #32 during this incident.
The facility investigation documented two additional incidents Resident #111 was involved in.
On 2/23/24, Resident #111 yelled at another resident and then lunged at the resident's neck, making contact.
On 3/4/24, Resident #111 pushed Resident #32 in his wheelchair into the nurses station, bumping Resident #32's knee into a cabinet.
On 10/11/24 at 9:58 AM, the facility administrator stated the incident on 3/9/24 seemed to be a rapid change in behavior for Resident #111.
The facility documented that the following actions were taken to protect residents and prevent a possible reoccurrence:
- Resident #32 was evacuated from his room.
- Staff had 1:1 supervision with Resident #111 until police arrived.
- Emergency Medical Services was called to evaluate Resident #32. Resident #32 refused to be evaluated and stated he was not injured.
- Resident #111 was taken by police to the hospital for psychological evaluation. He was discharged and not readmitted to the skilled nursing facility.
- All staff were re-educated about abuse and abuse prevention by 9/15/24.
These findings represent past noncompliance with this regulatory requirement. There was sufficient evidence the facility corrected the noncompliance as of 9/15/24 and there were no other occurrences of alleged abuse or neglect. At the time of this survey, the facility was in substantial compliance for this regulatory requirement and, therefore, does not require a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 2 of 4 residents (#42 and #46) reviewed for Pre-admission Screening and Resident Review (PASARR) level 2 evaluations. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include:
The facility's Pre-admission Screening and Resident Review policy, dated 11/28/17, documents positive level 1 PASARR's (a major mental illness has been identified) are forwarded to the state-designated authority for a level 2 PASARR evaluation.
The State Operation Manual, Appendix PP revised on 8/8/24, documents if a PASARR level 1 identifies a major mental illness, an in-depth evaluation, known as a PASARR level 2 evaluation is completed by the state-designated authority, which must be completed prior to admission to a nursing facility.
1. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses which included amputation, malnutrition, and bipolar disease.
Resident #42's care plan, created on 12/14/22, documented Resident #42 was prescribed antianxiety and antipsychotic medications related to his diagnosis of bipolar disease.
Resident #42's admission MDS (Minimum Data Set - an assessment used to identify the resident's clinical condition, cognitive and functional status, and use of services), completed on 12/27/22, documented his diagnosis of bipolar disease.
Resident #42's medical record documented he had a diagnosis of bipolar disease (a major mental illness) but the record did not include a completed PASARR level 1 screening or PASARR level 2 evaluation from the state-designated authority.
2. Resident #46 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia and non-Alzheimer's dementia.
Resident #46's care plan dated 3/8/24, documented she takes antipsychotic medication related to her diagnosis of schizophrenia.
Resident #46's admission MDS completed on 3/13/23, documented she had a severe mental disorder and a diagnosis of schizophrenia.
Resident #46's medical record documented a PASARR level 1 screening was completed on 4/5/23 (36 days after admission). The PASARR level 1 screening documented Resident #46 had a major mental illness of schizophrenia and instructed that the PASARR level 1 be forwarded to the states-designated authority for a PASARR level 2 evaluation.
Resident #46's medical record did not document a PASARR level 2 evaluation had been completed.
On 10/10/24 at 10:58 AM, the CRN stated the facility did not have a PASARR level 2 for Resident #42 or Resident #46.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR), was completed within the required timeframe for 2 of 4 residents (#42 and #46) reviewed for PASARR screenings. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility. Findings include:
The facility's Pre-admission Screening and Resident Review policy, dated 11/28/17, documented a PASARR level 1 will be completed prior to admission and is included in the required paperwork from the referring agency, hospital, or physician.
The State Operation Manual, Appendix PP revised on 8/8/24, documents all applicants to Medicaid-certified nursing facilities are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level 1 and should be completed prior to admission to a nursing facility.
1. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses which included amputation, malnutrition, and bipolar disease.
Resident #42's care plan, created on 12/14/22, documented Resident #42 was prescribed antianxiety and antipsychotic medications related to his bipolar disease.
