Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cascades At Desert View during CMS and state inspections, most recent first.
Grievances Not Responded To or Investigated: The facility failed to ensure grievances were responded to and investigated for two residents. One cognitively intact resident with COPD, obesity, and insomnia reported a CNA was disrespectful three times and said she filed a grievance. Another resident with quadriplegia, schizoaffective disorder, dysphagia, and hypotension had a grievance filed on his behalf about catheterization care and staff behavior. Review of the grievance binder showed missing grievance records, and the two residents’ grievances were not included in the grievance file.
Insufficient RN coverage was identified when the facility did not provide 8 consecutive hours of RN services during the reviewed schedule period. The facility policy required an RN to provide services at least 8 consecutive hours every 24 hours, seven days a week, but the schedule showed no RN coverage for 24 hours on one day, and the HR Director confirmed the gap.
Food was served to residents without proper temperature control during lunch service. A scoop of potato salad was left on the kitchen counter before being covered and served, and the remaining potato salad measured 83.6 degrees F. The peach cobbler fruit mixture was also served without being temperature checked. The Dietary Supervisor stated the potatoes had not been cooked the day before, did not have enough time to cool before being made into potato salad, and the potato salad should not have been left on the counter and served at that temperature.
Food storage, cleaning, and monitoring practices were not followed in the kitchen. Surveyors found multiple opened refrigerated and pantry items without proper opened or use-by dates, dirty food-contact equipment such as encrusted skillets and soiled plate covers, a missing or incomplete walk-in refrigerator temp log, and a Dietary Supervisor in the food prep area without a beard net. The Administrator and Food Service Manager gave differing statements about sanitizer bucket change frequency.
Infection control practices were not followed when an LPN handled a glucometer and wound care supplies without proper hand hygiene or barrier protection, placed equipment and supplies on resident bedside tables, and returned a glucometer to storage without sanitizing it. An LPN also used dressing supplies from another resident during wound care and did not perform hand hygiene before or after glove changes. In addition, the Maintenance Director stated the facility had eight swamp coolers on the roof but had never tested them for Legionella.
Activities program not directed by a qualified professional. The Administrator stated the Activity Director had quit and an Activities Assistant was filling the role. The acting Activities Director said she had only been in the position for a few weeks, did not have the required certification or license, and was not in a training program to become licensed.
Failure to follow orders affected multiple residents. Several residents with constipation had bowel flowsheets showing 4 to 8 days without a BM, but there was no documentation of ordered BM meds or other nursing interventions. One resident also reported CPAP problems, yet the record lacked an active CPAP order and the care plan did not address CPAP use. Another resident had repeated low BP readings below the ordered threshold without documented cardiology notification.
Incomplete daily nurse staffing sheets were found during review of records from multiple months. The surveyor noted that actual hours worked were not documented on many sheets, with several days showing no RN or nursing hours listed, no nurses scheduled for one or more shifts, and some missing daily staffing sheets. The ADON stated the staffing sheets should have been correctly completed and were not.
Failure to protect resident dignity and privacy: two residents were observed with conditions that compromised dignity. One resident’s urinary catheter bag was left uncovered and visible from the hallway, while another resident’s mattress remained soaked with urine and the room had a strong urine and body odor smell. The facility policy required staff to promote privacy and prohibit demeaning practices.
Failure to inform a resident or representative about psychotropic medication risks and benefits. A resident with Alzheimer’s disease and depression was ordered duloxetine for depression and PRN quetiapine for dementia agitation, but the record lacked documentation that the resident or representative was informed of the risks, benefits, or adverse effects. The CRN stated consents for the resident’s psychotropic meds were not available.
Resident's Drinking Water Was Not Within Reach: A resident with quadriplegia and DM was observed in bed with drinking water placed on a bedside table out of reach on multiple occasions. A CNA later acknowledged the water was not reachable, moved an overbed table closer, and placed the water directly in front of the resident so it could be reached.
A resident with acute respiratory failure with hypoxia and kidney disease did not receive the required NOMNC within the CMS timeframe. Record review showed the resident’s skilled Part A services ended before the required 2-day notice period, and the Administrator confirmed the notice should have been given 2 days before benefits ended.
