Cascades At Desert View
Inspection history, citations, penalties and survey trends for this long-term care facility in Buhl, Idaho.
- Location
- 820 Sprague Avenue, Buhl, Idaho 83316
- CMS Provider Number
- 135089
- Inspections on file
- 17
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Cascades At Desert View during CMS and state inspections, most recent first.
The facility failed to update care plans and conduct care conferences for several residents, including one who completed antibiotics for an infection without a care plan update, and others who had not participated in care conferences since their admission or readmission. The DON and Social Service Supervisor acknowledged these oversights.
The facility failed to provide the required 12 hours of in-service education per year for two CNAs, placing residents at risk. One CNA had only 9.5 hours documented for 2024 and incomplete documentation for 2025, while another had 4 hours for 2024 and 1.5 hours for 2025. The Administrator was unaware of the requirement based on hire date, and the DON confirmed the deficiency.
A facility failed to obtain informed consent before administering Seroquel to a resident with dementia and behavioral disturbances. Despite a pharmacist's recommendation to assess the risks and benefits due to a black box warning, there was no documented consent for the use of Quetiapine. The DON sent the pharmacist's recommendations to the attending physician, but no response was received, and the Social Services Supervisor confirmed the lack of a consent form.
The facility did not ensure a clean and safe environment for residents, with observations of dust on air vents, missing tiles, and protruding flooring. The Administrator acknowledged the need for flooring replacement, and the Maintenance Director noted annual vent cleaning. These issues indicate a failure to maintain the building as per policy.
A facility failed to accurately reflect a resident's hospice status in the MDS assessment. Despite having a physician's order and care plan indicating hospice care, the MDS inaccurately documented that the resident was not receiving hospice services. Interviews with the DON and Regional MDS nurse confirmed the coding error.
A facility failed to refer a resident with a mental disorder for a PASRR Level II re-evaluation after their stay exceeded 30 days. The resident, admitted with Alzheimer's and Major Depressive Disorder, required updated documentation to be sent to BLTC, which was not done. The Social Services Supervisor was aware of the lapse but did not submit the necessary documents.
A resident with peripheral vascular disease and a left leg amputation was at risk for adverse outcomes due to an incorrectly written physician order. The order specified a Tubigrip stocking for the left lower extremity, despite the leg being amputated. Observations and documentation showed the Tubigrip was applied to the left leg, and staff later confirmed the order should have been for the right leg.
The facility failed to implement and document new fall prevention interventions for two residents with a history of falls. One resident with cerebral infarction and traumatic brain injury experienced falls during transfers, and another resident with heart failure and dementia fell out of bed. Despite these incidents, no new interventions were added to their care plans, as confirmed by the DON and Regional MDS Nurse.
The facility failed to ensure controlled medications were properly tracked and secured, as evidenced by a missing nurse signature on a narcotic accountability record during a medication cart audit. An LPN confirmed that nurses should sign the accountability sheet when handling the medication cart. This lapse created the potential for undetected misuse or diversion of controlled medications, potentially affecting all residents receiving such medications.
A facility failed to ensure an attending physician acted on pharmacy recommendations for a resident prescribed Seroquel for dementia with behavioral disturbances. Despite the pharmacist's suggestions to assess and potentially discontinue the medication, there was no documented response from the physician. This deficiency was identified through policy review, record review, and staff interviews, highlighting a lapse in adherence to the facility's Medication Regimen Review Policy.
A facility failed to ensure the medical necessity for administering Seroquel to a resident with dementia, despite FDA warnings about increased mortality risk. The resident was prescribed Seroquel for behavioral disturbances, but the pharmacist later recommended discontinuation. However, there was no documented response from the attending physician to this recommendation, as confirmed by the DON.
A facility failed to maintain a medication error rate below 5%, with an error rate of 5.41% observed. An LPN improperly primed insulin pens with 1 Unit instead of the required 2 Units before administering the prescribed doses to a resident, leading to a deficiency in medication administration.
The facility failed to securely store controlled medications, as a bottle of lorazepam liquid was found in the medication refrigerator door rack without an additional locked compartment. An RN confirmed the lack of a specific locked compartment for controlled medications, posing a risk of theft or diversion.