Resident #42's admission MDS, completed on 12/27/22, documented a diagnosis of his bipolar disease.
Resident #42's medical record did not document a PASARR level 1 was completed.
2. Resident #46 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia and non-Alzheimer's dementia.
Resident #46's care plan dated 3/8/24, documented Resident #46 was prescribed antipsychotic medication related to her diagnosis of schizophrenia.
Resident #46's admission MDS completed on 3/13/23, documented she had a severe mental disorder and a diagnosis of schizophrenia.
Resident #46's medical record documented a PASARR level 1 screening was completed on 4/5/23 (36 days after admission). The PASARR level 1 screening documented Resident #46 had a major mental illness of schizophrenia and instructed the PASARR level 1 to be forwarded to the states-designated authority for a PASARR level 2 evaluation.
Resident #46's medical record did not document a PASARR level 1 was completed prior to admission.
On 10/10/24 at 10:58 AM, the CRN stated the facility did not have a PASARR level 1 for Resident #42 or a PASARR level 1, prior to admission, for Resident #46.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a comprehensive person-centered care plan related to a fall intervention of 30-minute checks for 1 of 22 Residents (#52). This deficient practice had the potential to affect residents health and wellbeing. Findings include:
Resident #52 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Parkinson's disease (a progressive brain disorder that causes movement problems, stiffness, and other issues) and bipolar disorder.
Resident #52's care plan documented 30-minute checks due to a fall on 6/9/24.
Resident #52's Interdisciplinary Team progress note dated 6/15/24, documented, The plan is to have Resident #52 be on 30-min checks at all times for increased safety.
Resident #52's CNA task [NAME], dated 6/18/24, directed CNA staff to perform 30-minute checks for safety and falls.
Resident #52's medical record did not document 30-minute checks were performed.
On 10/10/24 at 2:50 PM, the DON stated the care plan should have been updated and the 30-minute checks should have been removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy and record review, the facility failed to follow standard of practice during resident transfers for 1 of 2 residents (Resident #8), and follow a comprehensive person-centered care plan to maintain resident body weight for 1 of 22 residents (Resident #26). This deficient practice created the potential for harm or adverse outcomes. Findings include:
Facility Resident Mobility - Safety policy, revised 4/16/24, documented, Gait belts are used with resident requiring hands-on assistance unless contraindicated, for the primary purpose of staff and resident safety. Gait belts are considered part of a direct care staff's uniform.
1. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder (a serious mental health condition that involves a persistent low mood and a loss of interest in activities that were once enjoyable) and dementia.
Resident #8's care plan revised 4/27/23, stated Transfer: Limited/Extensive assistance with transfers with assist of 1 staff.
On 10/7/24 at 4:31 PM, observed CNA #5 use Resident #8's belt loop to assist during a bed to wheelchair transfer.
On 10/7/24 at 4:40 PM, CNA #5 stated she should have used a gait belt during the bed to wheelchair transfer, not Resident #8's belt loop.
2. Resident #26 was admitted to the facility on [DATE],with multiple diagnoses including dementia and diabetes.
Resident #26's medical record documented a 5.84% weight loss between 5/1/24 and 6/1/24.
Resident #26's care plan documented interventions to monitor resident weight and report significant weight changes to the medical director (MD).
Resident #26 medical record did not have documentation the MD had been notified of the 5.84% weight loss.
On 10/10/24 at 10:00 AM, the CRN stated the MD should have been notified of Resident #26's weight loss and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure 2 of 5 resident's (#32 and #47) records reviewed for oxygen use had complete orders, and 2 of 2 residents (#5 and #47) were using oxygen per physician orders. This created the potential for residents to experience harm, respiratory difficulties, and adverse outcomes. Findings include:
Facility Oxygen Therapy policy, revised 8/4/23, directed staff to verify physician orders prior to initiating oxygen therapy.
1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including panic disorder and dementia.
On 10/8/24 at 2:34 PM, it was observed Resident #5 had been transferred into bed without his oxygen nasal cannula in place.