Failure to Monitor Psychotropic and Opioid Side Effects: A resident with Alzheimer's Disease and depression received duloxetine, PRN quetiapine, fentanyl patch, and oxycodone, but the medical record did not show monitoring for psychotropic or opioid adverse effects. The CRN confirmed there was no side effect monitoring in place, despite facility policies requiring monitoring for opioid effectiveness, overdose, and psychotropic adverse consequences.
Missing discharge and transfer documentation: A resident discharged home did not have documentation of receiving required discharge papers, including a med list and stay recapitulation. Another resident with schizoaffective disorder, bipolar type, dysphagia, and hypotension had dark emesis, was sent to the hospital by EMS, and the record did not show that the hospital received the resident’s current medical record, face sheet, MAR, advance directive if available, or POST.
The facility failed to refer a resident with a positive PASARR Level 1 screening for mental illness for further evaluation by the state-designated authority. The resident had diagnoses including schizoaffective disorder, bipolar type, dysphagia, and hypotension, and the record also documented schizoaffective disorder. A CRN later stated the resident did not have a PASARR Level II screening and should have one.
A resident admitted with an unstageable pressure ulcer and severe sepsis did not have a baseline care plan completed within the required 48 hours. The plan was started but not completed or signed until 6 days after admission, and the CRN confirmed it should have been finished within 2 days.
A resident with quadriplegia, schizoaffective disorder, bipolar type, dysphagia, and hypotension had a care plan that did not document use of a splint or participation in the RNA program. Review of the RNA flowsheet showed BUE PROM was marked Not Applicable in multiple entries, and there was no documentation that the resident wore the splint. The ADON confirmed the care plan was missing this information.
A resident with quadriplegia, schizoaffective disorder, dysphagia, and hypotension had a care plan that listed halo bars for bed mobility, but staff observed no halo bar attached to the bed. The CRN stated the resident had been moved to another room, did not want the device installed, and the care plan should have been updated to reflect the change.
Failure to Rinse Mouth After Advair Inhaler Use: Two residents receiving Advair inhalers were observed taking their prescribed doses by mouth, but an LPN was not observed providing water for mouth rinsing afterward as ordered. One resident had asthma and acute/chronic respiratory failure with hypoxia, and the other had COPD and diabetes. The DON and CRN later stated both residents should have been given water to rinse their mouths after inhaler use.
Restorative ROM and splinting were not consistently provided for three residents with significant mobility limitations. A resident with quadriplegia had curled fingers and was not being helped with his splint, another resident with quadriplegia had carrot splints left on the bedside table because they were too big, and a resident with stroke and L-sided hemiplegia had a curled hand despite a restorative plan for active ROM and transfers. RNA documentation repeatedly showed interventions marked NA, and staff said they did not have enough time to complete all scheduled RNA programs.
Failure to provide ordered respiratory services for two residents. One resident with rib fractures and kidney failure was observed on O2 at 4 LPM even though the MD order was for 2 L/min NC while sleeping, and the care plan referenced nocturnal hypoxia. Another resident with metabolic encephalopathy and HF had an order for continuous O2 at 3 L/min NC with qshift SpO2 checks and a goal of >90%, but was observed without NC use, had documented low room-air SpO2 readings, and the chart lacked nursing intervention notes.
A resident's partial care plan and nursing note were included in Resident Council Meeting minutes, exposing PHI such as behavior goals, interventions, foot information, medications, and treatment refusals. Staff stated the minutes binder was available to the public and could be viewed by anyone who requested it.
Unsanitary kitchen practices and inadequate dishwashing sanitation: The dishwasher wash cycle repeatedly reached only 100 F instead of the required 120 F while utensils were being washed and stored, and the CDM acknowledged dishes washed below that temperature were not properly sanitized. Kitchen fire sprinklers and smoke alarms were observed with a thick layer of particles, and a staff member placed an open box of beef patties on the counter next to an open drink and left the meat uncovered in the food prep area.