The facility failed to ensure proper food storage, sanitation, and infection control during meal delivery. Observations revealed improperly dated food items, unsanitary kitchen equipment, and non-compliance with dish machine temperature requirements. Additionally, an RN delivered uncovered meal trays, contrary to infection control protocols, potentially affecting all 39 residents receiving meals.
The facility failed to ensure proper hand hygiene practices, as observed when residents were served meals without being offered or performing hand hygiene. A CNA admitted to usually washing residents' hands but did not do so on the observed day. The IP confirmed that hand hygiene should be offered before meals.
The facility failed to protect two residents from neglect during transport, resulting in physical harm. One resident suffered a significant cut to her leg, and another sustained a contusion and a non-displaced fracture of the femur due to improper securing of their wheelchairs in the van.
The facility failed to maintain kitchen equipment and environment, and store food safely. Observations included improperly stored food, inadequate temperature control in refrigerators, and unclean kitchen surfaces. The Kitchen Manager confirmed physical limitations prevented proper cleaning, and a damaged screen door was not replaced after a recent delivery.
The facility failed to assist three residents in formulating advanced directives, as required by their policy. The records for these residents, who had various serious medical conditions, did not include documentation that an advanced directive was offered or discussed with them or their representatives.
The facility failed to provide bed hold notices to two residents upon their transfer to the hospital, as required by policy. The records for both residents lacked documentation of the notices, which was confirmed by the DON.
The facility failed to maintain infection control practices for a resident with a foley catheter. The resident's drainage bag was observed lying on the floor, contrary to the facility's policy. The DON confirmed that the bag should be attached to the side of the bed. The resident had multiple diagnoses, including multiple sclerosis and adult failure to thrive.
The facility failed to provide pertinent health information to the receiving hospital for two residents during their transfer. The records for both residents did not include necessary documentation as required by the facility's Transfer or Discharge policy, which was confirmed by the Director of Nursing.
The facility failed to ensure appropriate assessments for assistive devices for two residents. One resident with a traumatic brain injury and another with multiple sclerosis were observed with HALO Safety Rings, but their records lacked documentation of the required assessments. The Maintenance Supervisor and DON confirmed the absence of these assessments.
The facility failed to ensure accurate PASARR Level I screenings and the completion of necessary PASARR Level II screenings for two residents, potentially impacting their access to specialized mental health services. One resident's bipolar disorder was not documented, and another resident's need for further screening was not followed up.
The facility failed to change respiratory equipment as indicated for a resident with severe cognitive impairment and multiple diagnoses, including congestive heart failure and kidney disease. The physician's order required the oxygen tubing and humidifier to be changed twice a month, but observations revealed that the equipment was not changed as scheduled.
The facility failed to obtain informed consent for the use of bed rails for two residents. Both residents had HALO safety rings installed on their beds without documented informed consent, as confirmed by the Director of Nursing.
The facility failed to ensure a resident was offered the pneumococcal vaccine. The resident, with multiple diagnoses including paranoid schizophrenia, chronic kidney disease, and dementia, had previously received PPSV23 and PCV13 vaccinations before admission. There was no documentation that the resident was offered the PCV20 vaccine after admission, and the IP could not confirm if it had been offered.
The facility failed to regularly inspect bed rails for two residents, both of whom had HALO safety rings attached to their beds. Despite care plans and initial measurements, there was no documentation of ongoing inspections, creating a potential risk for entrapment and injury.
The facility failed to ensure all call lights were functioning, affecting two residents. One resident with severe cognitive impairment and another with multiple sclerosis were observed without functioning call lights. Despite grievances and staff awareness, the issue remained unresolved, and alternative measures like bells were ineffective.
Failure to Update Care Plans and Conduct Care Conferences
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions, and did not encourage residents and their representatives to participate in care planning and attend care conferences. This deficiency was identified for four residents. Resident #8's care plan was not updated after completing a course of antibiotics for an active infection. The Director of Nursing and the MDS Resource nurse acknowledged that the care plan should have been updated. Resident #11 had not been informed or attended a care conference since his readmission, with the last documented care conference occurring before his readmission. Resident #21 reported not participating in care conferences, and there was no documentation of such conferences. Similarly, Resident #27's medical record lacked documentation of a care conference since June 2024, and the Social Service Supervisor confirmed that care conferences had not been completed since that time.
