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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | BOUNDARY COUNTY NURSING HOME | 135004 | 6640 KANIKSU STREET | BONNERS FERRY | ID | 83805 | 2019-01-31 | 689 | D | 0 | 1 | N5WL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, manufacturers guidelines, policy review, and record review, it was determined the facility failed to ensure staff utilized mechanical lifts properly to reduce potential injuries. This was true for 2 of 2 residents (#1 and #6) reviewed for supervision and accidents. These failed practices placed residents at risk of bone fractures and other injuries related inappropriate use of a mechanical lift. Findings include: The facility's The use of Mechanical Lifts Policy, revised 12/13/18, documented staff utilized mechanical lift equipment when residents could no longer support their weight on their own. The policy documented the facility used a Arjo Maxi Move Mechanical lift device and staff needed to demonstrate and verbalize the correct procedure to operate the lift. The facility's Transfers Policy, revised 10/17/18, documented a resident's ability to transfer was assessed at the time of admission. The policy documented wheelchair brakes needed to be locked during all transfers. The Arjo Maxi Move Instructions for Use, dated (MONTH) 2010, documented the Arjo was designed for safe usage with one caregiver. The instructions documented there were circumstances that dictated the need for a two-person transfer such as combativeness, obesity, contractures etc The instructions documented it was the responsibility of the facility to determine if a one or two person transfer was more appropriate based on the task, resident load, environment, capability, and skill level of the staff members. a. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 11/4/18, documented Resident #1 had severe cognitive impairment and she was dependent on one staff member for bed mobility, transfers, and toilet use. The MDS documented Resident #1 weighed 185 pounds. Resident #1's Care Area Assessment, dated 11/2/18, documented she was considered obese. The care pla… | 2020-09-01 |
| 2 | 2 | BOUNDARY COUNTY NURSING HOME | 135004 | 6640 KANIKSU STREET | BONNERS FERRY | ID | 83805 | 2019-01-31 | 812 | F | 0 | 1 | N5WL11 | Based on observation, review of facility policy and the (YEAR) FDA Food Code, and staff interview, it was determined the facility failed to ensure food was handled properly and maintained according to safe practices and proper hand hygiene was performed. This was true when Potentially Hazardous Food (PHF) cold food temperatures were not maintained at safe temperatures and/or were not assessed prior to service. The facility failed to ensure staff performed adequate hand hygiene to prevent possible cross-contamination of dirty to clean areas in the kitchen. These failed practices placed 12 of 12 residents (#1, #3, #4, #6, #7, #8, #9, #12, #13, #16, #18, and #72) reviewed who dined in the facility and the other 10 residents who dined in the facility, at risk of adverse health outcomes. Findings include: 1. The facility's Dietary Personal Hygiene Policy, revised 1/9/19, documented staff should wash their hands after handling soiled equipment or utensils. The policy documented staff should wet their hands, apply soap, rub their hands together for one minute and, rinse well and dry their hands. On 1/30/19 at 12:10 PM, Cook #1 was observed moving between tasks and she approached the sink, applied soap, rubbed her hands together under running water, banged her hands against the side of the sink, and obtained a paper towel to dry her hands. The whole process lasted 5 seconds. On 1/30/19 at 12:14 PM, Cook #1 repeated the steps above, and the process lasted four seconds. On 1/30/19 at 12:14 PM, the Certified Dietary Manager (CDM), who was present for the observation, stated she would expect staff to wash their hands minimally for 15-20 seconds. On 1/30/19 at 1:47 PM, Cook #2 was observed washing her hands in the dish room. She approached the sink, wet her hands, applied soap, rubbed her hands together, rinsed her hands off, and obtained a paper towel to dry her hands. The whole process lasted 6 seconds. The CDM, who was present for the observation, stated she did not see the staff member washing her hands because Cook #2 wa… | 2020-09-01 |
| 3 | 3 | BOUNDARY COUNTY NURSING HOME | 135004 | 6640 KANIKSU STREET | BONNERS FERRY | ID | 83805 | 2019-01-31 | 880 | F | 0 | 1 | N5WL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented as they related to laundry service practices, hand hygiene practices, and urinary catheter care. Failure to ensure staff processed and transported linens in a sanitary manner, had the potential to impact 12 of 12 residents (#1, #3, #4, #6, #7, #8, #9, #12, #13, #16, #18, and #72) reviewed who resided in the facility and the other 10 residents residing at the facility. Lapses in hand hygiene directly impacted 4 of 15 residents (#1, #6, #7, and #10) whose care was observed. Lapse in urinary catheter care directly impacted 1 of 1 resident (#9) reviewed who had a catheter. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: 1. The facility's Handwashing and Hand Hygiene policy, dated 9/3/17, documented staff should perform hand hygiene when they changed gloves and when moving from a unclean body site to a clean-body site during resident care. This policy was not followed. Examples include: a. On 1/28/19 at 11:15 AM, CNA #1 was observed providing peri care for Resident #7. After assisting Resident #7 with peri care CNA #1 removed her gloves but did not perform hand hygiene. CNA #1 continued to provide care for Resident #7 applying an incontinence pad, readjusting clothing, and transferring Resident #7 back to her recliner. On 1/28/19 at 11:34 AM, CNA #1 stated she should have performed hand hygiene after removing her gloves, prior to touching other items. b. On 1/28/19 at 1:15 PM, CNA #6 was observed assisting Resident #6 with peri care. CNA #6 was observed washing her hands and placing clean gloves onto her hands. CNA #6 retrieved clean supplies to change Resident #6's adult brief and prepared the supplies. CNA #6 began removing Resident #6's soiled pants and placed them into th… | 2020-09-01 |
| 4 | 4 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2020-01-24 | 578 | E | 0 | 1 | JSJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' advance directive information was periodically reviewed with the residents and/or their representatives and was accurate. This was true for 3 of 3 residents (#3, #13, and #14) whose records were reviewed for advance directives. This failed practice created the potential for harm if residents' wishes regarding end of life or emergent care were not honored if they became incapacitated. Findings include: The State Operations Manual, Appendix PP, defines an Advance Directive as .a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The State Operations Manual also states a Physician order [REDACTED]. medical condition into consideration. A POLST [MEDICATION NAME] form is not an Advance Directive. The facility's Advance Directives policy, dated 8/31/19, documented the following: * Staff will inquire and document whether there is an existing Advanced Directive. If one is provided it will be scanned into the medical record. * Copies of the Advanced Directive should be documented in the medical record and communicated clearly to staff involved with cares. This policy was not followed. 1. Resident #3 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #3's admission orders [REDACTED]. Resident #3's admission orders [REDACTED]. A care plan dated 1/10/20, documented Resident #3 did not want to prolong his life and requested comfort measures only. Resident #3's admission orders [REDACTED]. On 1/22/20 at 3:16 PM, the DNS stated there was a discrepancy in the documentation of Resident #3's code status and it should have been changed to reflect the residents wishes. 2. Resident #13 was admitted to the fa… | 2020-09-01 |
| 5 | 5 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2020-01-24 | 641 | E | 0 | 1 | JSJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interview, the facility failed to ensure MDS assessments accurately reflected the resident's status. This was true for 5 of 8 residents (#1, #5, #8, #11, and #12) whose MDS assessments were reviewed for accuracy. This failure created the potential for harm should residents receive inappropriate care related to discrepancies in the MDS assessment. Findings include: The facility's Restraint Policy, revised on 9/20/19, stated, Physical Restraint/Hold: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, body or head freely and/or a measure to prevent patient from exiting the bed/chair (e.g., mitts tied down, soft or leather wrist or ankle straps. The CMS Resident Assessment Instrument (RAI) Manual, Version 3.0, dated (MONTH) 2019, which is used as an instruction manual for completing MDS assessments, defines physical restraints as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The use of bed rails in the facility did not meet the definition of a physical restraint as documented in residents' MDS assessments, as follows: a. Resident #1 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's MDS assessments, dated 11/26/18, 2/19/19, 5/17/19, 8/17/19, and 11/15/19, documented bed rails were used daily as physical restraints. Resident #1's bed rail assessments, dated 2/19/19, 5/17/19, 8/16/19 and 11/15/19, documented bed rails were medically necessary and used for bed mobility, entering and exiting the bed safely, turning side to side, and positioning and moving up and down. The assessments did not include documentation the bed rails were used as a restraint. On 1/22/20 at 5:00 PM, Res… | 2020-09-01 |
| 6 | 6 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2020-01-24 | 657 | D | 0 | 1 | JSJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were regularly reviewed and revised for 1 of 16 residents (Resident #13) whose care plans were reviewed. This failure created the potential for harm if the resident was to receive inappropriate or inadequate care. Findings include: The facility's Resident Care Plan policy, dated 6/30/18, documented a comprehensive person-centered care plan was developed by an interdisciplinary team for each resident, and upon a change in status of the resident, the care plan was modified. This policy was not followed. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. On 1/21/20 at 3:31 PM, Resident #13 was observed in her room laying in bed with 2 bed rails up. A quarterly MDS assessment, dated 12/26/19, did not include documentation Resident #13 used bed rails. The next quarterly MDS assessments, dated 3/25/19, 6/25/19, and 9/25/19, documented Resident #13 used bed rails daily as a physical restraint. Resident #13's Care Plan did not include a revision for the use of bed rails or interventions why the resident needed them. On 1/23/20 at 5:15 PM, the DNS and MDS Coordinator were unable to locate a care plan for bed rails for Resident #13. On 1/24/20 at 10:45 AM, the Administrator stated Resident #13 did not have the use of bed rails documented on her care plan. | 2020-09-01 |
| 7 | 7 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2020-01-24 | 700 | D | 0 | 1 | JSJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure a resident was appropriately assessed and a consent was obtained prior to installing bed rails. This was true for 1 of 8 residents (Resident #13) reviewed for bed rails. This failure created the potential for harm from entrapment or injury related to the use of bed rails. Findings include: Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. On 1/21/20 at 3:31 PM, Resident #13 was observed in her room laying in bed with 2 bed rails up. Resident #13's MDS assessments, dated 3/25/19, 6/25/19, and 9/25/19, documented Resident #13 used bed rails daily as physical restraints. Resident #13's record included a bed rail assessment, dated 3/15/19, that was blank. Resident #13's chart did not include a current quarterly bed rail assessment. There was no risk versus benefit discussion documented in Resident #13's record or a consent for use of the bed rails by Resident #13. On 1/24/20 at 10:45 AM, the Administrator stated Resident #13 did not have a consent for the use of bed rails, the bed rails were not care planned, and her MDS assessment was inaccurate. | 2020-09-01 |
| 8 | 8 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2017-07-27 | 280 | D | 0 | 1 | V9TA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, it was determined the facility failed to ensure a resident's care plan was revised to reflect current needs. This was true for 1 of 7 (#4) sampled residents and had the potential for harm if residents did not receive appropriate incontinence care and interventions due to lack of direction on the care plan. Findings include: Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses, including urinary obstruction. Resident #4's physician order, dated 9/29/16, documented an order for [REDACTED].>Resident #4's current bladder continence care plan, dated 6/12/17, documented an intervention, Condom catheter on at all times. Resident #4's quarterly Minimum Data Set assessment, dated 6/28/17, documented the resident was cognitively moderately impaired, required extensive two-person assistance with toileting, was incontinent of bowel and bladder, and had an external catheter. Resident #4's progress notes, dated 6/30/17, documented a small area of the skin of the meatus was missing from Resident #5's penis, the physician was notified, and ordered barrier cream to the affected area. Progress notes, dated 7/7/17, documented the resident's penis had healed and no new issues were noted and we will continue to keep the condom catheters off at this time. Resident #4's (MONTH) (YEAR) active orders documented an order for [REDACTED].>On 7/25/17 at 12:55 pm, Resident #4 was observed with an absorbent incontinent pad beneath him and the resident said there was also a pad covering the top of his peri area. He said he no longer used the condom catheter and did not like to wear incontinent briefs when in bed. On 7/24/17 at 3:00 pm, CNA #5 (Certified Nurse Assistant) said Resident #4 was incontinent of bowel and bladder and used incontinent pads while in bed because he did not like to wear incontinent briefs and the pads were checked every two hours and changed if they were wet or … | 2020-09-01 |
| 9 | 9 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2017-07-27 | 281 | D | 0 | 1 | V9TA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, it was determined the facility failed to ensure physician orders [REDACTED]. This was true for 1 of 7 sampled residents (#4) and had the potential for harm if residents received inappropriate incontinent care. Findings include: Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses, including urinary obstruction. Resident #4's physician order, dated 9/29/16, documented an order for [REDACTED].>Resident #4's current bladder continence care plan, dated 6/12/17, documented an intervention, Condom catheter on at all times. Resident #4's quarterly Minimum Data Set assessment, dated 6/28/17, documented the resident was incontinent of bowel and bladder, and had an external catheter. Resident #4's nurse progress notes, dated 6/30/17, documented a small area of the skin of the meatus was missing from Resident #5's penis, the physician was notified and the resident received a barrier cream to the affected area. Nurse progress notes, dated 7/7/17, documented the resident's penis had healed with no new issues noted and the nurse documented, we will continue to keep the condom catheters off at this time. Resident #4's active physicians orders and treatment administration record from 7/1/17 to 7/27/17, documented a 9/29/16 physician order [REDACTED].>On 7/25/17 at 12:55 pm, Resident #4 said he no longer used the condom catheter and did not like to wear incontinent briefs when in bed. On 7/24/17 at 3:00 pm, CNA #5 (Certified Nurse Assistant) said Resident #4 was incontinent of bowel and bladder and used incontinent pads while in bed because he did not like to wear incontinent briefs. On 7/25/17 at 1:55 pm, CNA #6 said Resident #4 had used a condom catheter in the past, but had not used a catheter for a month or two. On 7/25/17 at 2:20 pm, LPN #1 said Resident #4 did not use a condom catheter. On 7/26/17 at 1:50 pm, the DNS (Director of Nursing Services) said the condom … | 2020-09-01 |
| 10 | 10 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2017-07-27 | 309 | D | 0 | 1 | V9TA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure physician orders [REDACTED]. This was true for 1 of 7 residents (#2) reviewed for physician orders. The physician orders [REDACTED]. This deficient practice had the potential for harm if Resident #2 experienced high or low blood glucose levels. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Physician order [REDACTED]. *Blood glucose testing 30 minutes before meals and at bedtime * [MEDICATION NAME], 50 units each morning * HumaLog insulin based on the pre-meal blood glucose results: Less than or equal to 150 mg/dL(milligrams per deciliter) = no insulin 151-200 mg/dL give 2 units 201-250 mg/dL give 4 units 251-300 mg/dL give 6 units 301-350 mg/dL give 8 units Greater than 350 mg/dL give 10 units Resident #2's orders also included the following: *[MEDICATION NAME] injection 1 mg intramuscular every 15 minutes as needed for low blood sugar. The Physician orders [REDACTED]. According to the American Diabetes Association, Standards of Medical Care in Diabetes - (YEAR), from the Diabetes Care Journal, Volume 39 Supplement 1, documented older adults with diabetes in a long term care (LTC) facility were at higher risk of experiencing hypoglycemic episodes, and providers should be called immediately in case of hypoglycemic episodes or when BG levels were less than 70 mg/dl. A position statement from the American Diabetes Association documented LTC facilities should increase the frequency of glucose monitoring, call the practitioner, and confirm high glucose values by laboratory testing. These steps were to be completed if residents experienced BG's greater than 300 during all or part of 2 consecutive days. (Munshi, M. N., Florez, H.,[NAME] E. S., et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care… | 2020-09-01 |
| 11 | 11 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2017-07-27 | 332 | D | 0 | 1 | V9TA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure a medication error rate less than 5 percent. This was true for 2 of 37 medications (5.4%) administered during medication pass and effected 2 of 5 residents (#9 and #10) observed during medication pass. This failed practice placed residents at risk of not receiving medications as ordered by the physician and had the potential to lessen the effectiveness of the medications administered. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux. Resident #9's Physician order [REDACTED].) On 7/25/17 at 8:25 am, LPN #1 (Licensed Practical Nurse) was observed as she administered morning medications to Resident #9, which included the medication [MEDICATION NAME]. The resident had completed her breakfast and was sitting in the activity room. The Medication Administration Record [REDACTED]. 2. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux. Resident #10's Physician order [REDACTED]. On 7/25/17 at 8:35 am, LPN #1 was observed as she administered morning medications to Resident #10, which included [MEDICATION NAME]. The resident had completed his breakfast and was sitting in his wheelchair in activity room. On 7/26/17 at 1:25 pm, the Director of Nursing stated the delivery of [MEDICATION NAME] should be given on the 7:00 am medication pass. | 2020-09-01 |
| 12 | 12 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2017-07-27 | 371 | E | 0 | 1 | V9TA11 | Based on observation and staff interview, it was determined the facility failed to ensure 7 of 11 plastic coffee mugs were free of debris and 4 of 6 plastic cereal and soup bowls were free from scratches and grooves. This had the potential to affect 7 of 7 (#s 1-7) sampled residents and all residents who dined in the facility. This failure created the possibility for food-born illness if bacteria remained on unsanitary surfaces. Findings include: On 7/26/17 at 11:05 am, 7 of 11 plastic coffee mugs were observed to contain a white filmy residue inside the mugs. The Lead Food Service Worker (LFSW) said it looked and smelled like soap residue. The LFSW said he would have them rewashed and wiped clean. 4 of 6 plastic soup and cereal bowls were observed to have several scratches inside the bowls. The LFSW said they all had scratches and grooves in them and he took them out of service and said he would replace them with new bowls. | 2020-09-01 |
| 13 | 13 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2017-07-27 | 431 | D | 0 | 1 | V9TA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to ensure medications were labeled in accordance to Federal and State regulations and that discontinued medications were removed from the medication cart. This was true for 2 of 17 medication bins checked for labeled and discontinued medications. This failed practice created the potential for residents to receive medications not ordered for them and to receive medication that had been discontinued. Findings include: On [DATE] at 2:00pm, a resident's medication bin had a bottle of Nitrostat 0.4 mg that did not have a pharmacy label which identified the medication, strength, expiration date, resident 's name, route of administration, appropriate instructions or precautions (such as shake well, with meals, do not crush, special storage instructions). A tube of Nystatin creme, found in the same bin, had the name of the medication and the resident's name was handwritten on a piece of paper and taped to the tube. It did not have a pharmacy label that identified the medication, strength, expiration date, resident's name, route of administration, appropriate instructions or precautions (such as shake well, with meals, do not crush, special storage instructions). The resident's medical record documented the Nystatin creme had been discontinued on [DATE], however, the tube remained in the resident's medication bin. On [DATE] at 2:00 pm, LN #1 stated a pharmacist checked the medication cart each morning and removed expired and discontinued medications from the residents' medication bins. LN #1 stated she did not know why the medications were not labeled or why the discontinued medication was not removed. LN #1 stated they should have been labeled and/or removed when discontinued. On [DATE] at 2:30 pm, the Director of Nursing stated pharmacy labels would be common practice. The Pharmacist stated the labels should be on the medications. The Pharmacist stated he did not know wh… | 2020-09-01 |