Ineffective Kitchen Pest Control: The facility failed to ensure its pest control program was effective in the kitchen. Surveyors observed a cockroach scurrying near the dishwashing area, live cockroaches on the floor, in cabinets and drawers, on packaged food products, and under the oven, along with dead cockroaches in sink areas, utensil drawers, and around garbage cans. The Maintenance Director stated the issue had been worsening for months, the pest control company had documented heavy cockroach activity, and the monthly service had not occurred as scheduled.
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.
Grievances Not Responded To or Investigated
Penalty
Summary
The facility failed to ensure grievances were responded to and investigated for 2 of 2 residents reviewed for grievances, Resident #5 and Resident #25. The facility’s grievance policy dated 10/2024 identified the Administrator as the Grievance Officer and stated the Grievance Officer, with assistance from social services, was responsible for overseeing the grievance process, receiving and tracking grievances through conclusion, leading investigations, maintaining confidentiality, issuing written grievance decisions, and coordinating with state or federal officials as needed. The policy also stated the Grievance Officer and/or designee would make reports available within five business days and provide residents a summary report of the investigation. Resident #25, who was cognitively intact and had diagnoses including COPD, obesity, and insomnia, stated she had felt a CNA was disrespectful to her three times within the last 30 days and that she filed a grievance. Resident #5, who had diagnoses including quadriplegia, schizoaffective disorder, bipolar type, dysphagia, and hypotension, had a grievance filed on his behalf related to catheterization care and staff behavior. Review of the grievance binder showed grievances from July 2025 through May 2026, but grievances for February, March, April, and May 10, 2026 were missing from the binder. The Administrator later provided grievance counts for those months, but Resident #5 and Resident #25 were not included in the grievance file, and the Administrator stated that if a grievance was brought to her attention she would take it right away and follow up, while also stating the best practice was to write every grievance.
Insufficient RN Coverage
Penalty
Summary
The facility failed to ensure sufficient RN services were provided at least eight consecutive hours per day, every 24 hours, seven days a week. The facility policy titled "Staffing, Sufficient and Competent Nursing," revised August 2022, stated that a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week. Review of the facility's three-week nursing schedule dated 4/19/26 through 5/10/26 showed the facility did not provide 8 consecutive hours of registered professional nursing coverage on 5/9/26. On 5/14/26 at 11:47 AM, the HR Director stated there was no RN coverage for 24 hours on 5/9/26.
Food Served at Improper Temperature
Penalty
Summary
The facility failed to ensure resident meals were palatable and maintained at the correct temperature during the lunch meal. During a follow-up kitchen observation on 5/11/26 at 11:45 AM, one scoop of potato salad was placed on small plates for each resident and left on the kitchen counter until it was covered with plastic wrap and served. The remaining potato salad was checked and found to be 83.6 degrees F. The peach cobbler fruit mixture was also served to residents without being temperature checked before service. During interviews on 5/13/25 and 5/13/26, the Dietary Supervisor stated the potatoes should have been cooked the day before and were not, and that the boiled potatoes did not have sufficient time to cool before being combined into potato salad and served. The Dietary Supervisor also stated the potato salad should not have been left on the counter and served at 83.6 degrees F, but it was.
Food Storage, Cleaning, and Monitoring Deficiencies
Penalty
Summary
Food was not stored, labeled, cleaned, or monitored in accordance with professional standards and the facility’s own food receiving and storage policy. During the kitchen tour, surveyors observed multiple opened refrigerated and pantry items without documented opened dates or use-by dates, including bread, sliced cheese, milk, half and half, olives, chicken stock, hard boiled eggs, elbow noodles, rice, and straight noodles. The facility’s policy stated that food stored in the refrigerator or freezer should be covered, labeled, and dated, and that refrigerated foods should be monitored so they are used by their use-by date, frozen, or discarded. The Food Service Manager stated that once a food package was opened, it should be documented at 7 days for use-by dates, but this had not been done. Surveyors also observed food-contact surfaces and equipment that were not clean, including plate covers with a black grease-like substance, three skillets with black encrusted food inside, and small plates and bowls with food spots on the edges. The walk-in refrigerator temperature log was not initially available for review, and when later posted it was missing temperature entries for several dates and shifts. In addition, the Dietary Supervisor was observed in the food prep area without a beard net over facial hair, and the Administrator stated sanitizer buckets should be changed every two hours, while the Food Service Manager stated they were made fresh each morning and again when the evening crew came in.