Inadequate In-Service Training for CNAs
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of in-service education per year for two Certified Nursing Assistants (CNAs), which placed residents at risk of receiving care from inadequately trained staff. CNA #2, hired on 3/22/19, had only 9.5 hours of in-service training documented for 2024 and incomplete documentation for 2025. Similarly, CNA #3, hired on 1/13/10, had only 4 hours of in-service training for 2024 and 1.5 hours for 2025. The Administrator acknowledged the requirement for 12 hours of in-service training but was unaware it was based on the hire date. The Director of Nursing (DON) confirmed that both CNAs did not meet the required in-service hours for the evaluation period.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medication to a resident, which is a deficiency in ensuring residents are fully informed about their health status, care, and treatments. The resident, who was admitted with diagnoses including surgical aftercare, Alzheimer's disease with early onset, and dementia, was prescribed Seroquel, an antipsychotic medication, for dementia with behavioral disturbance. Despite a pharmacist's recommendation to assess the risks versus benefits of continuing the medication due to a black box warning, the facility did not have a documented risk and benefits consent for the resident's use of Quetiapine. The Director of Nursing (DON) had sent the pharmacist's recommendations to the attending physician, but there was no response, and the Social Services Supervisor confirmed the absence of a consent form.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to provide residents with a clean, safe, and homelike environment, as evidenced by several observations of disrepair and uncleanliness. A thick layer of dust and dirt was observed on the ceiling air exchange vent in the North hallway, indicating a lack of regular cleaning. Additionally, there was a missing tile area on the floor by the copy room, and a piece of flooring was sticking up in the main dining room in front of the condiment counter. The Administrator acknowledged that the flooring should have been replaced, and the Maintenance Director stated that vents were cleaned annually in the Spring. These observations suggest a failure to maintain the building in good repair and free from hazards, as required by the facility's maintenance policy.
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding hospice care. This deficiency was identified for one resident who had been admitted and readmitted with diagnoses including heart failure and diabetes. Despite having a physician's order and a care plan indicating hospice care, the resident's Quarterly MDS inaccurately documented that the resident was not receiving hospice services. Interviews with the Director of Nursing (DON) and the Regional MDS nurse confirmed the error, as the MDS should have been coded to reflect hospice care.
Failure to Refer Resident for PASRR Level II Re-evaluation
Penalty
Summary
The facility failed to refer a resident with an exempted hospital stay and a diagnosed mental disorder to the appropriate state-designated authority for a re-evaluation and determination. This deficiency was identified for one resident who was admitted with multiple diagnoses, including surgical aftercare, Alzheimer's disease with early onset, and Major Depressive Disorder. A BLTC Medicaid reviewer had documented a PASRR Level II 30-day exemption for rehabilitation, with instructions to submit the most current MDS, physician orders, social notes, and psychiatric information if the resident's stay exceeded 30 days. However, upon review, it was found that the facility did not document a PASRR Level I or resubmit the requested documents when the resident's admission exceeded 30 days. The Social Services Supervisor acknowledged awareness of the 30-day timeframe but had not sent the required documentation to BLTC.
Incorrect Physician Order for Tubigrip Application
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed for a resident reviewed for quality of care. The resident, who was admitted with multiple diagnoses including peripheral vascular disease and a left leg, above-the-knee amputation, was at risk for adverse outcomes due to an incorrectly written physician order. The order, dated 11/19/24, incorrectly specified the application of a Tubigrip stocking to the resident's left lower extremity (LLE) for edema, despite the left leg having been amputated. Observations and documentation from 11/20/24 through 4/2/25 indicated that the Tubigrip had been applied to the LLE. On 4/2/25, both the Regional MDS Nurse and the Director of Nursing confirmed that the order should have been written for the right lower extremity (RLE).
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and document new fall prevention interventions for two residents with a history of falls. Resident #1, who has diagnoses including cerebral infarction and traumatic brain injury, experienced falls on two separate occasions when being transferred to bed. Despite these incidents, no new fall prevention strategies were added to the resident's care plan. The Director of Nursing (DON) acknowledged that the falls were attributed to behavioral issues, yet no new behavioral interventions were documented in the care plan following the falls. Similarly, Resident #6, diagnosed with heart failure and dementia, fell out of bed, but the care plan did not reflect any new interventions to prevent future falls. The Regional MDS Nurse confirmed the absence of new fall prevention measures in the care plan, and the DON admitted that there should have been new interventions documented. This lack of action increased the potential for additional falls and potential injury for these residents.