On 10/8/24 at 3:01 PM, CNA #4 stated Resident #5 should be using the oxygen at all times, but CNA #3 had forgot to put it back on him.
A physician's order, dated 8/4/23, for oxygen at 2 liters per minute, via nasal cannula, to help maintain Resident #5 adequate oxygen saturation.
2. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis of one side of the body) and end stage renal disease (a chronic kidney disease that has reached its final, permanent stage).
Resident #32's medical record included an incomplete order for oxygen usage (oxygen at 2 liters via nasal cannula). The oxygen order did not include the duration of use.
On 10/11/24 at 9:24 AM, CRN confirmed Resident #32's oxygen order was incomplete and should have stated duration of use.
3. Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the lungs have difficulty loading the blood with enough oxygen), and chronic obstructive pulmonary disease (a chronic lung disease that makes it difficult to breathe).
On 10/8/24 at 4:29 PM, observed Resident #47 wearing a nasal cannula that was attached to his oxygen portable unit but the oxygen liter flow had been set at zero.
On 10/8/24 at 5:30 PM, observed Resident #47 in the dining room with his oxygen portable unit set at zero.
Resident #47's medical record had an incomplete order for oxygen usage (oxygen at 2 liters via nasal cannula). The oxygen order did not include the duration of use.
On 10/8/24 at 5:34 PM, LPN #1 stated Resident #47's portable oxygen unit should have been set at 2 liter per minute.
On 10/11/24 at 9:25 AM, CRN stated that the oxygen order was incomplete and should have stated duration of use.

Based on review of facility staffing records and staff interview, it was determined the facility failed to ensure an RN was on duty at least 8 consecutive hours per day, 7 days a week. This was true for 1 of 38 days reviewed for RN staffing coverage. The failure created the potential for harm if routine and/or emergency nursing needs went unmet and had the potential to affect all residents living in the facility. Findings include:
Licensed Nurse time punches for 9/1/24 to 10/8/24, documented the facility did not have an RN on duty for 8 consecutive hours on 9/1/24.
On 10/10/24 at 5:15 PM, the CRN and DON stated on 9/1/24, the RN was covered by an LPN and confirmed there was not an RN for 8 consecutive hours that day.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, label, and serve foods. This deficient practice had the potential to affect the 59 residents who received meals in the dining room and eat snacks that had been stored in the snack refrigerators. This placed residents at risk for the potential for consuming contaminated and spoiled foods, and adverse health outcomes related to food-borne illnesses. Findings include:
Review of the Idaho Food Code, revised February 2021, stated,. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.
Facility Food and Supply Storage policy dated 11/28/17, documented, For food products that are opened and not completely used or prepared at facility and stored, the product should be labeled as to it contents and use by dates.
On 10/7/24 at 11:40 AM, 3 outdated yogurts (10/2/24) were observed in the walk-in refrigerator.
On 10/7/24 at 11:42 AM, the CDM stated the outdated yogurts should have been removed from the walk-in refrigerator on 10/2/24.
On 10/9/24 at 1:30 PM, an ice cream container with open date of 9/2/24 and used by date of 10/2/24, was observed in the resident snack freezer.
On 10/9/24 at 1:35 PM, the CDM stated the ice cream container should have been removed on 10/2/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, it was determined the facility failed to ensure all residents had access to their call lights while in their beds. This issue was observed in 1 of 22 resident's (Resident #5) observed for call light access. This failure had the potential for harm if residents were not able to summon staff assistance by activating the call light. Findings include:
Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including panic disorder and dementia.
Resident #5's care plan initiated 3/17/23, directed staff to keep his call light button within reach.
On 10/8/24 at 2:34 PM, Resident #5 was observed in his bed without the call light button which was across the room, on his dresser.
On 10/8/24 at 2:36 PM, Resident #5 stated he had been yelling for help because he was in pain but no one heard him.
On 10/8/24 at 2:48 PM, CNA #3 stated she forgot to give Resident #5 his call light.