Infection Control and Legionella Monitoring Failures
Penalty
Summary
The facility failed to ensure adherence to infection control and prevention practices when staff did not use barrier protection, did not perform hand hygiene at required times, and did not test swamp cooler water for Legionella. The report cited CDC and OSHA guidance stating that water systems and evaporative air coolers can support Legionella growth and that routine cleaning, disinfection, and testing are part of water management. The facility’s water management plan stated that effectiveness would be validated by routinely testing certain building water systems, including cooling towers, but the Maintenance Director stated the facility had eight swamp type coolers on the roof and had never tested them for Legionnaires disease. During medication administration and blood glucose monitoring, an LPN was observed with a glucometer, lancet, and alcohol swab on top of the medication cart, then carrying the glucometer and supplies into a resident’s room and placing them on top of the PPE cart without performing hand hygiene. Inside the room, the glucometer was placed on the resident’s bedside table without a barrier such as a paper towel. After the blood glucose check, the glucometer was returned to a zip-lock bag without being sanitized. The same LPN was later observed donning gown and gloves before entering another resident’s room without performing hand hygiene before donning PPE. During wound care for another resident, an LPN brought dressing supplies into the room, including Therablue taken from another resident’s dressing supplies, and placed the supplies on the bedside table without a barrier. The LPN donned gloves, removed the old dressing, cleaned the wound, then realized scissors had not been sanitized and left the room to get alcohol wipes. She returned, sanitized the scissors, cut the dressing material, changed gloves, applied collagen powder and Therablue, and covered the wound with gauze. The LPN was also observed applying lotion after changing gloves, and hand hygiene was not observed before putting on or after removing gloves during the dressing procedure. The IP stated hand hygiene should always be performed before and after changing gloves and that dressing supplies should not be shared with other residents.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to employ a certified Activities Director. On 5/11/26 at 10:45 AM, the Administrator stated the facility's Activity Director had quit and the Activities Assistant was filling the position for now. On 5/13/26 at 2:10 PM, the acting Activities Director stated she had only been in the position for a few weeks to see if she wanted to take it, and she said she did not have the certification or license and was not in a training program to be licensed.
Failure to Follow Orders for Bowel Care, CPAP, and BP Notifications
Penalty
Summary
The facility failed to follow physician orders and its bowel management protocol for 7 residents reviewed for bowel and bladder care and physician orders. The facility’s Bowel Management - Clinical Protocol stated that residents should be assessed, monitored, and managed according to individualized needs and orders, with specific interventions required after 2, 3, and 4 days without a bowel movement. For Residents #2, #4, #8, #10, #18, #23, and #38, bowel flowsheets documented multiple periods without bowel movements, ranging from 4 to 8 days, but the medical records contained no documentation of nursing interventions with the ordered bowel medications during those periods. The CRN stated these residents did not have any nursing BM interventions documented and should have. Resident #2 also had issues related to CPAP use. He was observed using oxygen at 5 LPM and stated he was having problems using his CPAP device and mask, reporting that he had told numerous staff but nothing had been done. The record did not show an active physician order for CPAP use at the time of review, although it did contain an older order for Trilogy CPAP at bedside with a start and end date in 2024. A progress note documented that he needed a new CPAP mask and tubing because his mask was torn and obstructing the airway, and another note stated staff and the medical team were aware of the concern and continued to monitor and address it. His care plan did not include CPAP usage, and the CRN stated CPAP should have had a physician’s order and been care planned. Resident #18 also had repeated low blood pressure readings without documented physician notification as ordered. The physician order directed daily blood pressure checks and to notify cardiology if systolic BP was below 100 in the morning for midodrine administration. The record listed multiple dates when systolic BP was below 100, including readings such as 90/58, 88/68, 94/67, 96/52, 97/59, and 93/60, but there was no documentation that cardiology was notified during those times. The CRN stated the medical record had no notification documentation to cardiology during the listed low blood pressure episodes and should have.