Failure to Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, which was evident during a review of one of the two medication carts. This deficiency was identified when a narcotic accountability record, covering the period from March 2 to April 1, was found to have a missing signature from a licensed nurse. This omission was observed during a medication cart audit on April 1. An LPN confirmed that nurses are required to sign the narcotic accountability sheet when they take responsibility for or hand over the medication cart. The lack of proper documentation created the potential for undetected misuse or diversion of controlled medications, potentially affecting all residents receiving such medications in the facility.
Failure to Act on Pharmacy Recommendations for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the attending physician acted upon pharmacy recommendations for a resident whose medication regimen was reviewed for psychotropic medication. The resident, who was admitted with multiple diagnoses including Alzheimer's disease with early onset and dementia, was prescribed Seroquel for dementia with behavioral disturbances. The pharmacist, during the monthly drug regimen review, recommended assessing the risks versus benefits of continuing the medication and later suggested discontinuing it. However, there was no documentation in the resident's medical record indicating that the attending physician responded to these recommendations. The deficiency was identified through policy review, record review, and staff interviews. The facility's Medication Regimen Review Policy required the attending physician to document any medication irregularity and the actions taken to address it. Despite the pharmacist's recommendations documented on two separate occasions, the medical record lacked any response from the attending physician. The Director of Nursing confirmed that the recommendations were sent to the attending physician, but no response was received, indicating a lapse in the facility's adherence to its own policies and procedures.
Failure to Ensure Medical Necessity for Psychotropic Medication
Penalty
Summary
The facility failed to ensure the medical necessity for the administration of psychotropic medication to a resident diagnosed with dementia. The resident was admitted with multiple diagnoses, including Alzheimer's disease with early onset and dementia. A physician order was documented for the resident to start Seroquel, an antipsychotic drug, for dementia with behavioral disturbance. However, the FDA has documented that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death, and Seroquel is not approved for such patients. On a later date, the pharmacist recommended discontinuing Seroquel, but there was no documented response from the attending physician to this recommendation. The Director of Nursing stated that the recommendation was sent to the attending physician, but no response was received.
Medication Error Rate Exceeds 5% Due to Improper Insulin Priming
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 5.41% affecting one of three residents whose medication administrations were observed. Specifically, a resident was prescribed a sliding scale insulin regimen, including Lantus insulin at 10 Units and Lispro insulin at 2 Units. During a medication pass, an LPN was observed priming both insulin pens with only 1 Unit of insulin instead of the required 2 Units before administering the prescribed doses. The LPN confirmed priming each pen with 1 Unit, which did not comply with the proper procedure for insulin administration.
Inadequate Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored securely, which could lead to potential theft or diversion. During an observation, a bottle of lorazepam liquid, a Schedule IV controlled medication, was found stored in the medication refrigerator door rack. An RN confirmed that while the medication refrigerator and the medication room door were locked, there was no additional locked, permanently affixed compartment inside the refrigerator specifically for controlled medications. This oversight created the potential for undetected misuse or diversion of controlled medications, affecting all residents receiving such medications in the facility.
Deficiencies in Food Storage, Sanitation, and Meal Delivery Protocols
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and sanitation in the kitchen, as well as adherence to infection control protocols during meal delivery. During a kitchen tour, it was observed that several food items, including bottles of lime juice and a carton of liquid whole eggs, were not properly dated or discarded according to the Idaho Food Code. Additionally, the kitchen equipment and surfaces, such as the walk-in refrigerator door, toaster, air fryer, and steam table, were found to have various substances on them, indicating a lack of cleanliness. The dish machine's rinse temperature was recorded below the required level, and sanitation was not documented, further highlighting the facility's failure to maintain sanitary conditions. Furthermore, during meal delivery, an RN was observed delivering trays to residents without covering the salad and hot spiced apples, which is against the infection control protocol. The RN was unsure if the food needed to be covered when transported over a long distance, and the dietary manager later confirmed that food should be covered during such deliveries. These deficiencies in food handling and infection control practices had the potential to affect all 39 residents receiving meals from the facility's kitchen.