| 14 | 14 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2017-07-27 | 526 | D | 0 | 1 | V9TA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident, hospice staff and facility staff interview, it was determined the facility failed to ensure coordination of care, including development of a coordinated plan of care, between the hospice provider and the facility. This was true for 3 of 3 residents (#s 5, #6, #7) sampled for hospice care. This failure had the potential for harm if the residents received inadequate care from the facility and/or hospice agency due to a lack of care coordination. Findings include: Resident #'s 5 and 7 local hospice agency contract, dated 3/6/12, documented, The plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care. Resident #6's local hospice agency contract, dated 5/13/14, documented, .hospice and facility shall jointly develop and agree upon the hospice patient's plan of care. 1. Resident #5 was readmitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION]. Resident #5's physician orders, dated 5/11/17, documented an order for [REDACTED].>Resident #5's Significant Change Minimum Data Set (MDS) assessment, dated 5/15/17, documented the resident was severely impaired, required extensive assistance from staff for all cares, and received hospice services. Resident #5's current facility Comfort Care (End of Life) care plan, dated 5/18/17, documented an intervention, (Hospice Agency) hospice to help maintain comfort for (Resident #5). No other information regarding hospice was documented in the care plan. Resident #5's record did not contain a delineation of duties between the hospice agency and the facility. On 7/26/17 at 9:25 am, Resident #5 was observed in his bed in his room. Hospice Nurse #1 was observed in the room who said she had just finished her assessment. Hospice Nurse #1 said she or another hospice nurse came into the facility at least once a week or as needed to assess th… | 2020-09-01 |
| 15 | 15 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2018-10-12 | 656 | E | 0 | 1 | SC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility failed to develop and follow resident-specific care plans. This was true for 5 of 10 residents (#1, #5, #12, and #64) whose care plans were reviewed. The residents' care plans did not address the use of [MEDICAL CONDITION] medications, wheelchair positioning, preference to sleep in a recliner, and follow aspiration precaution interventions. This failure created the potential for residents to receive inappropriate or inadequate care with a subsequent decline in health. Findings include: A facility policy Nursing Assessment, effective 06/30/18, stated an individualized plan-of-care will be formulated as soon as possible upon admission and updated based on ongoing assessment and patient needs. The policy stated the plan of care will include goals and interventions established in collaboration with the patient, family/significant other/guardian, and care providers. The policy also stated an RN will review and revise the plan as warranted in collaboration with the other disciplines. This policy was not followed. 1. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #5's physician orders, dated 7/13/18, directed staff to provide [MEDICATION NAME] (an antianxiety medication) 0.5 mg by mouth nightly and 0.25 mg every morning. On 8/23/18, an order for [REDACTED]. Resident #5's care plan, dated 5/22/18, documented the antianxiety medication was to help with Resident #5's worries she experienced over her children and family. The care plan did not identify specific behaviors Resident #5 exhibited related to her anxiety. On 10/11/18 at 3:30 PM, the DON and RCA stated the medication was for anxiety but could not identify the specific behaviors exhibited. 2. Resident #64 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Physician orders, dated 10/1/18, documented Resident #64 was to receive [MEDICATI… | 2020-09-01 |
| 16 | 16 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2018-10-12 | 684 | D | 0 | 1 | SC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure physician orders [REDACTED].#3 and #7) whose records were reviewed. Resident #7's blood glucose physician orders [REDACTED].#3's aspiration precautions were not followed. These failed practices had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include: 1. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An H&P, dated 8/28/18, documented Resident #7 received [MEDICATION NAME] (long-acting insulin) injections each morning, [MEDICATION NAME] (an oral diabetic medication) 50 mg once daily, and Humalog (a short-acting insulin) injections according to a sliding scale with each meal and at bedtime. The American Diabetes Association, website accessed 10/17/18, defines sliding scale as a set of instructions for adjusting insulin based on blood glucose test results, meals, or activity levels. Resident #7's MAR indicated [REDACTED]. The order was to check Resident #7's blood glucose at bedtime and 3:00 AM. The order stated if Humalog was given at bedtime to correct a high blood sugar, according to the ordered sliding scale, Resident #7's blood glucose was to be checked again at 3:00 AM. This order was not followed. Examples include: - On 9/2/18 at 9:21 PM, Resident #7 did not receive a Humalog injection. Her blood glucose was rechecked at 12:30 AM on 9/3/18, when it should not have been done per the orders, and it was not at 3:00 AM. - On 9/11/18 at 8:08 PM, Resident #7 received and injection of 1 unit of Humalog. At 2:52 AM, her blood glucose was not checked per physician order. At 4:36 PM on 10/11/18, the DON reviewed Resident #7's record and confirmed the blood glucose and insulin orders and stated they were not followed. 2. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Speech Evaluati… | 2020-09-01 |
| 17 | 17 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2018-10-12 | 690 | D | 0 | 1 | SC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the bowel protocol was followed and implemented for 1 of 2 residents (Resident #5) reviewed for bowel and bladder care. This had the potential to place residents at risk for fecal impaction and bowel blockage. Findings include: The facility's Bowel and Bladder Program policy, revised 4/9/18, directed staff to notify the physician for no bowel movement in 5 days. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A bowel continence care plan, dated 8/31/17, documented Resident #5's bowel movement pattern as one time a day 2 days apart. The care plan directed staff to refer to her medications for bowel care or call her physician to get an order if Resident #5 did not have a bowel movement by day 3. A physician order, dated 8/2/18, directed staff to provide Milk of Magnesia 30 mLs nightly as needed for constipation. A Pharmacy Review, dated 9/13/18, documented Resident #5 had not had a bowel movement for 3-4 days twice in the last 2 weeks. The bowel movement records, dated 9/9/18 through 9/22/18, documented Resident #5 did not have a bowel movement between 9/10/18 and 9/14/18 (5 days) and between 9/18/18 through 9/22/18 (5 days.) The Medication Administration Record [REDACTED]. A Pharmacy Review, dated 10/9/18, documented there were up to 5 days between bowel movements. The consultant pharmacist documented Resident #5 had Milk of Magnesia ordered as needed but none was given when Resident #5 went 5 days between bowel movements. On 10/12/18 at 2:30 PM, the DON stated residents received bowel care medication after 3 days without a bowel movement and the physician was notified on day 4. She confirmed the care plan and physician orders [REDACTED].#5. | 2020-09-01 |
| 18 | 18 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2018-10-12 | 756 | D | 0 | 1 | SC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and staff interview, the facility failed to ensure the pharmacy reported medication irregularities and were addressed by the atttending physician for an antibiotic ointment for 1 of 7 residents (Resident #1) whose medication records were reviewed for unnecessary medications and/or irregularities. This failure had the potential for Resident #1 to develop resistance to the antibiotic and result in lack of efficacy of future treatments for infections. Findings include: The facility's policy Medication Use in Long Term Care, effective 04/30/18, stated a pharmacy medication regimen review will occur for each skilled nursing facility patient at least monthly. The regimen review will include all prescribed medication orders and evaluated adequate indication for use, appropriateness of ongoing therapy, medical necessity, and duration. This policy was not followed. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's MAR indicated [REDACTED]. The antibiotic ointment was last administered 10/10/18 at 7:21 PM. On 10/09/18 at 12:10 PM and 3:36 PM, and on 10/10/18 at 9:00 AM, Resident #1 was not observed with visible signs of eye redness, swelling, or drainage. On 10/11/18 at 2:34 PM, the Pharmacy Director stated he was unable to find documentation regarding the discontinuation or the need for continuation of the antibiotic ointment. He stated he had a discussion with the Consultant Pharmacist regarding the notation of None for antibiotics on the monthly review. The Pharmacy Director stated there was a [DIAGNOSES REDACTED]. The Pharmacy Director stated the expectation was the continued use of the antibiotic ointment should have been addressed. On 10/12/18 at 11:28 AM, the Compliance Director stated the facility policy does not address long term use of antibiotics. On 10/12/18 at 3:42 PM, the DON stated the expectation was the antibiotic ointment was reviewed relate… | 2020-09-01 |
| 19 | 19 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2018-10-12 | 758 | E | 0 | 1 | SC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy and procedure review, it was determined the facility failed to ensure a.) residents' behaviors and potential side effects of [MEDICAL CONDITION] medications were routinely monitored b.) there was a clear indication for use of PRN [MEDICAL CONDITION] medication c.) non-pharmacological approaches were attempted prior to the use of PRN medications d.) physician orders for PRN antianxiety medications were time limited and e.) residents received PRN [MEDICAL CONDITION] medications only when clinically indicated for the treatment of [REDACTED].#5, #7, #9, #10, #11, #12, and #64) reviewed for unnecessary medications. This created the potential for harm should residents receive [MEDICAL CONDITION] medications that were unnecessary, ineffective, or used for excessive duration, and placed them at risk for adverse reactions from [MEDICAL CONDITION] medications. Findings include: The facility's policy for Medication Use in Long Term Care, revised 4/25/18, documented psychoactive medications are prescribed when necessary to treat specific medical conditions. When prescribed: * The [MEDICAL CONDITION] medications will have a documented indication for the medication in the medical record. * Psychoactive MEDICATION ORDERS FOR [REDACTED]. If there is a continued clinical need the prescriber will document in the medical record justification for continued use. * Each behavior monitoring record will identify the specific symptoms for which the drug is being used. The documentation of the behavior will be quantitative and objective. * Each resident will have care plan interventions specific to their mood, behavior, and activity. * Pharmacy medication regimen review will evaluate prescribed medications orders for an adequate indication for use, appropriateness of ongoing therapy, medical necessity, adverse drug reaction and side effects, and adequate monitoring of therapy. 1. Resident #12 was admitted to… | 2020-09-01 |
| 20 | 20 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2018-10-12 | 759 | D | 0 | 1 | SC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure a medication error rate less than 5 percent. This was true for 2 of 33 medications (6.06%) administered during medication pass and effected 2 of 5 residents (#65 and #114) observed during medication pass. This failed practice placed residents at risk of not receiving medications as ordered by the physician and had the potential to lessen the effectiveness of the medications administered. Findings include: 1. Resident #114 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #114's physician orders, dated 9/27/18, included [MEDICATION NAME] (an acid reflux medication) 40 mg by mouth every morning before breakfast (served at 7:45 AM - 8:45 AM). On 10/12/18 at 8:45 AM, RN #1 was observed as she administered morning medications to Resident #114, which included the medication [MEDICATION NAME]. Resident #114 had finished her breakfast and was sitting in the activity room. 2. Resident #65 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #65's physician's orders [REDACTED]. On 10/12/18 at 9:11 AM, RN #1 was observed as she administered morning medications to Resident #65, which included [MEDICATION NAME]. Resident #65 had finished her breakfast and was sitting in her wheelchair in her room. On 10/12/18 at 9:30 AM, RN #1 stated she did not know why the [MEDICATION NAME] for Resident #114 and Resident #65 were scheduled for 8:00 AM. RN #1 stated [MEDICATION NAME] was usually scheduled for 7:00 AM. On 10/12/18 at 2:35 PM, the DON stated sometimes the medication delivery times in the EMR changed. The DON stated the [MEDICATION NAME] should be given during the 7:00 AM medication pass. | 2020-09-01 |
| 21 | 21 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2019-03-01 | 568 | E | 0 | 1 | U2XH11 | Based on facility policy review, staff interview, and record review, it was determined the facility failed to ensure resident personal funds were maintained in separate accounts and quarterly statements were provided for 7 of 8 residents (#3, #4, #5, #10, #18, #20, and #37) whose personal funds were reviewed. The failure created the potential for harm if the residents or their representatives had concerns about their personal fund account, including inaccuracies, that were not addressed. Findings include: The facility's policy for transactions involving resident funds, dated 2/20/19, documented the following: * The facility will establish and maintain a system that assures a complete and separate accounting of each resident's personal funds. * Quarterly statements will be provided in writing to the resident, or the resident's representative, within 30 days after the end of the quarter and upon request. * The facility will ensure resident funds are not comingled with facility funds or funds of someone other than a resident. On 2/28/19 at 9:40 AM, the facility's Patient Financial Counselor, stated she did not manage residents' personal fund accounts. She stated CNA #1 provided resident transportation and managed the personal funds accounts for the residents. On 3/1/19 at 11:03 AM, during an interview with CNA #1, the Administrator, and the Patient Financial Counselor, CNA #1 reviewed current personal funds accounts. CNA #1 stated all the resident funds were in a single account with a local bank. CNA #1 provided a printout of a Trust Account Balance Sheet as of 3/1/19. The ledger identified current balances for Residents #3, #4, #5, #10, #18, #20, and #37. The Administrator stated the residents' money was in one interest bearing account. He said the interest generated from the account went into a Bingham Memorial Hospital account. The Administrator said the interest was then paid out to the individual residents. CNA #1 stated she had not sent out monthly or quarterly statements to residents or families, but she was … | 2020-09-01 |
| 22 | 22 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2019-03-01 | 623 | D | 0 | 1 | U2XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and family interview, facility policy review, and record review, it was determined the facility failed to ensure transfer notices were provided in writing to residents upon transfer. This was true for 2 of 2 residents (#12 and #25) reviewed for transfers. This deficient practice had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's policy and procedure for Transfer and Discharge, dated 10/2018, directed staff to notify the resident/resident representative for facility initiated emergency transfers and/or discharges for medical reasons. 1. Resident #25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A nurse's note, dated 2/11/19, documented Resident #25 was transferred to the emergency room for evaluation and treatment. The note documented Resident #25's wife was called and notified of the transfer. Resident #25's record did not include documentation he or his representative received a written notification of the reason for transfer to the hospital. On 2/27/19 at 1:23 PM, Resident #25's wife stated the facility did not provide written notification of her husband's transfer to the hospital. She stated the facility did not contact her. She stated she found out Resident #25 was transferred to the hospital when she came to see him. On 2/27/19 at 2:35 PM, RN #3 stated the family is called when a resident is transferred to the hospital but was not familiar with any transfer/discharge papers from the facility. On 2/27/19 at 2:50 PM, the LSW stated Social Services did not provide written notice of transfer and discharge to residents. On 2/27/19 at 3:15 PM, the Patient Financial Counselor stated she did not provide residents with written notice of transfer or discharge. 2. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. a. A nurse's note, dated 1/7/19, documented Resident #12 … | 2020-09-01 |
| 23 | 23 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2019-03-01 | 625 | D | 0 | 1 | U2XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family and staff interview, policy review, and record review, it was determined the facility failed to ensure a bed-hold notice was provided to a resident and/or their representative upon transfer to the hospital. This was true for 2 of 2 residents (Resident #12 and #25) who were reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold Notice Upon Transfer policy, dated 8/2018, documented the following: * In the event of an emergency transfer of a resident, the facility will provide within 24 hours, written notice of the facility's bed-hold policies. * The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. 1. Resident #25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A progress note, dated 2/11/19, documented Resident #25 was transferred to the emergency room for evaluation and treatment. The note documented Resident #25's wife was called and notified of the transfer. Resident #25's record did not include documentation he or his representative received a bed-hold notification when he was transferred to the hospital. On 2/27/19 at 1:23 PM, Resident #25's wife stated the facility did not talk with her about holding her husband's bed for his return. She stated she did not remember having signed a bed-hold notice. A bed-hold notice was not found in Resident #25's record. On 2/27/19 at 3:15 PM, the Patient Financial Counselor stated, We tell the resident verbally that we will do a bed hold. We don't have anything in writing. 2. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. a. A progress n… | 2020-09-01 |
| 24 | 24 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2019-03-01 | 684 | D | 0 | 1 | U2XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff and resident interview, it was determined the facility failed to ensure professional standards of practice were followed for bowel care and medication administration. This was true for 3 of 9 residents (#10, #25, and #189) reviewed for medications. This failed practice created the potential for harm if residents did not receive medications to prevent constipation or received medications contrary to physicians' orders. Findings include: 1. Resident #25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #25 was readmitted on [DATE] after a 3 day acute care stay for pneumonia. The 5 day MDS assessment, dated 2/21/19, documented Resident #25 had impaired cognition. Resident #25's admission physician's orders [REDACTED]. * If no BM day 2: Milk of Magnesia 30 cc by mouth 1 dose if not contraindicated, as needed. * If no BM day 2: [MEDICATION NAME] 10 mg by mouth 1 dose if no results from Milk of Magnesia, if not contraindicated, as needed. * If no BM day 3: [MEDICATION NAME] 10 mg rectal suppository 1 dose if not contraindicated, as needed. * If no BM day 3: Fleets enema per rectum 1 dose if not contraindicated, as needed. * If no BM day 3: If no results from enema, notify MD, as needed. The facility's policy and procedure for tracking bowel movements, dated 5/15/18, documented the following: * Bowel tracking protocol is to establish a system for the facility to track resident bowel movements, detect abnormalities of bowel movements, and implement appropriate interventions to prevent constipation and complications associated with constipation. * Bowel movement activity will be recorded in the vital section of the facility electronic record indicating whether the resident did or did not have a bowel movement on the shift and the size of the bowel movement. Resident #25's medical record documented the following: * From 2/1/19 - 2/6/19, for 6 days, there was no documenta… | 2020-09-01 |
| 25 | 25 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2019-03-01 | 695 | E | 0 | 1 | U2XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure staff changed and dated residents' oxygen tubing per physician orders [REDACTED].#6, #8, and #22) reviewed for oxygen use. This failure created the potential for harm from respiratory infections due to the growth of pathogens (organisms that cause illness) in oxygen humidifiers and cannulas. Findings include: The facility's policy and procedure for oxygen administration, dated 8/2018, directed staff to change oxygen tubing and the mask or cannula weekly and as needed if they became soiled or contaminated. Staff are directed to date and initial all oxygen tubing with the date of change. 1. Resident #8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. On 2/25/19 at 1:00 PM, Resident #8 was observed sitting in his room at bedside with his oxygen on. The oxygen tubing was connected to a prefilled bubble humidifier which was connected to an oxygen system on the wall. The bubble humidifier was dated, the oxygen tubing was not. Resident #8's (MONTH) 2019 Treatment Administration Record (TAR) directed staff to change the oxygen tubing every Sunday on nightshift. The oxygen tubing was changed on 2/3/19, 2/10/19, 2/17/19, and 2/24/19. On 2/26/19 at 4:45 PM, RN #3 stated oxygen tubing should be changed weekly and as needed. She stated the tubing was changed every Sunday. RN #3 said nurses initialed on the TAR but did not date oxygen tubing. On 2/26/19 at 5:06 PM, the DON stated staff changed oxygen tubing every Sunday. The DON stated the staff should put a piece of tape on the tubing with the date changed and their signature to identify the date it was changed. The DON stated Resident #8's oxygen tubing was not dated. On 2/27/19 at 10:32 AM, Resident #8 was sitting in his wheelchair in his room. The oxygen tubing was connected to an oxygen delivery system. The oxygen tubing did… | 2020-09-01 |