Incomplete Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure nurse staffing information was accurately completed and posted daily for each shift. During review of the daily staffing sheets from October 2025 through April 2026, the surveyor found that actual hours worked had not been documented on multiple daily staffing sheets, and several entries were incomplete or missing altogether. The missing or incomplete records included days with no RN scheduled or hours listed, no nursing staff scheduled for certain shifts, no nurses scheduled for day, evening, or night shifts, staffing listed for only 2 hours, and multiple missing daily staffing sheets. On 5/13/26 at 2:38 PM, the ADON stated the daily staffing sheets should have been correctly completed and were not.
Failure to Protect Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 2 of 14 residents reviewed for respect and dignity issues. The facility’s Dignity policy dated 2/2021 stated staff are to promote, maintain, and protect resident privacy, and that demeaning practices and standards of care that compromise dignity are prohibited. Staff are also expected to help residents maintain dignity, including keeping a urinary catheter bag covered. Resident #8, who was initially admitted and later readmitted with diagnoses including gastroparesis and diabetes, was observed on 5/11/26 with a catheter bag hanging on a trash can in the room without a privacy cover, making it visible from the hallway when the door opened. The resident stated the bag was always like that and never covered. Resident #23, admitted with diagnoses including stroke with left side hemiparesis and diabetes, was observed on 5/11/26 with a bed mattress soaked with urine in a large round area, with the sheets removed but the mattress left in place. The room had a very strong smell of urine and body odor, and the CRN stated the mattress should have been removed and replaced but had not been.
Failure to Inform Resident or Representative About Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure residents and/or their representatives were informed in advance of the risks and benefits of psychotropic medications and alternative treatment options. Based on record review, policy review, and staff interview, this deficiency involved 1 of 5 residents reviewed for unnecessary medications, Resident #43, who was admitted with multiple diagnoses including Alzheimer's Disease and depression. A physician's order showed Resident #43 was to receive duloxetine HCL 60 mg by mouth daily for depression and quetiapine fumarate 25 mg by mouth every 6 hours as needed for dementia agitation for 14 days. The resident's record did not contain documentation that she and/or her representative were informed of the risks and benefits of duloxetine and quetiapine fumarate or their adverse effects. The facility's Psychotropic Medication policy stated residents will not receive medications that are not clinically indicated to treat a specific condition and that residents, families, and/or representatives are involved in the medication management process. On 5/14/26 at 9:41 AM, the CRN stated they did not have the consents for Resident #43's psychotropic medications.
Resident's Drinking Water Was Not Within Reach
Penalty
Summary
The facility failed to ensure that Resident #28's drinking water was within reach. Resident #28 was admitted with multiple diagnoses including quadriplegia and diabetes and was observed in bed on 5/11/26, 5/12/26, and 5/13/26 lying in bed and watching television while drinking water was placed on top of the bedside table on the resident's right side near the head of the bed. The resident was observed moving the left hand, but no movement was noted in either arm, and the water was not within reach. On 5/13/26 at 10:21 AM, a CNA delivered the water and placed it on the bedside table; when asked whether the resident could reach it, the CNA stated, "Oh, you are right," then moved an overbed table next to the resident. The resident asked for the table to be moved closer, and the CNA positioned it directly in front of the resident over the lap and placed the drinking water where it could be reached.
Late Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (CMS-10123) within the CMS-required timeframe for Resident #19, who was reviewed for beneficiary protection notification. The facility’s policy dated 9/22 stated that when a resident’s Medicare-covered Part A stay or Part B therapies are ending, a NOMNC is issued at least two calendar days before benefits end. Resident #19 was initially admitted and later readmitted with multiple diagnoses including acute respiratory failure with hypoxia and kidney disease. Record review showed that the resident’s skilled Part A nursing services ended on 5/8/26, but the resident signed the NOMNC on 5/7/26, which was not the required two-day notice before the end of benefits. During interview, the Administrator stated the resident should have been given the skilled nursing services ending notice two days before 5/8/26 and had not been.