On 10/10/24 at 10:53, the DON stated staff should ensure all residents have access to their call lights while in bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide safe shower floors for all residents that use the east shower room. This deficient practice had the potential to cause harm due to slips or falls and distress for residents that use the east side shower. Findings include:
Resident #51 was admitted to the facility on [DATE], with multiple diagnoses including stroke and diabetes.
On 10/7/24 at 2:38 PM, Resident #51 stated the shower floor had been very slippery and he had almost fallen in the shower room because the floor anti-slip pads were missing.
On 10/8/24 at 9:22 AM, observed the non-slip strips had peeled up and were missing in the east hall shower room.
On 10/8/24 at 9:28 AM, CNA #2 stated the non-slip strips had peeled up about two months ago and a work order was submitted but nothing had been done yet.
On 10/8/24 at 3:30 PM, the Maintenance Director stated the missing shower floor non-slip strips needed to be replaced.
A facility work order #2674 (for the non-slip strips) in the east hall shower was created on 8/15/24. The east hall shower non-slip strips were not replaced until 10/8/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included the use of oxygen. This was true for 1 of 6 residents (Resident #47) whose comprehensive care plans were reviewed. This deficient practice created the potential for Resident #47 to receive inadequate care or treatment due to missing information in her care plan. Findings include:
Resident #47 was admitted to the facility on [DATE] with multiple diagnoses including generalized anxiety disorder.
An Annual MDS Assessment, dated 9/28/19, documented Resident #47 received oxygen therapy.
A physician's order, dated 9/24/19, included an order for oxygen at 2 liters per minute via nasal cannula continuously.
Resident #47's care plan did not document her use of oxygen.
On 10/15/19 at 3:00 PM, Resident #47 was observed in bed, receiving oxygen at 2 liters per minute via nasal cannula.
On 10/17/19 at 10:28 AM, RN #1 said Resident #47's care plan did not address her use of oxygen.

Based on observations, record review, staff interview, and review of the facility's guidelines, the facility failed to ensure the tubing for respiratory equipment included the date it was last changed. This was true for 4 of 6 residents (#5, #32, #35, and #51) reviewed for oxygen therapy. This placed residents at risk of respiratory infections due to the growth of pathogens (organisms that cause illness) in the tubing of respiratory equipment. Findings include:
The facility's Respiratory Equipment Change and Cleaning Guidelines, dated 7/6/18, documented the nasal cannula, weekly .label and date the cannula when changed.
This policy was not followed. Examples include:
a. Resident #5's record documented the resident had multiple diagnoses including sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts).
Resident #5's Quarterly MDS Assessment, dated 9/25/19, documented she required oxygen therapy.
Resident #5's Physician's Orders, dated 9/24/19, documented an order for oxygen at 3L/Min (liters per minute) via nasal cannula (in the nostrils) continuously, every shift for shortness of breath. The order instructed staff to change the oxygen tubing and clean the filter every week on Thursday.
Resident #5's Care Plan, documented she had altered respiratory status related to sleep apnea and oxygen therapy as needed for hypoxia (low oxygen in the blood resulting in low oxygen in body tissue). The care plan directed staff to change oxygen tubing, portable oxygen tubing and mask tubing used with a nebulizer (a drug delivery device used to administer medication in the form of a mist) every week and as needed.
On 10/15/19 at 10:30 AM, Resident #5 was sitting up in a chair at bedside, with nasal cannula inserted in bilateral nostrils and connected to a portable oxygen container. There was no date or label on the oxygen tubing to indicate when it had last been changed.
b. Resident #32's record, documented she had multiple diagnoses including COPD, a progressive lung disease that results in shortness of breath.
Resident #32's Quarterly MDS Assessment, dated 9/30/19, stated she was moderately cognitively impaired and required oxygen therapy.
Resident #32's Physician's Orders, dated 9/26/19 documented an order for oxygen at 2L/Min via nasal cannula continuously.
Resident #32's Care Plan documented she had altered respiratory status related to COPD, shortness of breath with lying flat and excretion, history of asthma, congestive heart failure and rhinitis (inflammation and swelling of the mucous membrane of the nose). The care plan directed the staff to change the oxygen/nebulizer tubing and clean the filter weekly.