| 26 | 26 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2019-03-01 | 756 | D | 0 | 1 | U2XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, staff interview, and record review, it was determined the facility failed to ensure the pharmacy recognized and reported medication irregularities. This was true for 3 of 3 residents (#6, #10, and #22) whose monthly pharmacy medication reviews were reviewed. This failure created the potential for harm should residents receive medications that were unnecessary, ineffective, or used for excessive duration, or should residents experience adverse reactions from medications. The facility's policy for use of [MEDICAL CONDITION] drugs, dated 11/2018, documented the following: * PRN orders for [MEDICAL CONDITION] drugs shall be used only when the medication is necessary to treat a diagnosed specific condition documented in the record, and for a limited duration (i.e. 14 days.) 1. Resident #22 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #22's 90-day MDS assessment, dated 2/25/19, documented she was cognitively intact and received antianxiety medications daily. Resident #22's physician orders, dated 11/27/18, directed staff to provide [MEDICATION NAME] 0.5 mg 4 times daily as needed for anxiety. The Pharmacist Medication Reviews, completed on 11/30/18, 12/30/18, 1/31/19, and 2/26/19 did not have comments or recommendations made by the Pharmacist. On 2/28/19 at 3:54 PM, the Pharmacist stated if he did not make recommendations, the Monthly Pharmacist Chart Review form had a zero in the comment section. He stated he put his recommendations in the comment section. On 2/28/19 at 4:13 PM, the Pharmacist stated he was not paying attention to the PRN [MEDICAL CONDITION] medications when he conducted the resident's monthly medication review. He stated he should have been reviewing them. On 3/1/19 at 11:30 AM, the DON confirmed she had not received any recommendations from the Pharmacist for Resident #22. The Pharmacist review of Resident #22 did not include review of PRN medications and whether th… | 2020-09-01 |
| 27 | 27 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2019-03-01 | 812 | D | 0 | 1 | U2XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy, it was determined the facility failed to store and distribute food in a safe manner related to expired supplements and unlabeled and undated food for 1 of 1 food pantry. These failures had the potential to impact all the residents in the facility and created the potential for harm should residents experience adverse health outcomes from improperly stored or outdated food. Findings include: The facility's policy for Date Marking for Food Safety, dated [DATE], documented: * Food should be clearly marked to indicate the date or day, by which the food should be consumed or discarded. * The dietary staff are responsible for checking the refrigerator daily for food items that are expiring and discard accordingly. On [DATE] from 11:05 AM to 12:05 PM, an inspection of the nursing pantry was conducted with the Nutritional Production Coordinator. A cupboard in the pantry contained a box of 24 four-ounce bottles of Ensure. The expiration date was [DATE]. There were 4 four-ounce bottles of Ensure in the refrigerator with the expiration date of [DATE]. The refrigerator in the pantry had a bowl with what appeared to be ham. There was no label or date on the product. There was a bag of what appeared to be turkey. There was no label or date on the product. The Nutritional Production Coordinator stated the items should have been labeled and dated. | 2020-09-01 |
| 28 | 28 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 155 | E | 0 | 1 | J25411 | Based on observation, record review and staff interviews, it was determined the facility failed to ensure staff received training necessary to understand and follow the facility's advanced directive policies. This was true for 7 of 24 sampled residents (#1, #4, #5, #21-#24) with DNR status, and had the potential to impact all residents who had established advanced directives. This failed practice created the potential for staff to initiate, or not initiate, resuscitation, contrary to residents' wishes. Findings include: On 6/12/16 at 6:35 pm, during the initial tour of the facility, the rooms of Residents' #1, #4, #5, and #21 - #24 were observed to have a blue dot by the residents' names. At 6:40 pm on the 300 hallway, CNA #6 and CNA #7 were asked what the blue dots meant. CNA #7 stated she was not sure. CNA #6 stated she did not know, but believed it meant DNR. LN #1 stated the blue dot meant the resident was a DNR. At 6:45 pm on the 400 hallway, CNA #2 stated the blue dot meant the resident was a full code. CNA #3 stated she was not sure what the blue dot meant. LN #5 stated it was the residents' code status, but did not know which and would have to check. LN #9 stated she was not sure, it was probably a code status, but at a previous place she worked it referred to assistive devices. On 6/13/16, the medical records of Residents' #1, #4, #5, and #21 - #24 were reviewed. Each residents' medical record documented the resident's code status as DNR. On 6/14/16 at 12:00 pm, the DNS stated the blue dot by residents' names meant DNR, not a full code. The DNS stated she was in the process of changing the program because it was confusing. The DNS stated that usually a code blue, means resuscitation. The DNS stated the policy was for staff to look in the chart at the actual advance directives. The code status of each resident was found in the first section of the resident's chart. | 2020-09-01 |
| 29 | 29 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 221 | E | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interviews, it was determined the facility failed to ensure residents were not physically restrained. This was true for 3 of 10 sampled residents reviewed for side rails (#2, #3, and #10). This resulted in the use of half to full side rails for residents who did not have the ability to lower the side rails and had no identified medical symptoms that required restraint. Findings include: 1. Resident #10's MDS assessment, dated 4/11/16, documented he was moderately cognitively impaired and required total assistance with mobility and cares. The MDS documented Resident #10 did not have any physical or mechanical device, or equipment, that could easily be removed. On 6/16/16 at 4:00 pm, Resident #10 was observed lying in bed. The bed was against the wall to his right side, with 4 side rails up. Resident #10's left side was affected by a previous [MEDICAL CONDITION]. Resident #10 stated he felt trapped. Resident #10 did have consents for use of side rails for use related to bed mobility, bed control and assistance with transfers, however, he did not have the ability to use the side rails for positioning and bed control. 2. Resident #3's MDS assessment, dated 6/13/16, documented she was severely cognitively impaired, and required total assistance for mobility and cares. The MDS assessment documented Resident #3 did not have any physical or mechanical device, or equipment, that could easily be removed. On 6/16/16 at 4:00 pm, Resident #3 was observed in bed with bilateral lower side rails. Resident #3 was observed not to be able to lower her side rails. Resident #3 did have consents for use of side rails for use for assistance with repositioning in bed, however, she did not have the ability to use the side rails for positioning and bed control. 3. Resident #2's MDS assessment, dated 4/22/16, documented she was severely cognitively impaired, and required total assistance with mobility and all … | 2020-09-01 |
| 30 | 30 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 225 | D | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident, staff and family interview, it was determined the facility failed to ensure that for 1 of 2 investigations reviewed for abuse/neglect, the allegations were identified as potential neglect and investigated and processed as such. This was true for 1 of 2 residents (#7) whose allegations and investigations were reviewed. The facility failed to recognize an allegation as potential neglect and handled the investigation as a general care complaint. This compromised the ability of the facility to identify, thoroughly investigate, and initiate corrective actions necessary to protect residents from neglect. Findings include: Resident #7 was admitted to the facility on [DATE] for rehabilitation following a total knee replacement. She had an admission [DIAGNOSES REDACTED]. At the time of admission, Resident #7 required staff assistance for toileting and transfers. During an interview on [DATE] at 2:10 pm, Resident #7 stated that she had problems with her bladder when she was initially admitted after knee surgery. She stated it was hard for her to get to the bathroom on time. Resident #7 stated that initially, it took 2 to 3 staff to assist her with toileting because of her limited weight bearing status following surgery. She stated she was prescribed [MEDICATION NAME] and was incontinent the first couple days because staff did not help her. Resident #7 stated she waited an hour to an hour and a half to be toileted. Resident #7 reported staff came to her room and turned off her call light and said they would come back, but did not come back. She stated she remained in wet incontinence briefs for extended timeframes. Resident #7 stated staff got angry when they had to come and assist her to the toilet. It took several staff to do so and reported one staff member stated, Again? when she needed assistance to toilet. Resident #7 suggested the surveyor speak with her family member, Family Member #1, because… | 2020-09-01 |
| 31 | 31 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 240 | E | 0 | 1 | J25411 | Based on observations, record review, and resident and staff interviews, the facility failed to ensure the dining experience in the main dining room promoted the enhancement of quality of life for residents. This directly impacted 12 of 20 sampled residents (#3, #6, #8 - #10, and #14 - #20) who resided in the facility at the time of survey and 6 of 7 residents in the group interview. It also had the potential to impact all residents who ate in the main dining room. Specifically: residents waited lengthy time frames to be served; meals were not always served on time; condiments such as salt and pepper and sugar were not easily accessible to residents who dined in the main dining room; a sufficient amount of beverages was not consistently served, including water; and beverages were served in cans, cartons and plastic bottles without residents being offered the option of having the beverages poured into cups. Findings include: 1. Meal service start times were posted on the wall adjacent to the primary entrance into the main dining room as follows: breakfast 7:20 am, lunch 12:20 pm, and dinner 5:20 pm. Between 30 to 35 residents were observed to eat their meals in the main dining room during the survey. a. On 6/13/16, breakfast observations were made in the main dining room beginning at 7:05 am. At this time, approximately 20 residents were present in the dining room, sitting at their tables. The remaining residents (approximately 10 residents) arrived and were present in the dining room by 7:15 am. Although most residents had one beverage at their places on the tables, breakfast meal service did not start until 7:40 am. This was 20 minutes after the posted meal time and 40 minutes after two thirds of the residents had been present. Meal service concluded at 7:55 am. Approximately 20 of the residents had been in the dining room since prior to 7:05 am, when observations began. Specific examples include: * At 7:15 am, Resident #20 stated (in regards to meal service) It takes a while. * At 7:45 am, 3 of the 4 residents … | 2020-09-01 |
| 32 | 32 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 241 | G | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family and staff interview, the facility failed to ensure 4 of 19 sampled residents (#1, #7, #12 and #13) were provided care and services in a manner enhancing their dignity and respect. This resulted in harm to Resident #1 when she experienced resentment and demoralization when a tab alarm was attached to her clothing and the loud alarm that sounded when she moved or stood. It also placed Resident #7 at risk of psychosocial harm when she was not provided with toileting assistance necessary to avoid incontinence and incontinence briefs were put on her when she had been continent previously. Residents #12 and #13 were administered insulin injections during meals in the main dining room, creating the potential of embarrassment and humiliation. Findings include: 1. Resident #1 was admitted to the facility on [DATE]; current [DIAGNOSES REDACTED]. Resident #1 received hospice care for end stage [MEDICAL CONDITION]. Review of the 4/20/16 quarterly MDS indicated Resident #1 was usually understood by others, had no behavioral symptoms, and had a history of [REDACTED]. Resident #1's Care Plan, reviewed and revised on 6/10/16, stated a tabs alarm was initiated to address the problem of potential for falls on 3/21/16. Documentation included, I may hide or disable it because the sound bothers me, remind me it alerts the staff that I may need help. Resident #1 was observed with large writhing movements, primarily of her arms and upper body, at various times during the survey (6/12/16 at 8:00 pm - 8:30 pm, 6/13/16 at 7:00 am and 9:30 am, and 6/14/16 at 6:10 pm). Resident #1 was interviewed on 6/13/16 at 9:30 am, and reported she had a history of [REDACTED]. She stated she resented the alarm due to the loud sound that emanated when it went off. She stated it was very important to remain independent as much as she could. Resident #1 was interviewed a second time on 6/14/16 at 9:50 am, and stated she was cap… | 2020-09-01 |
| 33 | 33 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 242 | D | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of Resident Council meeting minutes, review of an inservice record, and resident and staff interview, it was determined the facility failed to ensure 1 of 20 sampled residents (Resident #8), and 2 of 7 residents in the group meeting, were allowed to make choices regarding foods and condiments. This resulted in Resident #8, who was on a therapeutic diet, not being served foods she selected and wanted to eat, creating dissatisfaction. It also resulted in frustration of members of the resident group due to lack of response from the facility to their concerns. Findings include: 1. Resident #8 was admitted to the facility on [DATE], for rehabilitation following a fall at home. [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 5/6/16, indicated Resident #8 was understood by others and could understand others, had no behavioral indicators; however, was depressed, tired and having a poor appetite. The MDS assessment documented Resident #8 as being on a therapeutic diet with an initial weight of 216 pounds (lbs). Review of Resident #8's care plan, dated 5/6/16, identified the problem of I have potential altered nutrition related to my vitamin deficiency, chronic pain, and reflux. The goal was defined as I will maintain nutritional status through my next review date. One of the care plan approaches documented, I need a therapeutic cardiac, regular texture, thin liquid diet for meals. Review of the Resident #8's initial admission orders [REDACTED]. The plan of care notes, dated 5/6/16, stated, Meal intakes of cardiac, regular texture diet are fair at 50-75% due to the food being 'bland' per (Resident #8). Therapeutic menu extensions were provided for the week of the survey. Review of the cardiac diet menus showed: omission of high sodium meats such as bacon, ham, and sausage for breakfast, 1% milk was served versus 2%, substitution of whole wheat bread for bread, low salt gravies and sauces, … | 2020-09-01 |
| 34 | 34 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 244 | E | 0 | 1 | J25411 | Based on observation, record review, review of Resident Council meeting minutes, review of an inservice record, and staff, family, and resident interviews, it was determined the facility failed to ensure sufficient numbers of staff were available to meet the needs of residents. This was true for 5 of 19 sampled residents (#4, #5, #6, #7, and #8) and 6 of 7 residents in group interviews. This deficient practice resulted in residents experiencing incontinence due to lack of timely assistance with toileting placed residents at risk of psychosocial and physical harm due to unmet needs. Finding include: 1. On 6/12/16 at 6:00 pm, Resident #4 stated staff took over 30 minutes to answer call lights. Resident #4 stated staff would often just come in a turn off the call light without providing cares. Resident #4 stated there was not enough staff at night and during meals. Resident #4 stated, the facility pulled all the staff to the dining room to help with the meals so there was no one on the halls to answer the call lights. 2. On 6/13/16 at 12:30 pm, a family member stated she came to the facility several times a day because she felt she needed to be there because there was not enough staff. The family member stated the staff the facility had did a good job, but there was not enough of them. 3. On 6/14/16 at 10:10 am, Resident #6 stated the facility needed more help. Resident #6 stated she could push her call light and sometimes had to wait over 30 minutes for staff to respond or staff just ignored the call light. 4. On 6/15/16 at 10:20 am, during a group interview, the group stated there was not enough staff available during meals and during the night shifts. The group stated that after 10:00 pm, there were only 2 CNAs. The group stated they often had to wait up to 45 minutes for their call lights to be answered. The group stated the 400 and 500 halls were really short of staff. The group stated meal times took too long and did not understand why staff stood around the tray line waiting for trays. They stated that althou… | 2020-09-01 |
| 35 | 35 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 278 | D | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, it was determined the facility failed to ensure assessment documentation accurately reflected residents' abilities. This was true for 4 of 10 sampled residents reviewed for side rails (#2, #3, #6 and #10). This resulted in MDS assessment which did not accurately reflect the residents' ability to easily remove their side rails. Findings include: 1. Resident #10's MDS assessment, dated 4/11/16, documented he was moderately cognitively impaired and required total assistance with mobility and cares. The MDS assessment documented Resident #10 did not have any physical or mechanical device or equipment that could easily be removed. On 6/16/16 at 4:00 pm, Resident #10 was observed lying in bed. The bed was against the wall to his right side with 4 full side rails up. Resident #10's left side was affected by a previous [MEDICAL CONDITION]. Resident #10 stated he felt trapped. 2. Resident #6's MDS assessment, dated 6/13/16, documented she was cognitively intact, and required total assistance for mobility. The MDS assessment documented Resident #6 did not have any physical or mechanical device or equipment that could easily be removed. On 6/16/16 at 4:00 pm, Resident #6 was observed in bed with 4 full side rails up. Resident #6 stated she thought the side rails could be put down, but did not know if she could do it. Resident #6 stated,they (facility) just put them up, they (facility) did not ask. 3. Resident #3's MDS assessment, dated 6/13/16, documented Resident #3 was severely cognitively impaired, and required total assistance for mobility and cares. The MDS assessment documented Resident #3 did not have any physical or mechanical device, or equipment, that could easily be removed. On 6/16/16 at 4:00 pm, Resident #3 was observed in bed with bilateral lower side rails. Resident #3 was observed not to be able to lower her side rails. 4. Resident #2's MDS assessment, dated 4/22/16, documented Resident… | 2020-09-01 |
| 36 | 36 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 281 | D | 0 | 1 | J25411 | Based on observation, record review and staff interview, it was determined the facility failed to ensure professional standards of practice during medication administration were observed for 1 of 4 nurses reviewed for medication administration (LN #7). This directly impacted 2 of 4 residents (#12 and #13) sampled for medication administration. This resulted in residents' medications being pre-signed as given prior to actual administration. The practice placed residents at increased risk of adverse outcomes due to medication errors. Findings include: On 6/13/16 at 7:00 am, LN #7 was observed during medication administration to Resident #12 and Resident #13. LN #7 was observed to take the medication out of the cart, check the medication with the MAR, and then sign off the medication as given on the MAR. LN #7 then removed the medications from the cards and/or containers and administered the medications to the residents. Resident #12 was administered 16 different medications and Resident #13 was administered 12 different medications. During the observation, LN #7 was asked if those were her initials on the MAR for the medication she was about to administer. LN #7 confirmed her initials. The facility's Medication Administration Policy, dated 6/13/16, documented Medications are not signed off until the resident has received and/or swallowed the medication. Nursing: Scope and Standards of Practice (American Nurses Association, 2010), require documentation after the medication has been administered to avoid medication errors. | 2020-09-01 |
| 37 | 37 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 309 | D | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family and staff interviews, the facility failed to provide the necessary nursing care and services for 3 of 19 sampled residents (#5, #7 and #9). The facility's protocol to address [DIAGNOSES REDACTED], and physician orders [REDACTED].#5 and Resident #9, creating the potential for adverse health consequences. Resident #7's compression stockings were not applied in accordance with physician orders [REDACTED]. Findings include: 1. Resident #7 was admitted to the facility on [DATE] for rehabilitation following a total knee replacement surgery. She had admission [DIAGNOSES REDACTED]. Resident #7's TKA (total knee arthroplasty) Rehab Hospital Transfer Orders and Instructions, dated 6/3/16, documented thigh high compression stockings were to be to be worn throughout the day for [MEDICAL CONDITION], a stocking could be applied directly over the bandage, and the compression stockings should be removed at night and for showering. No documentation was found indicating compression stockings had been applied during Resident #7's admission to the facility. The Resident #7's Interim ADL (activities of daily living) Care Plan stated she had a self-care deficit related to the [DIAGNOSES REDACTED].#7 with ADLs, as needed, and to encourage her to complete ADLs as independently as possible. Compression stockings were not specifically addressed on the interim care plan. Resident #7 was observed in her room during the survey a total of 4 times. She was not wearing compression stockings during the following observations: * 6/12/16 at 6:50 pm * 6/13/16 at 11:25 am * 6:14;16 at 2:10 pm * 6/16/16 at 3:50 pm LN #1 was interviewed on 6/16/16 at 4:15 pm and stated Resident #7 was to wear compression stockings per physician's orders [REDACTED]. Resident #7 was interviewed on 6/16/16 at 3:50 pm. She stated her physician ordered compression stockings to be worn daily. She stated she was unable to put them on herself and … | 2020-09-01 |