Failure in Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, specifically in the area of hand hygiene. On March 31, 2025, it was observed that 12 residents were served meals in the dining room without being offered or performing hand hygiene prior to receiving their meals. Additionally, a registered nurse served meals to three residents in their rooms without offering or performing hand hygiene. A certified nursing assistant acknowledged that they usually wash residents' hands with washcloths before and after meals but failed to do so on this occasion. On April 3, 2025, the infection preventionist confirmed that residents should be offered hand hygiene before meals, both in the dining room and in their rooms.
Failure to Protect Residents from Neglect During Transport
Penalty
Summary
The facility failed to ensure residents' rights were protected from neglect, resulting in physical harm to two residents. Resident #191, who had spinal stenosis, suffered a significant cut to her lower left leg when the van she was riding in stopped suddenly, causing her to fall forward out of her chair. The seat belt and wheelchair restraints were inspected and found to be functioning properly, indicating that the issue was related to the proper securing of the resident in the van. The incident was not known to the current Administrator as it occurred before her tenure. Resident #192, who had multiple diagnoses including kidney disease and stroke, tipped backwards in his wheelchair while in the van, resulting in an open contusion to his right elbow and a non-displaced fracture of his right femur. The Maintenance Supervisor confirmed that the van's equipment was functioning correctly and attributed the incident to staff not properly securing the wheelchair. The Administrator confirmed that the metal hooks used to fasten the wheelchair were not tight enough, leading to the accident. These findings represent past noncompliance with the regulatory requirement to protect residents from neglect.
Removal Plan
- All facility drivers were in-serviced on the proper procedure for securing and un-securing passengers in wheelchairs.
- New seat belts were purchased, and maintenance added a monthly check of all seatbelts to routine van maintenance.
- All facility drivers were educated on ensuring all van straps were in place and tightened on the wheelchair before transport and the lap seatbelt was in place before the van moved.
- The van was inspected to ensure the seat belts were properly functioning.
- Training with return demonstration was provided to the van drivers.
- A 2-person wheelchair securement check before each resident transport was put into place.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen equipment and environment were maintained, and food was stored in a safe and sanitary manner. During an inspection of the dry food pantry, it was observed that the bottom shelves were only 4.25 inches above the floor, contrary to the FDA Food Code requirement of at least 6 inches. Additionally, a layer of dust was found on an upper shelf where a television was placed above an active cooling unit. The Kitchen Manager confirmed the pantry shelves were built-in and could not be changed and admitted to not noticing the dust on the pantry shelf as it was storing a television monitor and not food items. Refrigeration and freezer temperature logs revealed that the behavioral unit residents' food refrigerator's temperature was above 41 degrees for 14 of 30 days during both the morning and evening shifts. The Kitchen Manager verified that temperatures of the resident refrigerators and freezers were monitored by kitchen workers and stated that the maintenance supervisor was notified whenever the larger resident refrigerators were out of temperature range. However, the Maintenance Supervisor did not recall being notified of any issues with the larger resident fridges in May. During a kitchen tour, several deficiencies were observed, including an open bag of peas and carrots and multiple opened ice cream containers without use-by or receipt dates. The Kitchen Manager admitted that a kitchen aide forgot to put the dates on the food in the chest freezer. Additionally, the ventilation hood system was found to be inadequately cleaned, with dust-covered residue on the hood above the stove and oven, and an accumulation of dust hanging from the supporting chains. The cleaning schedules provided by the facility documented that the hood was not cleaned from May 1 through May 29. The Kitchen Manager confirmed that the two full-time kitchen workers, including herself, had physical limitations that prevented them from cleaning the kitchen surfaces well. Furthermore, the back delivery door was observed to be open, with a ripped and loose screen and a broken bottom left door guard, leaving a gap approximately 4 inches wide and 1 inch high. The Kitchen Manager stated that the screen door was damaged during a recent delivery and had not been replaced.