On 10/15/19 at 9:58 AM and 10/16/19 at 10:39 AM, Resident #32 was sitting up in a chair at bedside with nasal cannula inserted in bilateral nostrils and connected to a portable oxygen container. There was no date or label on the oxygen tubing to indicate when it had last been changed.
c. Resident #35's record documented she had multiple diagnoses including COPD.
Resident #35's Quarterly MDS Assessment, dated 9/30/19, documented she was severely cognitively impaired and required oxygen therapy.
Resident #35's Physician's Orders, dated 9/26/19, documented an order for oxygen at 2L/Min via nasal cannula continuously every shift related to COPD, to change the oxygen/nebulizer tubing and humidification bottle every week, and to clean the filter every week.
Resident #35's Care Plan documented she had altered respiratory status related to COPD, shortness of breath with lying flat and excretion, history of asthma, CHF, and rhinitis. The care plan directed the staff to change the oxygen/nebulizer tubing and clean the filter weekly.
On 10/15/19 at 9:33 AM, Resident #35's oxygen tubing had no date or label indicating when the oxygen tubing had last been changed.
d. Resident #51's record documented she had multiple diagnoses including COPD.
Resident #51's Quarterly MDS Assessment, dated 8/16/19, documented she was cognitively intact, independent with all ADLs, and required oxygen therapy.
Resident #51's Physician's Orders, dated 9/24/19, documented an order for oxygen at 2L/Min via nasal cannula continuously every shift related to COPD. The orders also instructed staff to change the oxygen/nebulizer tubing and humidification bottle and clean the filter on the nightshift every Thursday.
Resident #51's Care Plan documented that she had altered respiratory status related to COPD and shortness of breath with lying flat.
On 10/15/19 at 9:38 AM, Resident #51's oxygen tubing did not have a date/label indicating when the oxygen tubing had been changed.
On 10/17/19 at 9:30 AM, RN #1, said there was not a date or label on the oxygen tubing indicating when it was last changed for Residents #5, #32, #35, and #51.
On 10/17/19 at 9:50 AM, RN #1 said the oxygen tubing was changed every week on Thursday on the nightshift and was to be labeled with the date and initialed.
On 10/17/19 at 10:00 AM, the DON said I expect the oxygen tubing to be changed every Thursday night, labeled and dated. It also needs to be changed as needed if soiled.

Based on staff interview and policy review, it was determined the facility failed to ensure staff disposed of controlled medications consistent with the facility's policies to prevent possible diversion. This was true for 2 of 2 licensed nurses (RN #1 and LPN #2) interviewed during medication cart inspection. This had the potential to negatively impact each of the 79 residents residing in the facility. This failed practice created the potential for harm if controlled medications were diverted and residents did not receive the medications as ordered. Findings include:
The facility's policy for Management and Destruction of Controlled Substances, dated 11/28/17, documented two licensed nurses destroyed the controlled medications by rendering the controlled medications irretrievable by using the following example: Zorbitol plus, Drug Buster, Bleach, Drug Shedder.
The facility's policy for Medication Management, dated 11/28/17, documented licensed nurses were to follow appropriate procedures for the destruction and disposal of controlled, cytotoxic (toxic to cells), and non-controlled medications.
These policies were not followed.
On 10/18/19 at 2:17 PM, during the inspection of the East Medication Cart, RN #1 said controlled medications were destroyed or wasted in the presence of two licensed nurses. RN #1 said both nurses signed and dated the narcotic log book for the controlled medications to be destroyed or wasted. When asked how she destroyed the controlled medications, RN #1 said she put the controlled medications in the sharps container which was attached next to the medication cart.
On 10/18/19 at 2:27 PM, LPN #2 said controlled medications were destroyed in the presence of two licensed nurses. LPN #2 said both nurses signed and dated the narcotic log book. LPN #2 said he put the wasted controlled medications in the sharps container.