| 38 | 38 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 325 | D | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and family interview, it was determined the facility failed to ensure 1 of 19 sampled residents (Resident #5) was provided with care and services to ensure maintenance of adequate nutritional parameters. Resident #5 was not assessed for nutritional requirements to ensure her tube feeding regimen met her nutritional needs, and her tube feeding regimen was not reassessed in light of a significant weight loss, risk for skin breakdown, constipation, and onset of [DIAGNOSES REDACTED]. Findings include: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5 received all food and fluids via a gastrostomy (G) tube, had a [MEDICAL CONDITION], and received oxygen continuously [MEDICAL CONDITION]. Resident #5's 2/21/16 annual MDS assessment documented she was in a persistent vegetative state. Resident #5 was prescribed insulin and 2 medications daily for constipation. Resident #5 was observed during the survey from 6/12/16 - 6/17/16 to be non-responsive and totally dependent on staff for all cares. When the surveyor introduced herself to Resident #5 on 6/13/16 at 11:30 am, she did not respond in any manner. A Physician order [REDACTED].#5 was prescribed (on 12/10/14): Vital 1.0, 1 can, bolus feeding, twice a day at 4:00 am and 10:00 pm. This provided 20 grams (gm) of protein, 474 ml formula, and 474 calories a day. The amount of water the tube feeding formula provided was not documented. Resident #5 was also prescribed Vital High Protein, 1 can, bolus feeding, twice a day at 10:00 am and 4:00 pm. The Vital High Protein provided 42 gm protein, 474 ml formula, 474 calories. The amount of water the tube feeding formula provided was not documented. Resident #5 was also prescribed [MEDICATION NAME], one packet per day. Review of the nutritional analysis from Hormel Health Labs manufacturer, [MEDICATION NAME] instant whey protein supplement provided 8 gm protein and 30 calories… | 2020-09-01 |
| 39 | 39 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 329 | D | 0 | 1 | J25411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined the facility failed to ensure residents were not administered antibiotic medications without clinical rationale for continued use. This was true for 2 of 2 resident sampled for [MEDICATION NAME] antibiotic use (#1 and #4). This created the potential for residents to experience adverse outcomes resulting from unnecessary medications. Findings include: 1. Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. Recapitulated Physician Orders, dated 5/1/16, documented Resident #4 received [MEDICATION NAME] 500 mg every day for [MEDICATION NAME] treatment of [REDACTED]. A History and Physical, dated 11/9/14, documented Resident #4 had an indwelling suprapubic catheter and had experienced muliple urinary tract infections over the past several months. The History and Physical noted Resident #4 was likely colonized. Being colonized means you carry the infectious agent but are not actively sick with infection. Resident #4's Monthly Pharmacist Chart Review, dated 5/25/14-5/26/16, did not contain documentation regarding medication of any kind. 2. Resident #1 was admitted on [DATE], with end stage [MEDICAL CONDITION]. A History and Physical dated 6/30/15, documented Resident #1 was on Keflex 250 mg every day for [MEDICATION NAME] treatment of [REDACTED]. A subsequent History and Physical, dated 5/1/16, documented the continuation of Keflex due to a history of chronic UTI for patient comfort. Resident #1's Monthly Pharmacist Chart Review, dated 7/10/15-5/26/16, did not contain documentation regarding medication of any kind. Resident #1 and Resident #4's medical records did not contain documentation regarding reassessments, rationale for the antibiotic's continued use, and determination of the need for the continued use of the antibiotics. On 6/16/16 at 7:30 am, the DNS stated Resident #1 and Resident #4 were receiving antibiotic therapy for chronic UTIs, and the facility did not have other pa… | 2020-09-01 |
| 40 | 40 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2016-06-17 | 520 | D | 0 | 1 | J25411 | Based on staff interview, it was determined the facility failed to ensure a physician was a member of the facility's Quality Assurance Committee. The lack of physician involvement on the committee had the potential to compromise the efficacy of the Qualtiy Assurance program, thereby, placing residents at risk of adverse outcomes. Findings include: On 6/9/16 at 5:45 pm, the Administrator stated the QAPI committee members consisted of: the Administrator, DNS, LSW, MDS Coordinator, Activity Director, and Pharmacist. The Administrator confirmed that a physician was not a member of the committee. The Administrator stated the facility's medical director was sent an update, but does not actually attend the quarterly meetings. | 2020-09-01 |
| 41 | 41 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2017-09-21 | 311 | D | 0 | 1 | ZCF511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, and medical record review, it was determined the facility failed to provide a restorative nursing program for 1 of 7 residents (Resident #5) sampled for restorative nursing programs. The deficient practice created the potential for harm if the resident experienced a functional decline when restorative services were not provided. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's most recent quarterly Minimum Data Set (MDS) assessment, dated 7/22/17, documented the resident had moderate cognitive impairment, was dependent on two staff for bed mobility and transfers, and had limited use of his left arm and leg. Resident # 5's Activities of Daily Living care plan, dated 7/22/17, did not document the resident had a restorative nursing program, and no updates to add a restorative nursing program were documented. Resident #5's Physical Therapy Discharge Summary, dated 7/30/17, documented recommendations for restorative nursing services for strengthening and standing. The summary documented the resident's anticipated outcome was good with consistent staff follow through. On 9/19/17 at 9:15 am Resident #5 stated that he was told that the State said that he was no longer progressing and no longer eligible physical therapy, so he would be transferred to a restorative nursing program. Resident #5 stated it had been almost two months since his physical therapy ended, but he had not yet had any restorative nursing services. He stated he felt he may have lost some strength in his left leg by not being in a restorative program. On 9/19/17 at 10:10 am, Physical Therapist (PT) #2 stated she remembered Resident #5 and wrote a Restorative Plan for him as part of his discharge from skilled therapy 8/3/17. PT #2 stated she provided the Restorative Plan to the Director of Nursing (DON), as the DON oversaw the Restorative Nursing Program. She stated that she did not ge… | 2020-09-01 |
| 42 | 42 | BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION | 135007 | 98 POPLAR STREET | BLACKFOOT | ID | 83221 | 2017-09-21 | 441 | D | 0 | 1 | ZCF511 | Based on observation, staff interview and policy review, it was determined the facility failed to ensure hand hygiene occurred for 1 of 10 residents (#5) observed for hand hygiene. The deficient practice created the potential for harm if the resident developed infection from unsanitary practices. Findings include: On 9/19/17 at 3:15 pm, during suprapubic catheter care for Resident #5, LPN #1 washed her hands, placed the supplies on the over bed table, and put on a pair of gloves. LPN #1 removed the soiled dressing that covered the ostomy (surgically created opening between an internal organ and the body surface), then removed her gloves and replaced them with a new pair of gloves. LPN #1 did not wash her hands or use hand sanitizer between glove changes. LPN #1 cleaned the ostomy with sterile normal saline solution and then applied a clean dressing. LPN #1 then repositioned Resident #5 and removed her gloves. Following the dressing change, LPN #1 walked to the sink and washed her hands. On 9/19/17 at 3:30 pm, LPN #1 stated she forgot to sanitize her hands between glove changes. The facility Policy and Procedure titled Handwashing, Hand Antisepsis and Surgical Hand Scrub, Reference #921, Version 9 with an effective date of 6/30/17 documented, Hand hygiene must be performed at a minimum upon arrival to the facility, before and after touching each patient, before clean/aseptic procedures, after body fluid exposure, putting on gloves (clean or sterile), and after removing gloves, after touching anything in the patient's environment, before and after eating, after using the restroom, and when hands are visible soiled. On 9/19/17 at 4:10 p.m. the Director of Nursing (DON) stated it was facility policy that hand hygiene must be performed anytime gloves were removed. The DON stated that LPN #1 not sanitizing her hands after removing soiled gloves and replacing them with clean gloves was not following facility infection control policy. | 2020-09-01 |
| 43 | 43 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 583 | D | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and resident interview, it was determined the facility failed to ensure the resident's right to personal privacy was maintained during personal care. This was true for 1 of 1 resident (#1) observed during provision of personal care. The failure created the potential for Resident #1 to be embarrassed if her body was exposed to others unnecessarily. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's annual MDS assessment, dated 6/4/18, documented Resident #1 was cognitively intact. On 6/12/18 at 8:53 AM, CNA #5 provided morning care for Resident #1. CNA #5 was on the window side of the bed, and Resident #1 was in bed with her pants down to her knees. The window curtain was open and Resident #1's peri area was exposed. CNA #5 applied stockings and braces to Resident #1's legs prior to dressing her. CNA #4 arrived to assist with the transfer to the wheelchair with the Hoyer lift. Resident #1 was exposed for 3-5 minutes. No attempt was made by either CNA to cover Resident #1 or close the window curtain. On 6/14/18 at 1:32 PM, Resident #1 stated she tolerated the curtain being open. She stated she did not like it though. When asked if she told anyone about the open curtain, she shook her head no. and commented on how much she cared for facility staff. On 6/14/18 at 4:01 PM RN #2 stated she provided teaching on dignity and privacy to new hire staff. RN #2 stated the entire staff were expected to respect residents' privacy. RN #2 was not able to provide documentation regarding the teaching of personal privacy. | 2020-09-01 |
| 44 | 44 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 657 | D | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy and procedure review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated to maintain consistency and accuracy. This was true for 1 of 12 sample residents (#29) whose care plans were reviewed. This had the potential for harm if appropriate cares and/or services were not provided due to incorrect information on the care plan. Findings include: The facility's policy and procedure for Care Plans, dated 11/28/17, documented the following: * A comprehensive care plan is developed consistent with the residents' specific conditions, risks, needs, behaviors, preferences and with standards of practice . * The comprehensive care plan addresses services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. * The care plan is revised and updated to demonstrate the resident's current status. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses, including age-related cognitive decline and dysphagia (a swallowing disorder). Resident #29's significant change MDS assessment dated [DATE] documented moderate cognitive impairment with signs and symptoms of [MEDICAL CONDITION], a mechanically altered diet, and speech therapy was in place during (MONTH) (YEAR). Resident #29's physician orders, active as of 6/13/18, documented a regular diet, pureed texture, regular consistency. Resident #29's care plan documented the following: * Altered texture: nectar thick puree solids, pudding thick puree solids to be thinned to honey thick (as a max consistency) via cream whole milk, gravy/sauce or butter to improve bolus flow through esophagus per speech therapist recommendation, initiated on 5/11/18 and revised on 6/7/18. * Diet ordered by physician: regular diet, pureed texture, thin liquids, initiated on 7/16/14 and revised on 4/18/18. A Progress Note, dated 6/1/18 at 9:13 AM, documented Resident #29 had a … | 2020-09-01 |
| 45 | 45 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 684 | E | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure professional standards of practice were met related to neuro checks after resident falls, medication management, management of respiratory symptoms and not following physician orders. This was true for 2 of 3 residents (#12 and #16) reviewed for falls when neurological checks were not completed after resident falls, 3 of 12 residents (#2, #20, and #30) whose medications were reviewed when the recommended dose of Tylenol was exceeded and the ordered dose was exceeded for a nasal spray and antacid medication, 1 of 1 resident (#4) reviewed for respiratory symptoms and 1 of 16 residents (#132) where the nurses failed to follow physician orders. This failed practice created the potential for harm should residents experience undetected changes in neurological status after a fall, adverse side effects from excessive doses of medication, and undetected signs and symptoms of worsening respiratory status or [MEDICAL CONDITION]. Findings include: The facility's undated policy and procedure for nasal inhalers, sprays, and aerosols, documented the following: * Verify the physician's order, taking notice of the concentration of the medication and which nostril to treat. * Occlude one of the resident's nostrils, insert the tip into the open nostril and squeeze quickly and firmly one time. * Have the resident hold their breath for a few seconds then exhale through the mouth. * Repeat the ordered number of times in each nostril. The facility's policy and procedure for respiratory care, dated 11/28/17, documented the following: * Depending on the type of respiratory services the resident receives, physician orders and the individualized respiratory care plan, documentation should include, as appropriate: vital signs, respiratory rate, movement of the chest and respiratory effort, abnormal breath sounds, signs of dyspnea (shortne… | 2020-09-01 |
| 46 | 46 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 686 | G | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policies, resident records, and I and A Reports, it was determined the facility failed to prevent the development and worsening of a pressure ulcer. This was true for 1 of 1 sampled residents (#29) reviewed for pressure ulcers. This deficient practice caused harm to Resident #29 when she developed a blister on her coccyx (tailbone area) that deteriorated and became an unstageable pressure ulcer. Findings include: The facility's policy and procedure for Prevention and treatment of [REDACTED]. * Residents at risk for developing pressure ulcers are identified by using the Braden Scale. * Interventions for pressure ulcers and other wound and skin issues are developed by collaborating with the interdisciplinary team and are implemented to identify, prevent, or decrease the risk of developing pressure and/or non-pressure wounds. * Basic or routine care could include but was not limited to: redistribute pressure, minimize moisture contact with the skin and keep the skin clean, provide appropriate, pressure-redistributing, support surfaces, providing surfaces that are not irritating to skin, and maintain or improve nutrition and hydration status, where feasible. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses, including other abnormalities of gait and mobility, and muscle wasting atrophy. Resident #29's quarterly MDS assessment, dated 4/26/18, documented she was at risk for developing pressure ulcers and no pressure ulcers were present. Resident #29's Braden Scale for Predicting Pressure Sore risk, dated 5/1/18 at 11:33 AM, documented a moderate risk for developing pressures sores. Resident #29's significant change MDS assessment, dated 5/23/18, documented she was at risk for developing pressure ulcers and had one unstageable pressure ulcer measuring 2.0 (length) by 2.0 (width) by 0.2 deep. Resident #29's physician orders [REDACTED]. Resident #29's current care … | 2020-09-01 |
| 47 | 47 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 689 | G | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to provide sufficient supervision to meet resident's needs. This was true for 2 of 3 residents (#4 and #20) reviewed for supervision and accidents. Resident #20 was harmed when she sustained multiple injuries requiring medical evauation and care when the facility failed to implement interventions to prevent reoccurring falls. Resident #4 had multiple falls related to failure to implement the plan of care, ensure the bariatric extenders were locked . Findings include: The facility's policy and procedure for Fall Response and Management dated 11/28/17, directed staff to implement immediate interventions to prevent a repeat fall, to complete a post-fall investigation and event report, to review the post-fall evaluation and investigation, determine the cause, and to revise the care plan with interventions. The facility's policy and procedure for Accidents and Supervision to Prevent Accidents, dated 11/18/17, documented the following: *The facility staff observed, identified, and resolved potential hazards in the environment, while they took into consideration the unique characteristics and abilities of each resident. * The staff examined hazard and accident risk information for potential causes of accidents, and created interventions to reduce the risk of the hazard. * The facility monitored to confirm interventions were in place, evaluated interventions for efficacy, and changes and/or replaced interventions that were not effective. * The facility provided sufficient supervision to avoid accidents. The above policies were not followed. Examples include: 1. Resident #20 was readmitted to the facility 2/5/18 with multiple [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE], documented Resident #20 was moderately cognitively impaired. Resident #20 experienced four falls in (MONTH) (YEAR). a) A Post Fall Investigation, dated 4/3/… | 2020-09-01 |
| 48 | 48 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 693 | D | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of clinical records and policies, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 2 sample residents (#182) reviewed for medications through a feeding tube. This failure created the potential for harm if complications developed from improper feeding tube practices. Findings include: The facility's policy and procedure for Administering of Medication through an Enteral Feeding Tube, dated 5/28/15, directed staff that if a pump was not being used, check the tube for placement and patency using a 60 ml syringe, then flush with 15 to 30 mls of warm tap water prior to administering medication. Resident #182 was admitted to the facility on [DATE] with multiple diagnoses, including pneumonitis due to inhalation of food and vomit and dysphagia (a swallowing disorder). Resident #182's physician orders, dated 6/14/18 at 5:46 PM, documented the following: * [MEDICATION NAME] sodium tablet (a stool softener) give 100 mg through the tube twice a day. * [MEDICATION NAME] Fast-Max Congest Cough (a decongestant) 2.5-5-100 mg/5 ml give 10 ml through the tube twice a day. * Apixaban (Eliquis) tablet (a blood thinner) give 2.5 mg through the tube twice a day. Resident #182's current care plan documented he had a feeding tube related to dysphagia and directed staff to do the following: Monitor/document/report to physician as needed: aspiration (inhaling material into lungs), fever, shortness of breath, tube dislodged, infection of the tube site, self-removal of the tube, disturbance or malfunction of the tube, abnormal breathing or lung sounds, abnormal lab results, abdominal pain, distension, or soreness, constipation or impaction, diarrhea, nausea/vomiting, or dehydration. On 6/14/18 at 5:30 PM, RN #5 was observed administering medication to Resident #182 through his feeding tube. RN #5 briefly turned the valve on the stopcock to the feeding tube, observed a smal… | 2020-09-01 |
| 49 | 49 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 759 | D | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 25 medications (8%) which affected 1 of 7 residents (#2) whose medication passes were observed. This failure created the potential for harm when Resident #2 received doses in excess of physician orders [REDACTED]. Findings include: The facility's undated policy and procedure for nasal inhalers, sprays, and aerosols, documented the following: * Verify the physician's orders [REDACTED]. * Occlude one of the resident's nostrils, insert the tip into the open nostril and squeeze quickly and firmly one time. * Have the resident hold their breath for a few seconds then exhale through the mouth. * Repeat the ordered number of times in each nostril. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux disease and acute sinusitis. Resident #2's physician orders, active as of 6/14/18, documented the following: * [MEDICATION NAME] Proprionate Suspension (a nasal steroid spray) 50 mcg 2 sprays each nostril twice a day for chronic rhinosinusitis. * [MEDICATION NAME] Suspension 200-200-20 mg/5 ml give 2 tsp every 6 hours as needed for stomach upset. Resident #2's (MONTH) (YEAR) MAR indicated [REDACTED] * The [MEDICATION NAME] nasal spray was administered each day from 6/1/18-6/14/18. * The [MEDICATION NAME] was administered on 6/8/18, 6/10/18, 6/12/18, and 6/14/18. On 6/14/18 at 9:19 AM, RN #1 administered medications to Resident #2. RN #1 administered two sprays of [MEDICATION NAME] nasal spray to Resident #2's right nostril and left nostril. RN #1 then administered three additional sprays of [MEDICATION NAME] to Resident #2's right nostril and two additional sprays to the left nostril. When asked how many sprays should be administered, RN #1 said it was two sprays in each nostril. When the surveyor pointed out to RN #1 that sh… | 2020-09-01 |