Failure to Assist Residents in Formulating Advanced Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advanced directive. This deficiency was identified for three residents whose records were reviewed for advanced directives. The facility's policy, revised in September 2022, mandates that upon admission, the facility should determine if a resident has an advanced directive and, if not, offer assistance to formulate one. However, the records for Resident #6, Resident #36, and Resident #38 did not include documentation that an advanced directive was offered or discussed with them or their representatives. Resident #6, admitted with diagnoses including metabolic encephalopathy and hypertension, had no documentation of an advanced directive or any discussion about it. Similarly, Resident #36, with diagnoses including osteoarthritis and late-onset Alzheimer's disease, also lacked such documentation. Resident #38, diagnosed with multiple sclerosis and adult failure to thrive, had a care plan stating that advanced directives should be maintained in her chart, but there was no documentation that information about an advanced directive was provided or discussed. The Director of Nursing confirmed the absence of this documentation for all three residents.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to ensure that a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This deficiency was identified for two residents who were reviewed for transfer. The facility's policy, dated October 2022, required that the Notice of Facility Bed-Hold and Return policies be provided to the resident and representative within 24 hours of an emergency transfer. However, the records for two residents did not include documentation that such notices were provided when they were transferred to the hospital. Resident #6, who was admitted with multiple diagnoses including metabolic encephalopathy and hypertension, was transferred to the hospital due to seizure-like activity and low blood oxygen saturation. There was no documentation that a bed-hold notice was provided to him or his representative. Similarly, Resident #30, admitted with diagnoses including heart failure and type 2 diabetes, was transferred to the hospital for assessment based on a physician's order. Again, there was no documentation of a bed-hold notice being provided. The Director of Nursing confirmed the absence of these notifications in the medical records for both residents.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to ensure infection control and prevention practices were maintained, specifically in the care of a resident with a foley catheter. The facility's policy, revised in February 2024, directed staff to keep catheter tubing and drainage bags off the floor. However, during an observation on 5/28/24, the resident's foley catheter drainage bag was found lying on the floor next to his bed. The Director of Nursing (DON) confirmed on 5/30/24 that the drainage bag should not be placed on the floor and should be attached to the side of the bed. The resident involved had multiple diagnoses, including multiple sclerosis and adult failure to thrive, and was admitted to the facility on an unspecified date.
Failure to Provide Pertinent Health Information During Resident Transfers
Penalty
Summary
The facility failed to ensure pertinent health information was provided to the receiving hospital for two residents during their transfer. According to the facility's Transfer or Discharge policy, specific information such as the basis for the transfer, contact information of the responsible practitioner, resident representative information, advanced directive information, special instructions for ongoing care, comprehensive care plan goals, and other necessary information must be communicated to the receiving facility. Additionally, the policy requires documentation in the medical records of the basis for the transfer, notice provided to the resident or legal representative, date and time of transfer, new location, mode of transfer, summary of the resident's condition, and other relevant details. However, the records for two residents did not include documentation that pertinent medical information was provided to the receiving hospital upon their transfer. Resident #6, who was admitted with multiple diagnoses including metabolic encephalopathy and hypertension, was transferred to the hospital due to seizure-like activity and low blood oxygen saturation. The resident's record did not include documentation that pertinent medical information was provided to the receiving hospital. Similarly, Resident #30, admitted with diagnoses including heart failure and diabetes, was transferred to the hospital for assessment based on a physician's order. The resident's record also lacked documentation that pertinent medical information was provided to the receiving hospital. The Director of Nursing confirmed that the necessary discharge/transfer forms and documentation were not included in the residents' charts as required by the facility's policy.
Failure to Complete Assessments for Assistive Devices
Penalty
Summary
The facility failed to ensure appropriate assessments for assistive devices were completed for two residents. Resident #1, who was admitted with multiple diagnoses including a traumatic brain injury and a history of falls, was observed with a HALO Safety Ring on his bed. Despite the care plan's directive to assess entrapment risk quarterly and as needed, the facility could not provide documentation that Resident #1 was assessed for the safe use of the HALO Safety Ring. The Maintenance Supervisor confirmed the lack of documentation for this assessment. Similarly, Resident #38, admitted with multiple sclerosis and adult failure to thrive, was observed with a HALO Safety Ring on the left side of his bed. The care plan for Resident #38 also directed staff to assess entrapment risks to ensure proper usage of assistive devices. However, the resident's record did not include documentation of an assessment for the HALO Safety Ring. The Director of Nursing confirmed that the assessment had not been completed for Resident #38.