Failure to Monitor Psychotropic and Opioid Side Effects
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic and opioid medications was monitored for adverse effects. Based on record review, policy review, and interview, the deficiency involved Resident #43, who was admitted with diagnoses including Alzheimer's Disease and depression and had orders for duloxetine 60 mg daily for depression, quetiapine 25 mg every 6 hours as needed for dementia agitation for 14 days, fentanyl transdermal patch 25 mcg/hour every 72 hours, and oxycodone 5 mg by mouth. The facility's Pain Assessment and Management policy stated that when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. The facility's Psychotropic Medication Use policy stated that residents receiving psychotropic medications are monitored for adverse consequences including anticholinergic, cardiovascular, metabolic, neurologic, and psychosocial effects. Review of Resident #43's medical record did not include monitoring for the side effects of the psychotropic and opioid medications. During interview on 5/14/26 at 8:59 AM, the CRN confirmed there was no psychotropic and opioid side effect monitoring in place for Resident #43.
Missing Discharge and Transfer Documentation
Penalty
Summary
The facility failed to ensure that a resident discharged home was provided with necessary discharge information. Resident #3 was admitted with diagnoses including a left below-the-knee amputation and diabetes, and a discharge note documented that the resident was discharged to home. The record did not contain documentation that the resident was given discharge documents such as a medication list, a recapitulation of the stay, or other discharge information. On interview, the CRN stated there was no documentation that these discharge documents were provided. The facility also failed to provide hospital transfer documents for a resident transferred to the hospital. Resident #5 was admitted and readmitted with diagnoses including schizoaffective disorder, bipolar type, dysphagia, and hypotension. A nursing note documented episodes of dark emesis with coffee-ground-looking pieces, the provider was notified, and an order was received to transfer the resident to the hospital for evaluation; EMS then transported the resident. The record did not show that the hospital received the resident’s current medical record when he was transferred, and the CRN stated that the face sheet, MAR, advance directive if available, and POST should be sent with residents when transferred, but there was no documentation that these documents were sent.
Failure to Refer Resident With Positive PASARR Screening for Further Evaluation
Penalty
Summary
The facility failed to ensure a resident with a positive PASARR Level 1 screening for mental illness was referred for further evaluation to the appropriate state-designated authority. Resident #5 was admitted and later readmitted to the facility with multiple diagnoses including schizoaffective disorder, bipolar type, dysphagia, and hypotension. The facility's Resident Assessments PASRR Screening Coordination policy dated 4/2025 stated that residents with newly evident or possible serious mental disorder, intellectual disability, or related condition would be referred to the appropriate state-designated authority. A PASRR Level 1 Screening dated 12/29/25 documented that Resident #5 did not have major mental illness, even though the record also documented schizoaffective disorder diagnosed on [DATE]. On 5/14/26 at 1:25 PM, the CRN stated Resident #5 did not have a PASARR Level II Screening and should have one.
Baseline Care Plan Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours of admission for Resident #44. The facility’s Care Plans - Baseline policy dated March 2024 stated that a baseline plan of care to meet the resident’s immediate health and safety needs is developed for each resident within 48 hours of admission. Resident #44 was admitted with multiple diagnoses including an unstageable pressure ulcer and severe sepsis. The resident’s baseline care plan was initiated on 9/16/25 but was not completed or signed until 9/22/25, six days after admission. On 5/13/26 at 3:35 PM, the CRN stated the baseline care plan should have been completed within two days of admission and had not been.
Missing Splint and RNA Program in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive resident-centered care plan included the use of a splint and the RNA program for Resident #5, who was admitted and readmitted with diagnoses including quadriplegia, schizoaffective disorder, bipolar type, dysphagia, and hypotension. Review of the resident’s RNA flowsheet showed BUE PROM entries from 4/17/26 to 5/13/26 documented as Not Applicable in 18 of 25 opportunities, and the splint wearing tolerances for the 30-day look-back period had no documentation that the resident wore his splint. The resident’s care plan did not document that he was on the RNA program or that he wore a splint as tolerated. On 5/12/26, the ADON reviewed the care plan and stated the resident’s splint and RNA program were not documented and should have been included.