| 50 | 50 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 761 | E | 0 | 1 | GRQ011 | Based on observation, policy review, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration to residents. This was true for 1 of 2 medication storage rooms with expired Pneumococcal vaccine. This failed practice had the potential to effect 12 of 12 sampled residents who could receive expired medications (#2, #3, #4, #7, #8, #9, #16, #19, #20, #29, #30, and #132) and other 23 residents who resided in the facility. This failed practice created the potential for harm should residents receive expired vaccinations with decreased efficiency. Findings include: The facility Medication Management policy dated 11/28/17, documented medications were discarded by the expiration date unless indicated by the pharmacy and/or the manufacturer's instructions to discard sooner. On 6/14/18 at 10:58 AM, a medication room was inspected with RN #4. An unopened multi-dose vial of Pneumococcal vaccine with an expiration date of 9/27/17, was found in the refrigerator. At the time of inspection, RN #4 verified the expiration date and disposed of the expired medication. On 6/14/18 at 11:08 AM, the DON stated it was the staff and administration's responsibility to monitor for expired medications. Residents #2, #3, #4, #7, #8, #9, #16, #19, #20, #29, #30, and #132 and the other 23 residents residing in the facility were at risk of receiving expired Pneumococcal vaccine. | 2020-09-01 |
| 51 | 51 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 883 | F | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, it was determined the facility failed to ensure a) implementation of an immunization program to ensure residents' Pneumococcal (bacterial) pneumonia vaccine status were being tracked with receiving or declining the Pneumococcal vaccines PCV 13 and PPSV 23, consistent with current Centers for Disease Control and Prevention (CDC) recommendations, and b) residents who consented to administration of the Pneumococcal vaccinations, received the vaccinations. This is true for 9 of 9 residents (#2, #4, #7, #9, #12, #16, #19, #29, and #30) reviewed for Pneumococcal vaccinations, and had the potential to impact the other 26 residents residing in the facility. These deficient practices placed residents at risk of developing Pneumococcal pneumonia and developing subsequent serious, potentially life threatening, complications. Findings include: The Centers for Disease Control and Prevention (CDC) website, updated 11/22/16, documented recommendations for Pneumococcal vaccination (PCV 13 or Prevnar 13(R), and PPSV 23 or [MEDICATION NAME] 23(R)) for all adults [AGE] years or older: * Adults who were [AGE] years or older, who had not previously received PCV 13, should receive a dose of PCV 13 first, should follow 1 year later by a dose of PPSV 23. * If the patient already received one or more doses of PPSV 23, the dose of PCV 13 should be given at least 1 year after they received the most recent dose of PPSV 23. The facility's policy and procedure Patient Immunization Program dated 4/27/15, documented the facility would ensure all patients were offered appropriate Pneumococcal vaccinations in accordance with recommendations set forth by the Centers for Disease Control (CDC). The facility's policy Pneumococcal Program dated 10/31/17, documented vaccinations were available that could prevent two kinds of pneumonia: Pneumococcal conjugate vaccine (PCV 13 or Prevnar 13) and Pneumococcal [MEDICATION NAME]… | 2020-09-01 |
| 52 | 52 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2019-10-04 | 578 | D | 0 | 1 | VWS011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' records included an Advanced Directive or documentation of discussion regarding Advance Directives and their decision not to formulate one. This was true for 2 of 12 residents (#1 and #30) reviewed for Advance Directives. The deficient practice created the potential for harm should residents' wishes regarding end of life care not be honored when they are unable to make or communicate their health care preference. Findings include: The State Operations Manual (SOM) defined an Advance Directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The SOM defined a Physician order [REDACTED]. medical condition into consideration. A POLST [MEDICATION NAME] form is not an advance directive.If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether he or she has executed an advance directive or not, the facility may give advance directive information to the individual's resident representative in accordance with State Law. The facility's Advance Directives/Health Care Decisions policy and procedure, dated 10/1/17, documented Residents have the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate Advance Directives. In states with governance surrounding Advance Directives, facilities are to follow the State's specific requirements. This policy was not followed. 1. Resident #1 was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's record did not include an Advance Directive or documentation Advance Directives were discussed with her. On 10/3/19 at 10:… | 2020-09-01 |
| 53 | 53 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2019-10-04 | 625 | D | 0 | 1 | VWS011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, it was determined the facility failed to ensure a notice of their bed-hold policy was provided to residents or their representatives upon transfer to the hospital. This was true for 1 of 1 resident (Resident #17) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold Readmission policy and procedure, dated 11/28/17, documented the facility provided written information to the resident, or the resident's representative, about holding a resident's bed prior to or upon transfer to a hospital, and in cases of emergency transfer within 24 hours of transfer. This policy was not followed. Resident #17 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. A progress note documented Resident #17 was transferred to the hospital for evaluation on 9/26/19, when she exhibited increased weakness and had stopped eating and drinking. Resident #17's record did not include documentation a written notice of the facility's bed-hold policy was provided to her. On 10/4/19 at 2:03 PM, Resident #17 said she did not remember if she was given a bed-hold notice. On 10/4/19 at 3:10 PM, The DON said Resident #17's record did not include documentation she was provided written notice of the facility's bed-hold policy. | 2020-09-01 |
| 54 | 54 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2019-10-04 | 677 | D | 0 | 1 | VWS011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were assisted with hand hygiene. This was true for 1 of 12 residents (Resident #40) reviewed for ADL care. This failure created the potential for harm by potentially exposing residents to the risk of infection. Findings include: Resident #40 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/18/19, documented Resident #40 was cognitively intact and she required extensive assistance from one person for most activities of daily living. On 10/2/19 at 1:22 PM, CNA #4 was observed as she provided pericare to Resident #40. CNA #4 unfastened Resident #40's incontinence brief and Resident #40 scratched her genitalia vigorously using her right hand. CNA #4 asked Resident #40 to stop scratching and gave the resident a wet wipe. Resident #40 held onto the wipe, but did not clean her hands. CNA #4 proceeded to clean Resident #40's periarea and wiped it from front to back. CNA #4 then cleansed around Resident #40's catheter insertion site. Resident #40 then scratched her genitalia again using her right hand and her fingers were observed going to her catheter insertion site. CNA #4 reminded Resident #40 to stop scratching and gave Resident #40 another wet wipe. Resident #40 held onto the wipe, but did not clean her hands. CNA #4 then removed her gloves, performed hand hygiene, and applied new gloves. While CNA #4 was applying a new incontinence brief Resident #40 was observed to scratch her genitalia again. CNA #4 asked Resident #40 to stop scratching and said she was going to let the nurse know to check Resident #40's periarea. CNA #4 then assisted Resident #40 to sit on the edge of the bed and helped her to transfer to her wheelchair. As CNA #4 was helping Resident #40 to transfer to the wheelchair, Resident #40 scratched her nose and then wiped her mouth using her right hand. CNA… | 2020-09-01 |
| 55 | 55 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2019-10-04 | 684 | D | 0 | 1 | VWS011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for medication administration, bowel care, and skin care. This was true for 3 of 12 residents (#9, #16, and #30) reviewed for quality of care. These failed practices created the potential for harm should residents experience adverse effects from medications, constipation or fecal impaction, and skin breakdown. Findings include: 1. The facility's undated policy for Oral Inhalant Administration, directed staff to instruct residents receiving steroid inhalers to rinse their mouth thoroughly with water immediately following inhalation to wash away steroid residue in the mouth. This policy was not followed. Resident #9 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 7/22/19, documented Resident #9 had moderate cognitive impairment. Resident #9's (MONTH) 2019 physician's orders [REDACTED]. The order included special instructions for Resident #9 to rinse their mouth out with water and spit after administration. On 10/3/19 at 7:29 AM, RN #1 was observed when she administered Resident #9's medications which included the inhaled medication Breo Ellipta. Resident #9 was observed to take one puff of the Breo Ellipta orally, and then gave the inhaler back to RN #1. RN #1 then asked Resident #9 to take a sip of water. Resident #9 did not rinse his mouth after inhaling the Breo Ellipta. On 10/3/19 at 9:08 AM, RN #1 said she forgot to ask Resident #9 to rinse his mouth after administering the Breo Ellipta. RN #1 said she should have told Resident #9 to rinse his mouth with water and spit it out. 2. The facility's Bowel Care protocol, updated on (MONTH) (YEAR), documented the following: *Follow specific physician's orders [REDACTED]. * If the resident was 24-48 hours without a bowel movement documented, staff were to admini… | 2020-09-01 |
| 56 | 56 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 159 | E | 0 | 1 | 224111 | Based on resident and staff interview and review of the Resident Trust Fund Account, it was determined the facility failed to ensure quarterly trust account statements were provided to residents and/or their responsible parties. This was true for the 13 of 13 residents who had trust accounts, including 3 of 3 residents who participated in the resident group interview and had trust accounts. This created the potential for harm if residents and/or their responsible parties were unable monitor their trust fund accounts. Findings include: The Resident Trust Fund Account, reviewed on 10/20/16 at 12:27 pm, did not include documented evidence quarterly account statements were provided to 13 residents and/or their responsible parties, to make them aware of the balances and transactions in their trust accounts. During a resident group interview conducted on 10/18/16 at 11:00 am, 3 residents who had trust accounts reported not receiving quarterly statements to inform them or their responsible parties of balances or transactions. During an interview with the Business Office Manager on 10/20/16 at 12:27 pm, she reported 13 residents authorized the facility to manage their trust accounts. She confirmed she did not provide quarterly statements to the residents or their responsible parties, and added she sent out a monthly billing statement. She further stated she had not thought of sending out quarterly trust account statements because a monthly bill was provided, although the billing statement did not include information about the trust account activity, balance or transactions. | 2020-09-01 |
| 57 | 57 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 166 | E | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview and review of facility policies, it was determined the facility failed ensure grievances regarding lost items were resolved. This was true for 3 of 18 sampled residents (#15, #16 and #18). This deficient practice placed residents at risk of psychosocial harm due to lack of control over their belongings and inability to resolve their concerns through established processes. Findings include: 1. During the resident group interview on 10/19/16 at 11:00 am, Resident #15 reported several months ago he sent 3 pairs of pajamas to the laundry to be washed and only the tops of the pajamas were returned to him. He informed nursing staff immediately when his bottoms were not returned and nothing had been done. During an interview with the Assistant Social Worker (ASW) on 10/20/16 at 11:30 am, she reported the missing items were just brought to her attention yesterday on 10/19/16, after the group meeting ended at 12 noon and since then she had already ordered replacements for 4 sets of flannel pajamas from a local clothing store. She further stated she had since then informed Resident #15 the pajamas had been ordered and were scheduled for delivery in 7 days. 2. Resident #16 reported in the resident group interview on 10/19/16 at 11 am, that he had diabetes and [MEDICAL CONDITION]. He said he went to appointments at the [MEDICAL TREATMENT] clinic 3 times per week. Resident #16 reported he brought a blood sugar monitoring accu-check machine from home to the facility so he could check his blood sugar while away from the facility. Resident #16 reported the machine was kept in the nurse's medication cart and when needed he would request his machine. Approximately 2 weeks ago he requested his machine and the nurse informed him the machine was missing. He said he spoke with the supervisor immediately, however, no one to date had gotten back with him even though a concern/ grievance form was completed. During a subsequent in… | 2020-09-01 |
| 58 | 58 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 176 | D | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of facility policies, and record review it was determined the facility failed to ensure 1 of 2 (#19) random residents was assessed to safely self-administer medications. This deficient practice created the potential for medication errors and harm if Resident #19 did not take his medications timely. Findings include: Resident #19 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Physician orders, dated (MONTH) (YEAR), included: * Aspirin 81 mg tablet once a day for the heart * [MEDICATION NAME] Extended Release (ER) 20 meq by mouth every day as a supplement * [MEDICATION NAME] HCl 2 mg once a day for pain * [MEDICATION NAME] 100 mg give half a tablet once a day for [MEDICAL CONDITION] Resident #19's physician orders [REDACTED]. The facility's Self-Administration of Medications policy documented, if the Interdisciplinary Team (IDT) and the attending physician determine the resident is safe to self-administer medications a physician order [REDACTED]. The licensed nurses are responsible for following-up with the resident to validate the resident has taken the medication and should be documented on the resident's Medication Administration Record [REDACTED]. On 10/18/16 at 10:15 am, LN #4 was observed to dispense the above medications into a medication cup and enter Resident #19's room. Resident #19 refused to take the medications and stated, You know that I don't take my medications this early. He directed the nurse to place the dispensed medication in his lock box located in the closet. When the nurse asked him if he had the key for the box Resident #19 stated, No it is in my sock drawer. LN #4 was observed to remove the key from the drawer, unlock the box, place the medication inside the box, lock the box, and return the key to the sock drawer. Resident #19 stated he would take them later. The Electronic Medication Administration Record [REDACTED]. On 10/18/16 at 10:20 am,… | 2020-09-01 |
| 59 | 59 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 242 | D | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family member, and staff interviews, it was determined the facility failed to ensure that 1 of 18 sampled residents (Resident #4), choice of when to arise in the morning was respected. This placed Resident #4 at risk for a decline in his psychosocial well-being. Findings include: Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further documented Resident #4 had functional impairment on both sides of his upper and lower limbs. This consequently caused him to depend on 2 staff for extensive assistance in all transfers. Resident #4's 10/1/16 active physician orders [REDACTED]. On 10/18/16 at 9:30 am, Resident #4 was observed in bed. As he was lying in bed, with some assistance from Family Member #1, he frequently suctioned copious amounts of clear thick sputum. Resident #4 shared that he wanted to get up earlier in the day, when other residents who eat in the dining room were assisted up. He said when he sits up he has less phlegm, and therefore, less need for suctioning. Resident #4 said Family Member #1 comes early morning every day to help him shave and brush his teeth, before he has to go to speech therapy. Family Member #1, present for the interview, stated she offered to get Resident #4 ready to get up, if staff would assist with getting him out of bed earlier. On 10/18/16 at 4:50 pm, Resident #4 was observed slowly wheeling himself, independently, in his wheelchair. He stated at that time that he tried to do 3 laps around the inside of the facility as exercise. On 10/18/19 at 3:00 pm, the DON was asked if she was aware of Resident #4's desire to get up for breakfast when other residents get up. She said he used to get up earlier than his current rising, but staff was getting rushed trying to get him up. She said in the interest of safety, his transfer time was changed to after breakfast. The DON… | 2020-09-01 |
| 60 | 60 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 280 | D | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility failed ensure interventions on residents' care plans related to mobility/ transfer status were reviewed and revised to reflect their current status. This was true for 2 of 18 sampled residents (#4 and #6). This deficient practice placed residents at risk for injuries related to improper transfers. Findings include: 1. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment further documented Resident #4 had functional impairment to both sides of his upper and lower limbs. According to Resident #4's quarterly MDS assessment, dated 8/29/16, he required extensive assistance of 2 staff for transfers and was totally dependent on 2 staff for bed mobility. The assessment further stated Resident #4 had impaired range of motion to all limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift and transported him to his wheelchair. During the transfer Resident #4 did not stand. He was transferred in a squat like position. Resident #4's care plan dated 5/21/16 and revised on 10/7/16, with a focus on I… | 2020-09-01 |
| 61 | 61 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 281 | D | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure a) staff followed policies and procedures for medication administration, The failure to provide services that met or exceeded professional standards, directly impacted 1 of 18 sampled residents (#15). These deficient practices created the potential for residents not receive the appropriate mediation or other residents to have access to unsecured medications. Findings include: During initial tour of the facility on 10/17/16 at 10:05 am, Resident #15 was observed sitting upright in a chair in his room. On the bedside table were 2 round pills in a small plastic medication cup. Resident #15 made no attempt to take the medication. At 10:10 am, LN #1 entered Resident #15's room. During an interview with LN #1 at that time, she reported Resident #15 did not self-administer his medication and she left the medications at his bedside in error. LN #1 reported the 2 pills were TUMS and administered the 2 pills to Resident #15 at 10:13 am. Resident #15's physician orders, reviewed at 11:00 am on 10/17/16, included an order for [REDACTED]. The facility policy and procedure titled Medication Administration documented that during medication administration the licensed nurse was to remain at the bedside and observe the resident take the medication as prescribed. Leaving medications at the bedside was an infraction of facility standards of practice. | 2020-09-01 |
| 62 | 62 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 309 | D | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review it was determined the facility failed to ensure a) a resident received rapid acting insulin at the correct time, and that the amount of insulin administered was based on accurate blood sugar levels and b) physician orders [REDACTED]. This was true for 1 of 5 (Resident #2) residents observed during medication administration. This placed Resident #2 at risk of [MEDICAL CONDITION] when he was administered rapid acting insulin greater than one hour after the lunch meal. Findings include: Resident #2 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident #2's physician orders, dated 10/10/16, included [MEDICATION NAME] solution 100 units/ml - Inject as per sliding scale subcutaneously before meals and at bedtime for diabetes mellitus. The sliding scale was as follows: 0-149 = 0 units 150-200 = 3 units 201-250 = 6 units 251-300 = 9 units 301-350 = 12 units 351-400 = 15 units 401-450 = 18 units For blood sugar greater than 450 give 21 units and notify the medical doctor. The FDA's specifications for use state [MEDICATION NAME] subcutaneous injections should, generally be given immediately (within 5-10 minutes) prior to the start of a meal. On 10/18/16 at 11:50 am, Resident #2's blood sugar reading was 219 mg/dl, indicating he should receive 6 units of [MEDICATION NAME] per the sliding scale. LN #6 told Resident #2 she would administer his sliding scale insulin after lunch. On 10/18/16 at 1:00 pm, LN #6 was observed to administer 6 units of [MEDICATION NAME] to Resident #2. LN #6 stated she routinely administered Resident #2's sliding scale insulin after meals. When asked if she checked Resident #2's blood sugar after lunch prior to administering the sliding scale insulin, LN #6 stated she did not and gave the sliding scale insulin based on what Resident #2's blood sugar was prior to lunch. LN #6 stated Resident #2's physician was not aware she had been holding the sliding sc… | 2020-09-01 |