Failure to Ensure Accurate PASARR Screenings
Penalty
Summary
The facility failed to ensure that the PASARR Level I screenings for two residents contained accurate information and that necessary PASARR Level II screenings were completed. Resident #6, who was admitted with multiple diagnoses including metabolic encephalopathy and bipolar disorder, had a PASARR Level I screen that did not document his bipolar disorder. The Social Services Supervisor and the DON acknowledged that the error should have been recognized and corrected prior to admission. Additionally, there was no documentation that a PASARR Level II was completed for Resident #6. Resident #30, admitted with diagnoses including heart failure and psychosis, had a PASARR Level I screen indicating a major mental illness and the need for further screening. However, there was no documentation of a PASARR Level II being completed. The Social Services Supervisor was unaware of the location of Resident #30's PASARR Level II, and the DON confirmed that it should have been completed. These deficiencies indicate a failure in the facility's process for ensuring accurate and complete PASARR screenings, potentially impacting the provision of specialized mental health services for the residents.
Failure to Change Respiratory Equipment as Indicated
Penalty
Summary
The facility failed to ensure respiratory equipment was changed as indicated for a resident with severe cognitive impairment and multiple diagnoses, including congestive heart failure and kidney disease. The physician's order required the oxygen tubing and humidifier to be changed twice a month, on the 1st and the 15th, during the night shift. However, on 5/28/24, the resident's concentrator humidifier was observed to be dated 5/1/24, and the oxygen tubing was undated. The Director of Nursing confirmed that the oxygen tubing and water bottle should have been changed weekly and dated when changed.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to ensure informed consent was obtained from residents or their representatives for the use of bed rails. This deficiency was identified for two residents who had HALO safety rings installed on their beds. The facility was unable to provide a policy and procedure for the use of assistive devices and the requirement of obtaining informed consent prior to their use. The facility stated they followed the manufacturer's HALO Safety Ring Instructions for installation. Resident #1, who was admitted with multiple diagnoses including a traumatic brain injury and spastic hemiplegia, was observed with a HALO safety ring on his bed. However, his record did not include documentation of informed consent for its use. Similarly, Resident #38, admitted with multiple sclerosis and adult failure to thrive, was observed with a HALO safety ring installed on the left side of his bed, but his medical record also lacked documentation of informed consent. The Director of Nursing confirmed that neither resident had an informed consent for the use of the HALO safety ring.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure residents were offered the pneumococcal vaccine, specifically for one resident whose records were reviewed. The resident, admitted with multiple diagnoses including paranoid schizophrenia, chronic kidney disease, and dementia, had previously received PPSV23 and PCV13 vaccinations before admission. However, there was no documentation that the resident was offered the PCV20 vaccine after admission. During an interview, the Infection Preventionist (IP) was unable to confirm if the resident had been offered the PCV20 or PCV15 vaccine, and no further information or documentation was provided to the surveyors.
Failure to Inspect Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to regularly inspect bed rails to identify areas of possible entrapment for two residents. Resident #1, who had multiple diagnoses including a traumatic brain injury and spastic hemiplegia, was observed with a HALO safety ring attached to his bed. The Maintenance Supervisor stated he conducted visual inspections of the device but was unable to provide documentation of these inspections. This lack of documentation indicates that the facility did not have a consistent process for ensuring the safety of the bed rails and assistive devices used by Resident #1. Resident #38, diagnosed with multiple sclerosis and adult failure to thrive, was also observed with a HALO safety ring installed on his bed. The resident's care plan directed staff to assess entrapment risks, but there was no documentation in the medical record of such an assessment. The DON confirmed that the Maintenance Supervisor measured the space between the bed and the HALO safety ring upon installation, but again, there was no documentation to support that ongoing inspections were conducted. This failure to document and regularly inspect the bed rails created a potential risk for resident entrapment and injury.
Non-Functioning Call Lights for Two Residents
Penalty
Summary
The facility failed to ensure all call lights were functioning, affecting two residents. Resident #7, who had severe cognitive impairment and required maximum assistance for activities of daily living, was observed multiple times without his call light or cow bell within reach. He stated that he relied on his roommate to use a cell phone to call for help, but the cell phone was also out of reach. Staff confirmed that they made rounds every 15 minutes, but this did not address the immediate need for a functioning call light system. Resident #38, who was cognitively intact but had multiple sclerosis and required extensive assistance, also had a non-functioning call light. He filed a grievance stating his call light was not working, and a follow-up documented that a bell was given to both residents. However, Resident #38 had difficulty using the bell due to his condition. The Maintenance Supervisor and Administrator were aware of the issue, but the call light system remained unfixed, and there was no documentation of the family being informed or refusing a room change for Resident #7.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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