On 10/18/19 at 2:30 PM, the DON said the controlled medications were destroyed or wasted in the Drug Buster in the presence of two licensed nurses. The DON said two licensed nurses then signed and dated the narcotic log book. The DON said the wasted controlled medication should not be placed in the sharps container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 26 medications (11.5%) which affected 1 of 2 residents (Resident #45) whose medication administration was observed during medication pass. This failure created the potential for subtherapeutic effect when Resident #45's Mucinex (an expectorant, helps loosen congestion) was crushed, not administered as ordered, and she was not instructed to rinse her mouth after receiving the inhaled medications. Findings include:
1. Resident #45 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Resident #45's October 2019 recapitulated physician's order included Breo Ellipta Aerosol Powder Breath Activated (an inhaler taken orally containing corticosteroid) 100-25 mcg/inh (microgram per inhalation), one puff one time a day for COPD. The order included special instructions for Resident #45 to rinse his mouth out with water and spit back into the cup after administration. The order also included Mucinex tablet Extended Release, two tablets by mouth every 12 hours for congestion.
On 10/17/19 at 8:40 AM, LPN #1 was observed when she administered Resident #45's Breo Ellipta. Resident #45 was observed to take one puff of the Breo Ellipta orally, and then gave the inhaler back to LPN #1. LPN #1 then administered Resident #45's crushed medications which included one tablet of Mucinex. LPN #1 then gave Resident #45 a glass of shake which she finished. Resident #45 was not observed to rinse her mouth after inhaling the Breo Ellipta.
On 10/17/19 at 8:49 AM, LPN #1 said she did not ask Resident #45 to rinse her mouth after administering the Breo Ellipta. LPN #1 said she should have told Resident #45 to rinse her mouth with water and spit it out. LPN #1 was then asked to review Resident #45's physician's order for Mucinex. LPN #1 reviewed the physician's order and said she should have given two tablets of Mucinex to Resident #45. The Mucinex should not have been crushed. The website pharmacistanswers.com, accessed on 11/1/19, identifies Mucinex tables as extended release and they should not be crushed. Crushing may cause the entire dose to be delivered all at once and not over 12 hours as intended. Crushing may result in side effects such as nausea, diarrhea and gastrointestinal distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, it was determined the facility failed to ensure staff performed proper hand hygiene during resident cares. This was true for 1 of 15 resident (Resident #30) observed during resident cares. The deficient practice placed residents at risk of infection from cross-contamination. Findings include:
The facility's policy and procedure for Hand Hygiene/Handwashing, dated 11/28/17, directed staff to perform hand hygiene when moving from a contaminated body site to a clean body site during patient care, when removing gloves, intermittently after removing gloves, between contact with patients, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.
Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including hypertension and heart failure.
A Quarterly MDS Assessment, dated 9/24/19, documented Resident #30 required the assistance of one to two persons for ADL.
A physician's order dated 10/7/19, directed staff to apply skin prep (a fast drying, sterile, liquid form skin protectant) to Resident #30's right second toe until healed.
* On 10/16/19 at 9:16 AM, CNA #2 was observed providing peri care to Resident #30. CNA #2, with gloves on, unfastened Resident #30's soiled incontinence brief and wiped his genitalia and buttocks with a clean wipe. CNA #2 then applied a barrier cream on Resident #30's lower back without changing her gloves. CNA #3 entered the room and helped CNA #2 in repositioning Resident #30. CNA #2 then applied a new incontinence brief to Resident #30 and then removed her gloves and put on new gloves without performing hand hygiene. CNA #2 then cleaned Resident #30's mouth using a mouth swab and combed his hair. CNA #2 and CNA #3 removed their gloves and performed hand hygiene before leaving Resident #30's room.
On 10/16/19 at 11:16 AM, CNA #2 said hand hygiene was performed before and after resident contact and between glove changes. CNA #2 said she did not change her gloves when she applied the barrier cream to Resident #30's lower back and she did not perform hand hygiene between glove changes during Resident #30's care.