Care Plan Not Updated for Bed Mobility Device Change
Penalty
Summary
The facility failed to ensure residents' comprehensive care plans were revised timely and as needed. The facility's policy stated that assessments were ongoing and care plans were to be revised as residents' information and condition changed. Resident #5 was admitted and later readmitted with multiple diagnoses including quadriplegia, schizoaffective disorder, bipolar type, dysphagia, and hypotension. A care plan initiated on 12/2/25 documented that Resident #5 used halo bars for bed mobility. However, on 5/11/26 and 5/12/26, Resident #5 was observed lying in bed and there was no halo bar device attached to the bed. On 5/12/26, the CRN stated Resident #5 had been transferred to another room and did not want the halo device installed to the bed, and that the care plan should have been updated to reflect that the resident did not have the halo device.
Failure to Rinse Mouth After Advair Inhaler Use
Penalty
Summary
The facility failed to ensure medication was administered according to professional standards of practice for 2 of 5 residents observed during medication administration, involving Advair inhaler use. The report states that the Advair website documented that after inhalation the patient should rinse the mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. Resident #31, who had diagnoses including asthma and acute and chronic respiratory failure with hypoxia, had a physician order for Advair HFA Aerosol 115-21 mcg/act, two puffs by mouth twice daily, with instructions to wait one minute between puffs and rinse the mouth after use. On 5/12/26 at 7:15 AM, Resident #31 was observed taking two puffs of Advair HFA through her mouth, and LPN #1 was not observed to provide water for rinsing afterward. Resident #18, who had diagnoses including COPD and diabetes, had a physician order for Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 mcg/act, one puff by mouth twice daily, with instructions to rinse the mouth after use. On 5/12/26 at 7:42 AM, Resident #18 was observed taking one puff of Advair through her mouth, and LPN #1 was not observed to provide water for rinsing afterward. Later that morning, the DON with the CRN present stated that Resident #18 and Resident #31 should have been provided with water to rinse their mouths after taking their inhalers.
Restorative ROM and Splinting Not Consistently Provided
Penalty
Summary
The facility failed to ensure residents received restorative nursing treatment and services to prevent further decrease in ROM for 3 of 3 residents reviewed for ROM-related care. The facility’s Restorative Nursing Services policy, revised in 2024, stated residents would receive restorative nursing care as needed to help promote safety and independence. Surveyors observed that restorative nursing activities and splinting were not being consistently provided as care planned, and RNA flow sheets repeatedly documented "Not Applicable" for scheduled interventions. Resident #5, who had diagnoses including quadriplegia, schizoaffective disorder, bipolar type, dysphagia, and hypotension, was observed in bed with curled fingers on both hands and stated he was not being assisted to put on his splint. A hand brace/splint was seen on top of his chest drawers, and RNA documentation showed bilateral upper extremity PROM was marked Not Applicable in 18 of 25 opportunities, with no documentation that he had worn his splint during the 30-day look-back period. RNA #1 stated it would take about an hour to complete his RNA program and put on the splint, and that the resident was very specific about how the splint should be applied. Resident #28, who had quadriplegia and diabetes, was observed with his right hand closed in a fist while two carrot splints were on his bedside table; he stated the splints were too big for his hands. His RNA flowsheet documented passive ROM for the bilateral lower extremities as Not Applicable in 18 of 28 opportunities and assistance with splint or brace as Not Applicable in 18 of 28 opportunities. Resident #27, who had stroke, dementia, and left-sided hemiplegia, was observed with his left hand curled, and therapy records showed a restorative plan for active ROM and transfers 6 to 7 times per week. However, the RNA flow sheet documented maintain upper extremity mobility as Not Applicable in 8 of 30 opportunities, and RNA staff stated they did not have time to see all residents on their list and that group exercise would not address the resident’s left-hand contracture.
Failure to Provide Ordered Respiratory Services
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for 2 of 5 residents reviewed for respiratory services. One resident was admitted with multiple diagnoses including multiple rib fractures and kidney failure. The resident was observed lying in bed awake and receiving oxygen via nasal cannula at 4 LPM, while the physician order documented oxygen at 2 L/min via nasal cannula while sleeping. The care plan documented oxygen therapy related to nocturnal hypoxia, oxygen use as needed and ordered, room air saturations as ordered, and weaning as able/ordered. The CRN later stated the resident's oxygen should have been set at 2 LPM and was not. A second resident was initially admitted and later readmitted with multiple diagnoses including metabolic encephalopathy and heart failure. An oxygen concentrator was observed in the resident's room, but the resident was not wearing a nasal cannula and stated she only uses oxygen at night. The physician order documented oxygen per nasal cannula at 3 L/min continuous with O2 saturation checks every shift and a goal to maintain O2 sats above 90%. The medical chart documented low room air SpO2 readings of 81.0%, 84.0%, and 88.0%, and there was no documentation of nursing interventions related to the low SpO2 values. The CRN stated the medical record should have had nursing intervention documentation notes and did not.