| 63 | 63 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 323 | J | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of manufacturer's recommendations, and staff interviews, it was determined the facility failed to ensure 2 of 3 residents (#4 and #6) requiring the use of mechanical devices for assistance with transfers, were monitored and re-evaluated for the continued appropriateness and safety of the devices; and staff were trained how to use the devices. These failures placed the health and safety of Residents #4 and #6, who required the use of a sit-to-stand device for transfers, in immediate jeopardy of serious injury, harm, or death. Findings include: 1. Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further noted Resident #4 had functional impairment to both sides of his upper and lower limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift and transported him to his wheelchair. During the transfer Resident #4 did not stand. He was transferred in a squat like position. LN #1 was present during the above transfer of Resident #4 on 10/18/16 at 9:30 am, utilizing the sit-to-stand … | 2020-09-01 |
| 64 | 64 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 328 | E | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident, staff, and outside service provider interview, the facility failed to ensure the maintenance on the oxygen (O2) concentrators was current for 2 of 3 residents in the facility that were using oxygen (#1 and #14). The lack of maintenance placed residents at risk of injury and/or adverse health outcomes due to malfunctioning O2 concentrators. Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 had a physician's orders [REDACTED]. During an interview on 10/17/16 at 2:30 pm, Resident #1 showed the surveyor his oxygen concentrator. The back of the plastic case showed signs the machine had gotten hot and the plastic was partially melted. Observation of the filter in the machine showed there was buildup of material. Resident #1 stated he had told staff about the problem and that he could not remember when the plastic case melted. The maintenance sticker on the front of the machine showed the last maintenance was 11/13/13 and was due again 11/13/14. There was a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The Administrator was informed on 10/17/16 at 4:00 pm, and removed the machine from Resident #1's room. 2. Resident #14 was admitted to the facility 5/15/15, with [DIAGNOSES REDACTED]. Resident #14's physician's orders [REDACTED]. A physician's orders [REDACTED]. On 10/17/16 at 4:15 pm, Resident #14's O2 concentrator was examined. The filter was in need of cleaning and the last maintenance performed was 9/21/14, and noted maintenance was due to be performed on 9/21/15. Resident #14 stated, at that time, he used the machine every night with his [MEDICAL CONDITION] machine and was not aware of the maintenance issue. The Administrator was notified of the maintenance issues on 10/17/16 at 4:00 pm. At 4:15 pm, the Administrator was observed removing concentrators from oxygen storage room. There were five machines that were remo… | 2020-09-01 |
| 65 | 65 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 332 | E | 0 | 1 | 224112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure a medication error rate less than 5 percent. This was true for 5 of 33 medications (15%) during medication pass observations which affected 4 of 12 sampled residents (#14, #16, #20 and #21). The failure created the potential for [DIAGNOSES REDACTED] when rapid acting insulin was administered too early before a meal and for oral [MEDICAL CONDITION](thrush) to develop from lack of rinsing and spiting after inhalation of a corticosteroid medication. Findings include: The manufacturer's documented [MEDICATION NAME] (Insulin [MEDICATION NAME]) as a rapid acting insulin and that an injection of [MEDICATION NAME] should immediately be followed by a meal within 5-10 minutes. On 12/14/16 at 11:10 am, the Administrator provided the facility's Insulin Quick Reference, dated 2002, which documented [MEDICATION NAME] insulin, Should be given just prior to .eating. The Nursing (YEAR) Drug Handbook patient teaching regarding [MEDICATION NAME]documented, .give insulin at appropriate time around a meal . 1. Resident #14 was readmitted to the facility in (MONTH) (YEAR) with multiple diagnoses, including DMII, asthma and [MEDICAL CONDITION]. Resident #14's Active Orders As Of: 12/14/16 included a 4/6/16 order for [MEDICATION NAME]per sliding scale SQ before meals and at bedtime and a 7/24/16 order for [MEDICATION NAME] suspension inhaled twice a day. a. On 12/13/16 at 11:10 am, LN #3 was observed as she administered Resident #14's rapid acting [MEDICATION NAME] insulin. At 11:15 am, the LN said lunch was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. Resident #14's rapid acting insulin was administered 50 minutes before the meal. b. On 12/14/16 at 8:55 am, LN #1 was observed as administered an inhaler medication, 6 oral medications then [MEDICATION NAME] (corticosteroid) inhalatio… | 2020-09-01 |
| 66 | 66 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 333 | E | 0 | 1 | 224112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's Insulin Quick Reference, and resident and staff interview, it was determined the facility failed to ensure there were no significant medication errors for 4 of 12 sampled residents (#14, #16, #20 and #21) during medication pass observations. The failure created the potential for the residents to experience [DIAGNOSES REDACTED] when rapid acting insulin was administered too early before meals and after Resident #16 said he was not going to eat a meal. In addition, Resident #16's insulin dose was changed without a physician's orders [REDACTED].>The manufacturer documented [MEDICATION NAME] (Insulin [MEDICATION NAME]) as a rapid acting insulin and that an injection of [MEDICATION NAME] should immediately be followed by a meal within 5-10 minutes. On 12/14/16 at 11:10 am, the Administrator provided the facility's Insulin Quick Reference, dated 2002, which documented [MEDICATION NAME] insulin, Should be given just prior to .eating. Regarding [MEDICATION NAME] insulin, the Nursing (YEAR) Drug Handbook patient teaching documented, .give insulin at appropriate time around a meal . 1. Resident #16 was admitted to the facility in 2013 with multiple [DIAGNOSES REDACTED]. Resident #16's Active Orders As Of: 12/14/16 included orders for [MEDICATION NAME]per sliding scale SQ with meals every day, dated 8/3/16. On 12/13/16 at 11:15 am, LN #3 said the lunch meal was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. On 12/13/16 at 11:30 am, Resident #16 told LN #3 that he may not eat lunch. LN #3 told Resident #16 his sliding scale called for 4 units of [MEDICATION NAME]. Resident #16 said he would take 2 units of insulin but not 4 units. Resident #16 also refused 2 oral medications and said he was not going to eat at lunch time. On 12/13/16 at 11:35 pm, the LN was observed as she administered [MEDICATION NAME] 2 units SQ into Resident … | 2020-09-01 |
| 67 | 67 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 456 | D | 0 | 1 | 224111 | Based on observations, review of the facility maintenance log, and staff interview, it was determined the facility failed to ensure resident care equipment was maintained and serviced for 1 of 18 sampled residents (Resident #4). This failure to monitor and maintain equipment allowed staff to continue to use pertinent care equipment for the critical management of a resident requiring frequent suctioning, and placed the resident at risk of aspiration if the machine malfunctioned. Findings include: 1. On 10/18/16 at 8:45 am, a suction machine in Resident #4's room was observed to have a canister attached with approximately 100 cc of clear sputum. The inspection safety test was documented as most recently completed on 2/5/15. The label indicated the next date for the machine to be evaluated was 2/2016. A second suction machine in the room contained an inspection safety test label that documented the last time the machine was evaluated was 2/15/15 and required another inspection to be completed in 2/2016. 2. During the Environmental Tour On 10/18/16 at 10:00 am, with the Maintenance Director, he confirmed not all equipment was checked routinely as required. The Maintenance Director could offer no explanation of the facility's failure to ensure the necessary inspections were completed. Review of the Maintenance Log at this time showed the following items were due for inspection in (MONTH) (YEAR), but were not inspected: * Dining Room Suction Machine * Bath Patient lift/scale * 2 Patient Suction Machines | 2020-09-01 |
| 68 | 68 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 463 | D | 0 | 1 | 224111 | Based on observation and resident and staff interview, it was determined the facility failed to ensure the resident call system was functional and equipped to receive resident Emergency calls from private bathrooms for 2 of 30 residents residing in the facility (#12 and #13). This created the potential for harm when residents were unable to summon staff assistance when needed. Findings include: Resident #12 who resided in room 204, and Resident #13 who resided in room 206, shared an adjoining bathroom. During environmental rounds with the Maintenance Director on 10/19/16 at 10:50 am, the emergency call bells for residents who resided in rooms 204 and 206 were tested for proper functioning. When the bathroom emergency call bell was pulled for testing, the Maintenance Director immediately reported this call bell has not worked since 10/6/16. The Maintenance Director provided the following information: On the morning of 10/6/16, a CNA presented him with a detached pull cord from the emergency call bell that serviced rooms 204 and 206. It was observed that the call light was not illuminating at the nurses' station or over the door of either resident's room, even when the call bell was pulled manually. On 10/6/16, electric company representatives came to the facility to assess the problem. They were unable to fix the call bell. Cordless doorbells were placed in the residents' bathroom for them to push when they needed assistance while in the bathroom. The doorbells sounded at the nurses' station through a cordless speaker. A TABS (trademark) Alarm was also placed for the 2 residents to use in the event they fell and could not reach the doorbell. Resident #12 resided in room 204. Her MDS assessement, dated 9/15/16, documented she had the ability to express her ideas and the ability to understand others. On 10/19/16 at 10:55 am, she was asked how she would call for help if she were in her bathroom and required assistance. She reported she was mostly independent but would use the call bell in the bathroom. Resident #12 r… | 2020-09-01 |
| 69 | 69 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 490 | F | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, resident, and outside service provider interview, review of manufacturer's recommendations, and record review, the facility failed to ensure it was administered in such a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 6 of 18 sampled residents (#1, #4, #6, #12, #13, and #14). The administration failed to ensure a) LNs and CNAs were competent for the safe transfer of residents with mechanical lifts, b) oxygen concentrator equipment was safe for resident use, and c) suction equipment, call lights, and mechanical lifts were inspected and maintained in manner that protected residents from harm. Findings include: 1. Refer to F323 (Immediate Jeopardy) as it relates to the failure of the facility to ensure residents requiring the use of mechanical sit-to-stand lifts for assistance with transfers, were monitored and re-evaluated for the continued appropriateness and safety of the devices; and that staff were trained how to use the devices. This deficient practice placed 2 residents at risk of serious harm, injury, or death. The Administrator was questioned on 10/20/16 at 11:00 am, about competency of the staff who used the sit-to-stand lifts on residents. He indicated competencies were to be reviewed annually by an outside agency who monitored the facility. The Administrator said the Staff Development Coordinator was to report to the QA (Quality Assurance Committee) on the progress of the competencies. The Administer confirmed he was not aware staff competency evaluations for the use of sit-to-stand lifts were not being completed. 2. Refer to F328 as it relates to the failure of facility administration to ensure the maintenance on the oxygen (O2) concentrators was current. The Administrator, District Director of Clinical Services, and Staff Development Coordinator were interviewed 10/18/16 at 3:00 pm, about the failed maintenanc… | 2020-09-01 |
| 70 | 70 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 498 | F | 0 | 1 | 224111 | Based on review of staff training records and staff interviews, it was determined the facility failed to ensure 17 of 17 CNAs (#1-#5 and #7-18) whose competency evaluations were reviewed, were verified as competent to appropriately and safely transfer residents using a sit-to-stand mechanical lift. This resulted in the unsafe transfer of 2 residents requiring the use of a sit-to-stand mechanical lift. Findings include: 1. CNA skills competencies were reviewed for CNAs #1-#5 and #7-18. None of the new hire core competencies or the annual competencies for these staff included a demonstration of competency with the sit-to-stand mechanical lift. During an interview with the SDC, on 10/19/16 at 6:30 pm, she stated newly hired CNAs received, as part of their orientation, training on the Hoyer lift and the sit-to-stand. She said the new employee was paired with a CNA mentor for orientation on the floor. The SDC said the new employee would perform a return demonstration with the mentor (using the mechanical lifts) and the mentor then notified the nurse if the new employee was competent or needed more training. The nurse then signed off the core clinical competency based on the verbal report from the mentor. The SDC said she only followed-up on training of the mechanical lifts if there were concerns. The SDC said nurses were not required to complete the training or competencies for the mechanical lifts. Nurses, whose competency with the sit-to-stand mechanical lift was not verified, were responsible for checking off the competency of CNAs. The SDC provided an in-service, dated 7/8/16, for the sit-to stand. The in-service was a table top in-service where staff read the information and signed that they read it. It did not include a return demonstration. 2. Refer to F323 (Immediate Jeopardy) as it relates to the failure of the facility to ensure residents requiring the use of mechanical sit-to-stand lifts for assistance with transfers, were monitored and re-evaluated for the continued appropriateness and safety of the device… | 2020-09-01 |
| 71 | 71 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 520 | E | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of manufacturer's instructions, and record review, it was determined the facility failed to have a Quality Assurance and Assessment (QAA) program that identified resident safety issues requiring the development and implementation of appropriate plans of action to correct the issues. This deficient practice directly impacted 6 of 18 sampled residents (#1, #4, #6, #12, #13, and #14). These deficient practice placed residents at risk of harm due to unsafe mechanical lift transfers and ill-maintained oxygen concentrators, suction machines, call lights, and bath/scale lift. Findings include: 1. Staff were observed unsafely transferring Resident #4 and Resident #6 without following the manufacturer's instructions when using the sit-to-stand mechanical lift. a. Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further noted Resident #4 had functional impairment to both sides of his upper and lower limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff recovered him and returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift… | 2020-09-01 |
| 72 | 72 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 602 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and review of policies, clinical records, employee time records, and facility investigations, it was determined the facility failed to ensure 1 of 7 sampled residents (#9) was free from misappropriation of a controlled pain medication. This failed practice resulted in misappropriation of Resident #9's [MEDICATION NAME] by Staff #[NAME] It also created the potential for other residents to experience uncontrolled pain if misappropriation of their controlled pain medications was undetected. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. There was no documentation that [MEDICATION NAME] was administered to Resident #9 in the (MONTH) (YEAR) MAR. There was no documentation in the progress notes, dated 11/7/17 through 11/30/17, that [MEDICATION NAME] was administered to Resident #9. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg were delivered to the facility. The narcotic count sheet documented Staff #A signed that she administered 15 of 16 doses between 11/14/17 and 11/20/17. One dose, dated 11/19/17 at 12:00 PM, documented different initials in the Administered By column, but was the same handwriting as Staff #A's in all the other documentation. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A signed that she administered 15 of 15 doses between 11/22/17 to 11/26/17. The narcotic count sheet documented 11 doses remained in the bubble pack card. An undated summary of the facility's investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented, On 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of the medication cards on (Resident #9's name) had medications taped back into the … | 2020-09-01 |
| 73 | 73 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 608 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and review of facility investigations and a police report, it was determined the facility failed to report misappropriation of a controlled medication to law enforcement within 24 hours. This was true for 1 of 7 residents (#9) whose medications were reviewed. The delay in reporting created the potential for misappropriation of controlled medication to continue without detection. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. An undated summary of a facility investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented, On 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of the medication cards on (Resident #9's name) had medications taped back into the card. The investigation documented (Staff A's name) had signed out the medications to this resident and that the medications taped in did not correlate, in appearance, with what was described on the Pharmacy identification tag. The summary documented the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented the police department was notified on 12/1/17, four days after the misappropriation of Resident #9's controlled medication by Staff #A was reported to the DNS on 11/27/17. On 4/16/18, the facility provided a Police Department Detail Incident Report, dated 12/1/17. The report documented a police officer responded to the facility regarding a reported theft of medication. The police report documented a police officer spoke to Staff #A on 12/2/17 and Staff #A, .admitted to taking the pills between 11/14/17 and 11/17/17 .she had taken at least eleven [MEDICATION NAME] pills, possible (sic) more, though she did not remember the exact amount .she had taken the pi… | 2020-09-01 |
| 74 | 74 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 609 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, review of facility investigations, and review of the Bureau of Facility Standards Long Term Care Reporting System, it was determined the facility failed to report misappropriation of a controlled medication to the State Survey Agency within 24 hours. This was true for 1 of 9 residents (#9) whose medications were reviewed. The delay in reporting created the potential for misappropriation of controlled medication to continue without detection. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. An undated summary of a facility investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented, On 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of the medication cards on (Resident #9's name) had medications taped back into the card. The investigation documented (Staff A's name) had signed out the medications to this resident and that the medications taped in did not correlate, in appearance, with what was described on the Pharmacy identification tag. The summary documented the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The Bureau of Facility Standards Long Term Care Reporting System documented the facility notified the State Survey Agency on 12/1/17 at 11:25 AM, four days after the facility knew about the misappropriation of the controlled medication by Staff #[NAME] | 2020-09-01 |
| 75 | 75 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 655 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined the facility failed to ensure a baseline care plan included the instructions needed to provide effective and person-centered care. This was true for 1 of 3 sample residents (#4) whose baseline care plans were reviewed. This deficient practice created the potential for Resident #4 to experience hyper/hypoglycemic (high/low blood sugar) events without the implementation of corrective interventions. Findings include: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including diabetes mellitus. Resident #4's 4/2/18 hospital discharge medication list and the resident's (MONTH) (YEAR) facility recapitulation of orders, documented the following medications for diabetes: * insulin [MEDICATION NAME] solution 12 units by subcutaneous injection two times a day; * insulin [MEDICATION NAME] solution per sliding scale before meals and at bedtime, notify the physician if the resident's BG was less than 60 and if the BG was greater than 500, give 12 units of insulin and notify the physician; * [MEDICATION NAME] 1 mg by intramuscular injection as needed for [DIAGNOSES REDACTED] (low blood sugar). Resident #4's care plan documented the potential for nutritional problems related to diabetes. The care plan did not include further reference or interventions related to diabetes. On 4/12/18 at 9:15 AM, the DNS provided the facility's Diabetic Protocol policy and procedure, revised (MONTH) (YEAR), which documented the following: * Call the physician if the diabetic resident has a fever, low blood pressure, lethargy or confusion, abdominal or chest pain, respiratory distress, or functional and/or mental decline. * If the BG is 0-65 and the resident is conscious and able to swallow: give juice, 2% milk or 1 pouch of glucose gel combined with a protein snack, notify the supervisor, recheck the BG in 15 minutes, repeat the intervention and BG check 15 minutes later if the BG is st… | 2020-09-01 |