* On 10/16/19 at 10:59 AM, LPN #2 was observed as he performed wound care to Resident #30. LPN #2, with gloves on, removed Resident #30's right Prevalon boot (a heel protector to keep the heel off the mattress to relieve pressure). LPN #2 said Resident #30's right toe was already healed and was being maintained with skin prep. LPN #2 then removed his gloves, put on new gloves, and applied skin prep to Resident #30's right toe. LPN #2 was not observed to perform hand hygiene between glove changes.
On 10/16/19 at 11:03 AM, LPN #2 said hand hygiene should be performed before and after resident contacts and between glove changes. LPN #2 said he did not perform hand hygiene when he changed his gloves to apply skin prep to Resident #30's right toe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine and received information and education consistent with the current Center for Disease Control (CDC) recommendations. This was true for 1 of 5 residents (#20) reviewed for pneumococcal immunizations. This failure created the potential for harm to residents should they acquire, transmit, or experience complications from pneumococcal pneumonia. Findings include:
The CDC website, accessed on 10/22/19, documented recommendations for Pneumococcal vaccination (PCV 13 or Prevnar13®, and PPSV 23 or Pneumovax23®) for all adults 65 years or older:
* For those who have already received 1 or more doses of PPSV23, or those with unclear documentation of the type of pneumococcal vaccine received: Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose.
* Administer a second dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the previous dose of PPSV23
* Administer 1 final dose of PPSV23 at 65 years or older. This dose should be given at least 5 years after the most recent dose of PPSV23.
The facility's policy and procedure for the Pneumococcal Program, dated 10/31/17, directed staff to reduce the risk of pneumococcal infection and transmission, residents and their family members were provided education regarding the benefits and potential side effects of the two-step pneumococcal immunization. Residents were offered and given the Pneumococcal vaccine according to physician's orders unless medically contraindicated, they have already received the vaccine, or the vaccine is refused.
The policy further documented PCV13 and PPSV 23 were available and recommended for adults over the age of 65 and people with certain medical conditions to include chronic heart and lung disease, diabetes mellitus, liver disease, renal failure, smoking, alcoholism, immunodeficiency's, cancers, organ transplants and others. Revaccination with PPSV 23 is recommended if more than five years had elapse after the first dose of PPSV 23 and one year after the Prevnar 13.
Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including diabetes mellitus and hypertension.
Resident #20's Annual MDS Assessment, dated 9/13/19, documented she was up to date with Pneumococcal immunizations.
Resident #20's physician's order, dated 9/27/17, documented May have Pneumovax vaccine if no history of vaccine.
Resident #20's record documented, she received PPSV 23 on 1/3/12 when she was [AGE] years old and Prevnar 13 on 7/10/18 when she was [AGE] years old. Resident #20's record did not include documentation she received or was offered the second dose of PPSV 23 at least one year after the Prevnar 13 vaccination.
On 10/17/19 at 9:15 AM, the DON said she was unable to find documentation Resident #20 was offered the second dose of PPSV 23 vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, it was determined the facility failed to ensure rooms with multiple residents had at least 80 square feet space per resident. This was true for 3 of 32 resident rooms (rooms 111, 112 and 114) which did not meet the requirement of 80 square feet per resident. This was true for 6 of 6 residents (#15, #17, #18, #24, #35 and #51) whose rooms did not have 80 square feet of living space. This failure created the potential for residents to experience a loss of well-being due to lack of living space. Findings include:
*Resident #35 and Resident #51 were in room [ROOM NUMBER], which had 78.6 square feet per resident.
*Resident #18 and Resident #24 were in room [ROOM NUMBER], which had 79.0 square feet per resident.
*Resident #15 and Resident #17 were in room [ROOM NUMBER], which had 79.5 square feet per resident.
On 10/18/19 at 1:15 PM, Resident #15, #17, #18, #24, and #51 said they liked their rooms. The furniture in the rooms was observed to be arranged in a manner that provided for ease of access to the beds and closets.
The facility had a room size requirement waiver for rooms 111, 112 and 114 which was granted on 9/12/18 and was in effect until the next on-site survey.
On 10/18/19 at 2:00 PM, the Administrator said the facility wanted to renew its room size requirement waiver.