Resident PHI Included in Publicly Accessible Council Minutes
Penalty
Summary
The facility failed to ensure residents' identifiable information was not accessible to the public. During record review, policy review, and interviews, Resident #16's partial care plan was found in the Resident Council Meeting minutes, including behavior goals and interventions, along with a nursing department note containing medical information about the resident's feet, medication, and treatment refusals. The facility's policy stated that protected health information would not be used or disclosed except as permitted by law. Staff interviews confirmed the Resident Council Meeting minutes binder was available to the public and could be viewed by anyone who asked for it.
Unsanitary kitchen practices and inadequate dishwashing sanitation
Penalty
Summary
The facility failed to ensure the dishwasher maintained proper sanitation temperatures for dishware. During observation, the Certified Dietary Manager was seen washing kitchen utensils and placing them in storage, but the dishwasher wash cycle reached only 100 F during the second cycle. A second set of dishes was then placed in the dishwasher, and the wash cycle again reached only 100 F. The Certified Dietary Manager stated the dishwasher should reach 120 F and acknowledged that dishes washed below that temperature were not properly sanitized. The facility also failed to keep kitchen fire sprinklers and smoke alarms in clean and sanitary condition, and food was stored in an unsanitary manner. During a kitchen inspection, two fire sprinklers and two smoke alarms were observed with a thick layer of peppered particles extending from the top of the sprinklers down to the water lines. The Certified Dietary Manager stated she had been instructed not to clean the sprinklers or alarms because they were the responsibility of the Maintenance Director, and the Maintenance Director acknowledged they were excessively dirty but said he had not cleaned them because the kitchen was not his department. In addition, a staff member removed a box of beef patties from the freezer, placed it on the kitchen counter next to an open drink, opened the box to expose the patties, and then left the kitchen through the back door. The Certified Dietary Manager stated personal drinks should not be present in food preparation areas and confirmed that leaving meat uncovered was unsanitary.
Ineffective Kitchen Pest Control
Penalty
Summary
The facility failed to ensure its pest control program was effective in the kitchen. During observation, the kitchen door was not locked, and when it was opened a cockroach was seen scurrying from under the dishwashing area toward the ice machine. A strong chemical odor was present in the kitchen, parts of the area were draped in thin plastic sheathing, and the floor was damp in areas. Additional observations included a cockroach flailing in the walkway between the food service tray line and the coffee preparation area, brown coffee ground-like droppings behind kitchen equipment on a countertop, live cockroaches crawling on the floor, in kitchen cabinets and drawers, on packaged food products, and under the oven, as well as dead cockroaches under sink areas, in utensil drawers, and around the garbage cans. The Maintenance Director stated that a pest control company had sprayed pesticide in the kitchen at 6:00 PM that day as a special in-depth treatment rather than a routine visit. He also stated that cockroaches began becoming an issue at the end of 2024 and beginning of 2025 and had gotten worse in the last month. The pest control company’s service record from 9/19/25 documented heavy cockroach activity in the kitchen and noted that a cockroach treatment would be scheduled for the next month. The Maintenance Director later stated that the pest control company had not been to the facility for its monthly October service and that a special treatment for the kitchen had not been scheduled until 10/23/25.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 43 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Buhl
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Serenity Transitional Care | 13.2 mi | ★★★★★ | 0 | 0 |
| Bridgeview Estates | 14.6 mi | ★★★★★ | 0 | 0 |
| Twin Falls Transitional Care Of Cascadia | 16 mi | ★★★★★ | 0 | 0 |
| Oak Creek Rehabilitation Center Of Kimberly | 20.2 mi | ★★★★★ | 27 | 0 |
| Bennett Hills Rehabilitation And Care Center | 23.6 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.