| 76 | 76 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 656 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined the facility failed to implement comprehensive resident-centered care plans. This was true for 2 of 4 (#3 and #6) residents reviewed for diabetes management care plans and had the potential for harm if residents experienced hyper/hypoglycemic (high/low blood sugar) events. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses, including diabetes mellitus. An admission MDS assessment, dated 2/12/18, documented Resident #3 was cognitively intact and required extensive assistance of 1-2 staff members for cares. The care plan addressing diabetes mellitus, dated 2/20/18, documented signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. The care plan did not include instructions for staff on how to treat hypoglycemic events or hyperglycemic events. On 4/12/18 at 5:35 PM, the ADON stated the care plan should have documented staff were to follow the facility's diabetic protocol. The ADON stated the diabetic protocol was located on the nursing medication carts for all the nurses to reference. 2. Resident #6 was admitted to the facility in (YEAR) and readmitted on [DATE] with multiple diagnoses, including diabetes mellitus. The care plan addressing diabetes mellitus, dated 3/7/18, documented staff were to assess Resident #6 for signs of skin breakdown and provide diabetic medications as ordered. The care plan did not include instructions for staff on how to treat hypoglycemic or hyperglycemic events and the symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] staff were to monitor for. On 4/12/18 at 5:35 PM, the ADON stated the care plan should have documented staff were to follow the facility's diabetic protocol. | 2020-09-01 |
| 77 | 77 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 684 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and review of policies, resident records, facility investigations, it was determined the facility failed to ensure professional standards of practice for medication management were followed for 3 of 9 sample residents (#3, #8, and #9) whose medications were reviewed. Resident #8 continued to receive an IV antibiotic after she may have experienced an allergic reaction to the medication. Resident #9's narcotic medication was discontinued and not destroyed in a timely manner, which contributed to the misappropriation of Resident #9's narcotic medication. Resident #3 did not receive ordered IV antibiotic medications, placing her at risk of ineffective antibiotic therapy. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/4/18, documented Resident #8 was cognitively intact and received IV antibiotics. a. Resident #8 began a six-week treatment of [REDACTED]. The facility continued to administer [MEDICATION NAME] to Resident #8 after she experienced possible signs and symptoms of an allergic reaction to the antibiotic as follows: The care plan addressing Resident #8's septic arthritis, dated 1/29/18, documented staff members were to obtain and monitor her lab work, as ordered, and report these results to the Infectious Disease (ID) physician. The care plan documented Resident #8 was on IV [MEDICATION NAME] for the infection. Physician orders [REDACTED].#8 received daily doses of IV [MEDICATION NAME], varying from 450 mg to 500 mg, [MEDICAL CONDITION]. Resident #8's MAR indicated [REDACTED]. During this period, Progress Notes included communication from the Nurse Practitioner (NP) to nursing staff, dated 2/20/18 at 10:30 AM, Resident #8 had a bilateral rash and swelling to her lower extremities that may be related to a possible reaction to [MEDICATION NAME]. The NP documented he would re-assess the rash after the [MEDICATION N… | 2020-09-01 |
| 78 | 78 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 726 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Idaho Board of Nursing rules, and staff interview, it was determined the facility failed to ensure residents' care plans were developed and revised by licensed nurses. This was true for 3 of 9 sample residents (#1, #3, & #6) whose care plans were reviewed. The failure created the potential for harm if the residents' needs and/or wishes were not competently and comprehensively addressed in their care plans. Findings include: The Idaho Board of Nursing rules at IDAPA (Idaho Administrative Procedures Act) 23.01.01.401, state one of the functions of a Registered Nurse is to develop and document a plan for nursing intervention based on assessment, analysis of data, identified nursing [DIAGNOSES REDACTED]. The Idaho Board of Nursing rules at IDAPA 23.01.01.460, state one function of a Licensed Practical Nurse is to participate in the development and modification of the plan of care. The Idaho Board of Nursing rules at IDAPA 23.01.01.490, Unlicensed Assistive Personnel, documented, The term unlicensed assistive personnel .is used to designate unlicensed personnel employed to perform nursing care services under the direction and supervision of licensed nurses . and, unlicensed assistive personnel may complement the licensed nurse in the performance of nursing functions, but may not substitute for the licensed nurse . The rules do not allow Unlicensed Assistive Personnel to develop and document nursing care plans or make modifications to the plans. 1. Resident #6 was admitted to the facility in (YEAR) and readmitted on [DATE] with multiple diagnoses, including metabolic [MEDICAL CONDITION], dementia, altered mental status, urinary tract infection, [MEDICAL CONDITIONS] bladder, right [MEDICAL CONDITION], diabetes mellitus, [MEDICAL CONDITION], kidney disease, right eye [MEDICAL CONDITION], and hypertension. All of Resident #6's care plan Focus areas, goals, and interventions/tasks dated 3/7/18, were documented as… | 2020-09-01 |
| 79 | 79 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 755 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, facility policy review, and staff interviews, it was determined the facility failed to ensure prescription medications were available for administration to 1 of 9 residents (#8) whose medications were reviewed. This failure had the potential to compromise Resident #8's respiratory status and allow exacerbation of her [MEDICAL CONDITION] reflux disease. The facility also failed to ensure medications were secured and locked, including controlled medications. This was true for 8 of 8 bubble pack medication cards left unsecured on the counter at a nurses' station. This failure created the potential for residents, staff, and visitors to access medications not prescribed for them, including controlled medications. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/4/18, documented Resident #8 was cognitively intact and received IV antibiotics. a. Resident #8's physician orders [REDACTED]. * 40 mg [MEDICATION NAME] by mouth for [MEDICAL CONDITION] reflux disease, ordered 2/7/18, * 1 inhalation orally of 18 microgram (mcg) dose of [MEDICATION NAME] every day for asthma, ordered 1/28/18 and discontinued 3/8/18, and * 1 inhalation orally of 100-50 mcg/dose [MEDICATION NAME] every 12 hours for asthma, ordered 1/28/18 and discontinued 3/8/18. Resident #8's (MONTH) (YEAR) MAR indicated [REDACTED] * [MEDICATION NAME] was not administered on 2/9/18 at 8:00 PM and on 2/13/18 and 2/14/18 at 8:00 AM and 8:00 PM. * [MEDICATION NAME] was not administered on 2/26/18 at 7:00 AM. * [MEDICATION NAME] was not administered on 2/26/18 at 7:00 AM. A Progress Note, dated 2/9/18 at 10:34 PM, documented Resident #8's [MEDICATION NAME] was on order from the pharmacy. Two Progress Notes, dated 2/13/18 at 9:54 AM and 9:47 PM, documented Resident #8's [MEDICATION NAME] was ordered from the pharmacy during the morning shift and it had not arrived. The not… | 2020-09-01 |
| 80 | 80 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 835 | F | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and review of personnel files, a police report, and facility investigations, it was determined facility administration allowed a staff member, who was suspended from the facility for diversion of narcotics, to return to work when the administration had knowledge the staff member had misappropriated a resident's medication. This was true for 1 of 2 employees (Staff #A) whose personnel files were reviewed. The failure directly impacted 1 of 7 (#9) sample residents residing in the facility and placed the other 74 residents residing in the facility at risk of misappropriation of medications. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A Physician's verbal order, dated 11/21/17, documented Resident #9's [MEDICATION NAME] 10 mg every four hours as needed for pain was discontinued. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg. The narcotic count sheet documented Staff #A signed that she administered 16 of 16 doses between 11/14/17 and 11/20/17, before the [MEDICATION NAME] was discontinued on 11/21/17. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A continued to sign that she administered 15 of 15 doses between 11/22/17 to 11/26/17. Resident #9's narcotic count sheet for [MEDICATION NAME] documented 11 doses remaining in the bubble pack card. An undated summary of the facility's investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented that on 11/27/17 it was reported to the DNS that during an attempt to dispose of a discontinued narcotic, one of Resident #9's medication cards had medications taped back into the card. The DNS identified Staff #A as the only nurse signing the narcotic count sheet for Resident #9 and discovered the remaining 11 doses in the bubble pack card were [MEDICATION NAME], n… | 2020-09-01 |
| 81 | 81 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-04-12 | 565 | E | 1 | 1 | WTPU11 | > Based on Resident Council meeting minutes, Resident Group interview, policy review, and staff interview, it was determined the facility failed to address Resident Council concerns. This was true for 8 of 8 residents (#3, #8, #17, #26, #36, #45, #60, and #64) who participated in the Resident Group interview. The deficient practice had the potential to cause psychosocial harm for residents frustrated by the perception their concerns were not valued or addressed by the facility. Findings include: The facility's Grievance policy, revised on 1/2018, documented the facility would make prompt efforts to resolve grievances, including Resident Council concerns, and to keep residents notified of progress toward resolution. Resident Council minutes, dated 2/28/19, documented complaints of cold meals and coffee, and long wait times for response to call lights. Resident Council minutes, dated 3/28/19, documented the residents wanted follow through with the issues they talked about in the meetings and still wanted hot coffee. The facility did not document what actions were taken to resolve the concerns identified at the 2/28/19 meeting. On 4/10/19 at 10:10 AM, during the Resident Group interview, Residents #3, #8, #17, #26, #36, #45, #60, and #64 said the food concerns were not addressed, the food was still cold, and did not taste good. Residents #3, #26, #36, #45, #60, and #64 said the call light concern was not addressed and was still an issue. On 4/11/19 at 8:52 AM, the Resident Council Liaison said she emailed the Resident Council minutes and concerns to the department head so they could respond back to her. She said not all of the department heads responded back to the concerns. On 4/11/19 at 2:18 PM, the DM said she received the Resident Council minutes, attempted to fix the concerns, but did not respond to the emails or notify the Resident Council Liaison or the Resident Council of her response. On 4/11/19 at 2:44 PM, the DON said he received the Resident Council minutes, had completed call light audits due to the con… | 2020-09-01 |
| 82 | 82 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-04-12 | 585 | D | 1 | 1 | WTPU11 | > Based on record review, policy review, resident, resident representative, and staff interview, it was determined the facility failed to document, investigate, and report complaints expressed by 1 of 19 residents (Resident #227) whose complaints were reviewed. This failure created the potential for harm if residents' verbal grievances were not acted upon and residents did not receive appropriate care or were at risk for abuse or neglect. Findings include: The facility's Grievance Policy, dated 1/2018, documented residents had the right to file a grievance orally or in writing and the right to obtain a review in writing; and when a grievance was voiced to a staff member a grievance form would be completed and the grievance would be evaluated and investigated. The facility's Grievance file did not include a grievance for Resident #227. On 4/10/19 at 9:56 AM, Resident #227 and his representative stated they reported incidents to the facility staff, as well as other concerns that were medical in nature, as follows: - A nurse answered the call light and said she could not help Resident #227 but was going to get a CNA to help. The CNA never came, and Resident #227 had to sit in urine and feces for an extended period of time causing skin issues in his peri-area. - A nurse yelled at Resident #227 and chewed him out when his representative called the DON to complain about the care the nurse had given to Resident #227. The representative said she used her cell phone and a land line phone to connect the DON directly to Resident #227's room so the DON could hear the way Resident #227 was treated by a particular nurse. - Resident #227 received rough care by a CNA who had transferred him, unassisted, using a Hoyer lift (a mechanical lift). During the transfer, Resident #227 was bumped against the Hoyer lift and the foot board of the bed which caused damage to his knee, which was the site of a recent surgical procedure. Resident #227 reported the same CNA picked up his leg, jerked the stump away from his body and dropped his s… | 2020-09-01 |
| 83 | 83 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-04-12 | 657 | D | 0 | 1 | WTPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure residents' care plans were revised as needed. This was true for 1 of 21 residents (Resident #67) whose care plans were reviewed. This failure had the potential for harm if cares and/or services were not provided due to inaccurate information. Findings include: The facility's Care Planning policy, undated, directed staff to develop a comprehensive care plan for each resident and care plans were to be updated quarterly and as needed. Resident #67 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. a. Resident #67's quarterly MDS assessment, dated 3/21/19, documented she required the assistance of two staff with toilet use and transfers, and the assistance of one person with eating. Resident #67's care plan documented she required one-person assist with toilet use and transfers. The care plan was not consistent with the MDS assessment for Resident #67 which documented she required the assistance of two staff with toilet use and transfers and the assistance of one staff for eating. b. An Incident and Accident report, dated 1/21/19, documented Resident #67 had a fall and fractured her right shoulder. A hospital evaluation, dated 1/21/19, documented Resident #67 had a right shoulder fracture and directed staff to provide a sling for comfort. Resident #67's MAR, dated 1/30/19 through 3/18/19, documented a sheepskin sleeve was to be placed around the strap of the sling, in the neck area, for comfort. Resident #67's physician's progress notes, dated 2/6/19, 3/6/19, and 4/3/19, directed staff to provide a sling for her right shoulder fracture. Resident #67's care plan, documented she was at risk for falls and had a history of [REDACTED]. Resident #67's care plan did not include documentation she fractured her right shoulder and she required the use of a shoulder sling with a sheepskin sleeve over the … | 2020-09-01 |
| 84 | 84 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-04-12 | 804 | E | 0 | 1 | WTPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, review of Resident Council minutes, resident interview, Resident Group interview, test tray evaluation, and staff interview, it was determined the facility failed to ensure palatable food was served. This was true for 15 of 18 residents (#1, #3, #8, #17, #20, #26, #27, #36, #38, #41, #45, #53, #54, #60, and #64) reviewed for food and nutrition. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The facility's Food Quality and Palatability policy, revised 9/2017, documented food will be palatable and served at an appetizing temperature. Resident Council minutes, dated 2/28/19, documented complaints of cold meals and coffee. Resident Council minutes, dated 3/28/19, documented the residents wanted follow through with the issues they talked about in the meetings and still wanted hot coffee. The facility did not document what actions were taken to resolve the concerns identified at the 2/28/19 meeting. On 4/10/19 at 10:10 AM, during the Resident Group interview, Residents #3, #8, #17, #26, #36, #45, #60, and #64 said the previously mentioned food concerns were not addressed, the food was still cold, and did not taste good. Residents were interviewed regarding the food served at the facility. Examples include: * On 4/8/19 at 4:18 PM, Resident #38 stated she did not like the greasy noodles that were served by the facility. * On 4/8/19 at 4:30 PM, Resident #54 stated the facility put Mrs. Dash and garlic on everything, and the food was lukewarm 90 percent of the time. * On 4/8/19 at 4:44 PM, Resident #27 stated the chicken was pasty. She stated the only fruit the facility had were apples, canned peaches, and fruit cocktail, and they were not very flavorful. She stated she told the DM her concerns with the food, and the DM told her everyone had told her that they liked the food. * On 4/8/19 at 5:58 PM, Resident #53 stated he did n… | 2020-09-01 |
| 85 | 85 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-04-12 | 812 | F | 0 | 1 | WTPU11 | Based on observation, policy review, and staff interview, it was determined the facility failed to a) date items in the freezer and refrigerator, b) ensure staff contained all hair with a hair net, c) ensure infection control practices were implemented when gathering ice to be used to keep foods cool and d) clean and maintain the kitchen floor. These deficient practices placed 18 of 18 sample residents (#1, #2, #11, #22, #23, #26, #27, #36, #42, #43, #44, #62, #65, #67, #71, #76, #228, and #229) who dined in the facility, and the other 61 residents who dined in the facility, at risk food borne illness or other disease-causing pathogens. Findings include: The facility's food labeling and dating policy, dated (YEAR), directed staff to date food upon receipt before being stored. The policy also documented food moved from the freezer to the refrigerator for thawing was to be labeled with the removal date and a use by date. The facility's Staff Attire policy, dated 9/2017, directed staff members to have their hair off the shoulders and confined in a hair net or cap. On 4/8/19 from 4:00 to 4:30 PM, during a tour of the kitchen the following were observed: * An open half bag of brussel sprouts was in the freezer. The bag was not dated when it was opened. Five other bags of brussel sprouts were found in the refrigerator without labels or dates as to when they were moved from the freezer to the refrigerator. * DA #1 had on a baseball cap in the kitchen. The lower half of her hair was loose and hung almost to her shoulders. * A plastic pitcher was face down on top of the ice machine. DA #1 took the plastic pitcher and filled it with ice and walked across the kitchen to a plastic tub with milk and juice cartons in it and poured the ice into the plastic tub. At that time, the DM told DA #1 to use the ice scoop and not the pitcher. The DM then instructed DA #1 to place the plastic pitcher in the dish washing area. * The floor throughout the kitchen and storage areas was dirty, with grime build up along the walls, door frames,… | 2020-09-01 |
| 86 | 86 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-04-12 | 880 | E | 1 | 1 | WTPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review, and staff interview, it was determined the facility failed to implement appropriate infection control practices when assisting residents during dining and after a Hoyer lift transfer of a resident on contact precautions. This was true for 2 of 6 residents (#33 and #42) observed in the assisted dining room and 1 of 4 residents (Resident #16) in contact precaution rooms. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: The facility's Infection Control policy, dated 9/29/17, directed staff to disinfect equipment after each use for residents in contact precaution rooms. 1. Resident #16 was admitted to the facility on [DATE]. Resident #16's record included a physician's orders [REDACTED]. On 4/11/19 at 2:00 PM, CNA #2 and CNA #3 assisted Resident #16 in a Hoyer lift transfer. All staff persons in the room wore personal protective equipment during the transfer. After the task was completed, CNA #2 removed the Hoyer lift from the room and took it down the hall to the shower room. CNA #2 placed the Hoyer lift in the shower room and left the room. On 4/11/19 at 2:30 PM, CNA #2 said she did not cleaned the Hoyer lift after it was used to transfer Resident #16. CNA #2 said she should have cleaned it as the Hoyer lift could have been used for other residents. The Hoyer lift was left in the shower room for use by other staff for other residents without being properly sanitized between uses. On 4/11/19 at 3:10 PM, RN #1 said the Hoyer lift should be disinfected after each use. On 4/11/19 at 3:15 PM, LPN #2 said she thought the Hoyer lift should be cleaned before and after use with each resident. On 4/11/19 at 4:00 PM, the DON said he expected staff to clean the Hoyer lift between resident use. 2. On 4/9/19 at 12:19 PM, CNA #1 sat between Resident #33 and Resident #42 at the assisted dining table in the dini… | 2020-09-01 |
| 87 | 87 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-04-12 | 883 | D | 0 | 1 | WTPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff and resident interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine and information and education consistent with current Centers for Disease Control and Prevention recommendations. This was true for 1 of 7 residents (Resident #23) reviewed for pneumococcal immunizations. This failure created the potential for harm to residents should they acquire, transmit, or experience complications from pneumococcal pneumonia. Findings include: The Centers for Disease Control and Prevention (CDC) website, updated 11/22/16, documented recommendations for Pneumococcal vaccination (PCV 13 or Prevnar13(R), and PPSV 23 or [MEDICATION NAME](R)) for all adults [AGE] years or older: * Adults [AGE] years or older who have not previously received PCV 13, should receive a dose of PCV 13 first, followed 1 year later by a dose of PPSV 23. *If the patient already received one or more doses of PPSV 23, the dose of PCV 13 should be given at least 1 year after they received the most recent dose of PPSV 23. The facility's Immunizations policy and procedures, dated 9/2018, directed staff to minimize the risk of residents acquiring, transmitting, or experiencing complications from pneumococcal pneumonia by assuring that each resident was informed about the benefits and risks of immunizations and had the opportunity to receive, unless medically contraindicated or refused or already immunized, the pneumococcal vaccine. Resident #23 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #23's quarterly MDS assessment, dated 2/1/19, documented her cognition was intact, and her pneumococcal vaccination was up to date. Resident #23's record documented she received [MEDICATION NAME] 23 pneumococcal vaccine on 10/10/14. Resident #23's record did not include documentation she received the Prevnar 13 pneumococcal vaccine, consent, or information about the … | 2020-09-01 |
| 88 | 88 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2016-06-24 | 167 | C | 0 | 1 | X31E11 | Based on observation and visitor and staff interview, it was determined the facility failed to ensure the results of the most recent surveys were readily accessible to residents. This deficient practice was true for any resident or their representative or visitors who may want to review the survey results, including 13 of 13 sample residents (#s 1-13). Findings included: On 6/20/16 at 1:55 pm, a survey results binder was observed on the wall near the nurses' station in Hallway C. The binder contained the results of the last annual recertification survey, dated 6/13/14. The results of two complaint surveys, dated 1/27/15 and 2/11/15, were not located in the binder. On 6/21/16 at 9:10 am, the DON said he did not see the two complaint surveys in the binder. On 6/22/16 at 12:30 pm, Visitor A was observed to read the survey results, which also included the two newly placed complaint surveys. She said she had been visiting facilities and reading survey results in order to make a decision on where to find the right home for a family member. The complaint survey results were not available to Residents #1 - #13, or others who may wish to review the results. | 2020-09-01 |
| 89 | 89 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2016-06-24 | 309 | D | 0 | 1 | X31E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's hospice agreement, and staff and resident interview, it was determined the facility failed to ensure hospice communications were available for staff, and physician orders were clarified regarding catheter size and catheter balloon fill amounts. This was true for 1 of 2 (#11) residents reviewed for hospice care and 2 of 3 (#1 & #14) residents reviewed for catheters. This failure had the potential for more than minimal harm if residents did not receive appropriate services based on lack of coordination of hospice care or experienced pain due to improper catheter size or improper inflation of catheter balloons: Findings include: 1. The facility's Hospice Agreement, dated 10/1/06, stated: Documentation of Services. Both parties shall maintain appropriate documentation of services provided under this Agreement in accordance with applicable state and federal laws and regulations .Patient medical records and documentation maintained by each Party shall be available for review and inspection by the other Party . Resident #11 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #11's 10/12/15 physician's orders documented an ongoing order for hospice services. Resident #11's hospice care plan documented an intervention, dated 7/15/15 of, Work cooperatively with hospice team to ensure (Resident #11's) spiritual, emotional, intellectual, physical and social needs are met . Resident #11's clinical record did not contain hospice visit notes from 5/21/16 to 6/22/16. On 6/23/16 at 11:35 am, LN #3 said she coordinated with hospice staff when they provided services for residents on hospice. She said if she did not receive a verbal update from the hospice staff, she would review hospice nurse and CNA visit notes. On 6/23/16 at 11:40 am, the DON said the hospice notes from 5/21/16 through 6/22/16 were just received from Resident #11's hospice agency and had not been av… | 2020-09-01 |
| 90 | 90 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2016-06-24 | 431 | E | 0 | 1 | X31E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the safe and secure storage of drugs including narcotics and Schedule 2 controlled drugs in a locked storage area, and failed to permit only authorized personnel to have access to the keys. This created the potential for more than minimal harm to residents if they were to ingest the medications, and for diversion of medications by individuals present in the facility. Findings include: The medication cart on R Hall on 6/22/16 at 11:00 am, was observed to be was unattended with the keys left in the lock of the medication cart. The key to gain access to the medication cart and a separate/different key to gain access to narcotics and other controlled drugs in a locked drawer were kept on the same key ring holder. The medication cart was left in the hallway of R Hall near room [ROOM NUMBER], which was a few feet away from the R Hall doorway leading into the facility lobby. There were no residents, visitors, or staff observed in the R Hall at the time. After observing the medication cart continuously for 3 minutes, LPN #2 was observed walking at a rapid pace from the lobby to the medication cart, then removing the keys and locking the medication cart. During an interview with LN #2 on 6/22/16 at 11:05 am, LN #2 stated that she had left the medication cart to take a medication to a resident who was in the Physical Therapy/Occupational Therapy Department. LN #2 stated that she was away from the medication cart for approximately 3 minutes and that while she was in the therapy department she realized she left the keys in the lock of the medication cart when she reached into her pocket and the keys were not in her pocket. LPN #2 also stated the keys to the medication cart and the locked drawer were never to be left in the lock of the medication cart except when the nurse was pouring medications and if she had to leave the medication cart, the medication cart was to be locked and the… | 2020-09-01 |
| 91 | 91 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-08-09 | 660 | D | 1 | 0 | 1TM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received an adequate and/or updated discharge plan, timely referrals to home health services, and/or involve residents in the discharge planning process. This was true for 3 of 4 residents (#1, #3 and #4) reviewed for discharge planning. This failure created the potential for harm if residents' various discharge needs were not met. Findings include: The facility's Discharge Planning Process policy, dated (MONTH) (YEAR), documented: *Provide and document sufficient preparation to ensure a safe and orderly discharge. *Identify changes that require modification of the discharge plan.The discharge plan must be updated, as needed, to reflect these changes. *Involve the IDT, residents and resident's representative in developing the discharge plan. *Document the evaluation of the resident's discharge needs. 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including malignant neoplasm of the esophagus [MEDICAL CONDITION] (breathing tube), gastrostomy (feeding tube), and muscle weakness. Resident #3 was discharged from the facility on 5/29/18. Resident #3's discharge area of the care plan, dated 4/10/18, directed staff to: * Establish a pre-discharge plan with the resident. * Evaluate the resident's progress and revise the discharge plan. * Make arrangements with required community resources to support independence post-discharge. * Did not have a preferred home health provider. The discharge area of the care plan did not document Resident #3's needs regarding his [MEDICAL CONDITION] and PEG tube. Resident #3's Weekly Skilled Review meeting, dated 5/24/18, documented several staff attended without the resident present. The notes documented Resident #3's progress towards discharge, including his PEG (feeding tube) tube and [MEDICAL CONDITION] management status. Resident #3's Family Meeting and Social Serv… | 2020-09-01 |
| 92 | 92 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-08-09 | 661 | D | 1 | 0 | 1TM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' records contained a complete discharge summary. This was true for 2 of 2 residents (#3 and #4) reviewed who were discharge from the facility. This failure created the potential for harm and inappropriate care due to incomplete documentation related to residents' discharge. Findings include: The facility's Discharge Summary policy, dated (MONTH) (YEAR), documented a recapitulation of residents stay included diagnoses, course of illness/treatment or therapy, pertinent lab, radiology, and consultation results. The policy did not address the need to include other care areas listed on the resident's most recent comprehensive assessment. 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including malignant neoplasm of the esophagus [MEDICAL CONDITION] (breathing tube), gastrostomy (feeding tube), and muscle weakness. Resident #3 was discharged from the facility on 5/29/18. Resident #3's Weekly Skilled Review meeting, dated 5/24/18, documented several staff attended without the resident present. The notes documented Resident #3's progress towards discharge, including his PEG tube and [MEDICAL CONDITION] management status. Resident #3's Family Meeting and Social Service notes, dated 5/25/18, documented he and a family member were present. The notes documented Resident #3 wanted to discharge from the facility and agreed to be discharge on 5/29/18, after he was able to independently manage his [MEDICAL CONDITION] and PEG tube. Resident #3's Social Service notes, dated 5/29/18, documented, Resident approached discharge planner multiple times throughout the day to discuss discharge .Discharge orders were obtained and reviewed with resident .referral was sent to (Local Home Health Agency). Discharge planner stated it could take a few days for services to begin but resident could expedite process by contactin… | 2020-09-01 |
| 93 | 93 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-10-03 | 551 | D | 1 | 0 | 4YWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined the facility failed to ensure a resident's rights were not delegated to an unauthorized person for 1 of 8 residents (Resident #3) whose records were reviewed. This resulted in the potential for a resident's rights to be violated. The findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/12/19, documented Resident #3's BIMS score was 12, indicating she had mild cognitive impairment. The assessment also documented Resident #3 had the ability to express ideas and wants, she had clear comprehension, and she had the ability to understand others. An Advance Beneficiary Notice of Non-coverage (ABN), dated 7/8/19, documented Resident #3 had reached her maximum level of potential with her Physical and Occupational therapies and would benefit from restorative nursing. The ABN stated, Talked on phone to POA (Power of Attorney) (name of daughter) on 7/8/19 at 2:30 p.m. and is in agreement with plan. Resident #3's Face Sheet, dated 8/2/18, listed her daughter as an emergency contact, not PO[NAME] Resident #3's record included a document which stated her end of life treatment wishes and was signed by Resident #3 and dated 12/5/87. The document included a section to designate a representative for Resident #3 if she was unable to make her own decisions, which was left blank. On 10/3/19 at 7:25 AM, the DON was asked whether Resident #3 had a PO[NAME] The DON stated the facility was trying to figure it out. The facility failed to ensure Resident #3's rights were not delegated to an unauthorized person. | 2020-09-01 |
| 94 | 94 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-10-03 | 559 | D | 1 | 0 | 4YWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined the facility failed to ensure residents received a written notice prior to a change in their room for 1 of 1 resident (Resident #3) who was reviewed for a room change. This resulted in a lack of information being provided to a resident necessary to make an informed decision. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/12/19, documented Resident #3's BIMS score was 12, indicating she had a mild cognitive impairment. The assessment also documented Resident #3 had the ability to express ideas and wants, she had clear comprehension, and she had the ability to understand others. Resident #3's record included an untitled document, dated 9/1/19, which stated Resident #3 was moved to a different hall and room that day. The comments section of the document stated DON requested due to Resident altercation. Family notified & patient agreed. An investigation report, dated 9/6/19, included a statement from an RN about an incident which occurred on 9/1/19. The RN statement documented (Resident #3) was moved into a different room on another hall around 10am (sic). (Resident #3) is confused as to what is going on and where her new room is. On 10/3/19 at 7:25 AM, the DON stated there was no additional information related to Resident #3's room change. The facility failed to ensure Resident #3 received a written notice prior to her room change. | 2020-09-01 |
| 95 | 95 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-10-03 | 578 | D | 1 | 0 | 4YWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined the facility failed to ensure a resident's advance directives were recognized and her physician's orders [REDACTED].#3) whose advance directives were reviewed. This resulted in the potential for a resident's choices for end of life treatment not being honored. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's record included a document which stated her end of life treatment wishes and was signed by Resident #3 and dated 12/5/87. The document stated Resident #3 did not want electrical or mechanical resuscitation if her heart stopped beating, naso-gastric tube feeding if she was unable to take nourishment by mouth, mechanical respirations if she was unable to sustain breathing, and if she was declared brain dead, she did not want mechanical means to prolong her life. Resident #3's current Physician order [REDACTED]. On 10/3/19 at 7:25 AM, the DON was asked about Resident #3's code status. The DON stated the facility was trying to figure it out. The facility failed to ensure Resident #3's advance directives were honored. | 2020-09-01 |
| 96 | 96 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-10-03 | 657 | D | 1 | 0 | 4YWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident care plans were appropriately revised for 2 of 8 residents (#1 and #3) whose care plans were reviewed. This failure had the potential for residents to not receive care and services which met their needs. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/12/19, documented Resident #3's BIMS score was 12, indicating she had a mild cognitive impairment. The MDS documented Resident #3 had no behaviors. An investigation, dated 9/6/19, stated on 9/1/19 at 3:00 AM, Resident #5 reported to a CNA on duty Resident #3 was yelling out and he (Resident #5) went into Resident #3's room and found her without covers. The investigation stated Resident #5 replaced the covers on Resident #3 and then reported it to the CN[NAME] The investigation included 3 statements from residents, dated 9/1/19, whose rooms were near Resident #3. The statements documented the following: - One resident (Room B21) statement documented Resident reported he is often awake at night and can hear (Resident #3) yell out frequently throughout the night. Resident stated she (Resident #3) often repeats 'help me, help me.' - The second resident (Room B18) statement documented Resident stated her neighbor (Resident #3), often yells at night and will often yell 'help me, help me.' Resident stated she and (Resident #5) have visited with this resident (Resident #3) at night to help calm her down. - The third resident (Room B23) statement documented Resident stated there is a resident (Resident #3) who calls out throughout the night. Resident stated .she yells out for a long time. Resident #3's care plan did not include a care area or interventions related to nighttime behaviors. On 10/3/19 at 7:25 AM, the DON stated Resident #3's care plan did not address nighttime behaviors and no concerns wer… | 2020-09-01 |
| 97 | 97 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-10-03 | 684 | D | 1 | 0 | 4YWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, it was determined the facility failed to ensure a resident's care plan was implemented for 1 of 8 residents (Resident #3) whose care plans were reviewed. This resulted in a resident not consuming most of her lunch meal. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's care plan related to eating, dated 2/27/19, stated Resident #3 was to be provided with frequent cueing to eat as much as possible of her meals. Resident #3 was oserved eating lunch on 10/2/19 from 12:15 PM to 12:40 PM. The lunch consisted of a tuna salad sandwich, pasta salad, water, juice, and ice cream. At 12:20 PM, Resident #3 was sitting at the table in the dining room for lunch service. She picked up her tuna salad sandwich. As she was moving the sandwich to her mouth, the contents of the sandwich fell on to her clothing protector. Resident #3 appeared to be unaware that the tuna salad had fallen from the sandwich and she proceeded to eat the bread. Resident #3 then placed her bowl of pasta salad on her plate and a styrofoam container of ice cream on her plate. Resident #3 picked up both her fork and spoon and held them in her right hand, the utensils were held in a crisscrossed position. She then used her fork, which was upside down, to scoop ice cream from the cup. Resident #3 was noted to obtain approximately 1/2 teaspoon of ice cream on her fork and eat it. She repeated this a second time. On the third scoop, 2 tines of the fork became inserted and stuck into the side of the styrofoam cup. Resident #3 let go of the fork and it remained stuck in the side of the cup. Resident #3 then used her spoon and retrieved a large scoop of ice cream. As she lifted the spoon to her mouth, the ice cream fell on to her lap. Resident #3 retrieved a second scoop of ice cream from the cup and as she lifted the spoon to her mouth, the ice cream fell on to her lap. At 12… | 2020-09-01 |
| 98 | 98 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2017-10-13 | 157 | D | 0 | 1 | 247411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, it was determined the facility failed to ensure a resident's physician was notified of significant changes in the resident's clinical condition. This was true for 1 of 17 (#2) sample residents and had the potential for more than minimal harm when the facility failed to notify Resident #2's physician of the resident's low blood sugar readings. Findings include: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's diabetes mellitus care plan documented Monitor/document/report to MD (Medical Doctor) PRN (as needed) signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar). Resident #2's 10/2/17 Order Summary Report documented Humalog (Insulin [MEDICATION NAME]): .If BG (blood glucose) is 70 or below notify MD. Resident #2's 8/1-8/31/17 Medication Administration Record [REDACTED]. Resident #2's 9/1-9/30/17 MAR indicated [REDACTED]. Resident #2's 10/1/17-10/31/17 Medication Administration Record [REDACTED]. On 10/12/17 at 1:05 pm, Resident #2 said he did not notice any symptoms when his blood glucose was low. He did not know if his physician was notified when this occurred. On 10/13/17 at 9:24 am the DON (Director of Nursing) said there was no documentation Resident #2's physician was notified, he did not recall if the physician was notified. The DON stated the nurse should follow physician's orders [REDACTED]. | 2020-09-01 |
| 99 | 99 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2017-10-13 | 164 | D | 0 | 1 | 247411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure a resident's privacy during peri care (cleaning between the resident's legs.) This was true for 1 of 17 sample residents (#4). This deficient practice created the potential for harm should Resident #4 become embarrassed if others observed her receiving peri care and her exposed body was seen by others. Findings include: Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] and 7/3/17 with [DIAGNOSES REDACTED]. On 10/11/17 at 4:55 pm, Resident #4 was lying in bed and CNA (Certified Nursing Assistant) #3 entered the resident's room. CNA #3 told the resident she was going to change her disposable briefs and pulled the privacy curtain between the bed and the door. The window blinds were in the open position on the other side of the resident's bed. It was possible to see through the resident's window into a grassy courtyard with a bench facing towards the resident's window. The Courtyard was an open area for staff, visitors, and residents to walk around and sit on the bench. CNA #3 proceeded to pull down Resident #4's pants to her knees, exposing the abdomen, disposable brief, and upper legs. When asked if the resident's privacy was protected, CNA #3 looked at the window and said she should have closed the blinds. | 2020-09-01 |
| 100 | 100 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2017-10-13 | 241 | D | 0 | 1 | 247411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, it was determined the facility failed to ensure residents were treated with dignity and respect during their dining experience when staff stood over a resident while assisting the resident to eat. This was true for 1 of 17 sample residents (#7) and created the potential for harm if residents' sense of self-worth or self-esteem was negatively affected. Findings include: Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #7's 9/8/17 quarterly (Minimum Data Set) assessment documented severe cognitive impairment, and supervision was required for eating. On 10/12/17 at 12:35 pm, CNA (Certified Nursing Assistant) #4 was observed feeding Resident #7 in his room as he sat up in bed. CNA #4 stood on the left side of the resident as she fed him. The resident occasionally opened his eyes to verbal stimuli as CNA #4 fed him a sandwich and potato and assisted him to drink water. On 10/12/17 at 12:45 pm, when asked about how to ensure the resident is treated with respect and dignity during meals, CNA #4 said she should have been sitting down as she fed the resident and she forgot. | 2020-09-01 |
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CREATE TABLE [cms_ID] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );