Cascades at Desert View

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, it was determined the facility failed to ensure that residents' drinking water was within their reach. This was true for 1 of 1 resident (Resident #28) reviewed for accommodation of needs. This deficient practice had the potential for residents to experience urinary tract infection, confusion and other health conditions if they were not able to maintain their hydration. Findings include:Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia (partial or total loss of motor and sensory function in all four limbs) and diabetes.Resident #28 was observed in bed on the following days 5/11/26 at 2:50 PM, 5/12/26 at 3:59 PM, and 5/13/26 at 9:55 AM, lying in bed and watching the television. Drinking water was observed on top of his bedside table located on his right side by the head of his bed. Resident #28 was observed moving his left hand. There was no movement noted on Resident #28's arms. The drinking water was not within Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 provide the Notice of Medicare Non-Coverage (NOMNC CMS-10123) within the CMS required timeframe to 1 of 3 residents (Resident #19) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended. Findings include:The facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices policy dated 9/22, documented if the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form 10123) is issued to the resident at least two calendar days before benefits end.Resident #19 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a critical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and policy review, and interview, it was determined the facility failed to ensure residents were monitored for the adverse effects of their psychotropic and opioid medications. This was true for 1 of 5 residents (Resident #43) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents experienced side effects of the medication and were undetected due to lack of appropriate monitoring. Findings include: The facility's Pain Assessment and Management policy, dated 7/2022, Implementing Pain Management Strategies section 4, stated, when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose.The facility's Psychotropic Medication Use policy, dated 7/2022, Policy Interpretation and Implementation, section 13, stated, Residents receiving psychotropic medications are monitored for adverse consequences including: a. anticholinergics effects, flushing, blurred vision, dry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 1) ensure residents who were discharged home were provided with the necessary discharge information to ensure a smooth and safe transition of care. This was true for 1 of 1 resident (Resident #3) whose record was reviewed for planned discharge and 2) provide hospital transfer documents for 1 of 3 residents (Resident #5) whose records were reviewed for hospitalization. This deficient practice created the potential for residents to experience harm if they were not treated in a timely manner due to lack of information. Findings include: The facility's Transfer or Discharge policy date 10/2022, under Orientation for Transfer or Discharge (planned) documented, A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review and staff interview, it was determined the facility failed to ensure a resident with positive PASARR Level 1 screening for mental illness was referred for further evaluation to the appropriate state-designated authority. This was true for 1 of 2 residents (Resident #5) whose PASARR I was reviewed. This deficient practice created the potential for harm if residents required but did not receive specialized services for mental health while residing in the facility. Findings include:The facility's Resident Assessments PASRR Screening Coordination policy dated 4/2025, documented the facility would refer to the appropriate state-designated authority any resident with newly evident or possible serious mental disorder, intellectual disability or related condition.Resident #5 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including schizoaffective disorder, bipolar type, dysphagia (difficulty swallowing), and hypotension.A PASRR Level 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 1 of 3 residents (Resident #44) reviewed for baseline care plan. This failure created the potential for harm when the care plan failed to provide direction for care. Findings include:The facility's Care Plans - Baseline policy dated March 2024, documented a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including unstageable pressure ulcer and severe sepsis (a life-threatening medical emergency occurring when an infection causes an overwhelming immune response, resulting in dysfunction or damage to one or more vital organs).Resident #44's baseline care plan was initiated on 9/16/25, and was not completed or signed until 9/22/25, six days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included the use of splint and RNA program of a resident. This was true for 1 of 14 residents (Resident #5) whose care plans were reviewed. This deficient practice created the potential for residents to receive inadequate or inappropriate care due to missing information in their care plan. Findings include:The facility's Care Plans Comprehensive Person-Centered policy revised 3/2022, documented the care plan Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident #5 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including quadriplegia (partial or total loss of motor and sensory function in all four limbs), schizoaffective disorder, bipolar type, dysphagia (difficulty swallowing), and hypotension.Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, record review, and interview, it was determined the facility failed to ensure residents' comprehensive care plans were revised timely and as needed. This was true for 1 of 14 residents (Resident #5) whose care plans were reviewed. This deficient practice created the potential for residents to receive inappropriate care due to inaccurate information in their care plans. Finding include:The facility's Care Plans, Comprehensive Person-Centered policy revised March 2022, documented assessments of residents were ongoing and care plans were revised as information about the residents and the residents' condition changeResident #5 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including quadriplegia (partial or total loss of motor and sensory function in all four limbs), schizoaffective disorder, bipolar type, dysphagia (difficulty swallowing), and hypotension.A care plan initiated 12/2/25, documented Resident #5 used assistive devices halo bars…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Advair website, record review, and staff interview, it was determined the facility failed to ensure medication was administered according to professional standards of practice. This was true for 2 of 5 residents (#18 and #31) observed during medication administration. This created the potential for residents to develop yeast infection when they did not rinse their mouth with water after taking their inhaler medication. Findings include:The Advair website accessed on 5/19/26, documented after inhalation the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis (a fungal infection caused by an overgrowth of Candida [yeast]).1.Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including asthma and acute and chronic respiratory failure with hypoxia (low levels of oxygen in the blood).A physician' order dated 2/23/26, documented Resident #31 was to receive Advair HFA Aerosol 115-21 mcg/act (Fluticasone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents received treatment and services to prevent further decrease in range of motion (ROM). This was true for 3 of 3 residents (#5, #27 and #28) reviewed for treatment and services related to ROM. This failed practice placed residents at risk of harm when they did not receive their restorative program as care planned to prevent further deterioration of their existing ROM limitations. Findings include:The facility's Restorative Nursing Services policy revised 2024, documented that residents would receive restorative nursing care as needed to help promote safety and independence. 1. Resident #5 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including quadriplegia (partial or total loss of motor and sensory function in all four limbs), schizoaffective disorder, bipolar type, dysphagia (difficulty swallowing), and hypotension. On 5/11/26 at 10:52 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 5 residents (#10 and #18) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include:1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including multiple rib fractures and kidney failure.On 5/11/26 at 1:55 PM, observed Resident #10 lying in his bed awake, getting oxygen via nasal cannula at 4 LPM.On 5/11/26 at 3:02 PM, Resident #10's physician oxygen order documented oxygen at 2 L/min via nasal cannula while sleeping.Resident #10's care plan documented he has oxygen therapy r/t nocturnal hypoxia. Oxygen use as needed and ordered, check Room air saturations as ordered, wean as able/ordered On 5/13/26 at 3:42 PM, the CRN stated Resident #10's oxygen should have been set at 2 LPM and was not. 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, policy review, and interviews, it was determined the facility failed to ensure residents' identifiable information was not accessible to the public. This was true for 1 of 1 resident (Resident #16) whose care plan was found to be in the Resident Council Meeting minutes. This deficient practice created the potential for residents to experience psychosocial harm due to loss of dignity and emotional distress. Findings include: The facility's policy titled Protected Health Information Uses and Disclosures of, dated 2001, policy stated, Protected health information will not be used or disclosed except as permitted by law. On 5/12/26 at 4:10 PM, the Resident Council Meeting minutes were reviewed. The Resident Council Meeting minutes included Resident #16's partial care plan with the focus on behavior goals and interventions, and a nursing department note with medical information about his feet, medication, and treatment refusals.On 5/12/26 at 4:18 PM, the Administer stated the Resident Council Meeting minutes binder was available to the public when they asked for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility's sanitation policy, the facility failed to ensure: A) dishwasher temperatures were maintained to ensure proper sanitation of dishware, B) fire sprinklers and alarms were maintained in clean and sanitary condition, and C) food was stored in an unsanitary manner. These failures created the potential for cross-contamination and adverse health outcomes, including foodborne illness. Findings include:The facility's sanitation policy, revised May 2024, documented that all kitchen and dining areas must be kept clean, free from garbage and debris, and protected from rodents and insects. It also documented that the low-temperature dishwasher must maintain a wash cycle temperature of 120 F, rinse with 50 parts per million hypochlorite on dish surfaces, and that chemical concentrations must be tested on ce per shift.1. On 10/24/25 at 7:10 AM, the Certified Dietary Manager (CDM) was observed washing kitchen utensils and placing them in storage. During the second cycle, the dishwasher reached only 100 F during the wash cycle.A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure their pest control program was effective in the kitchen. This failure impacted the 33 residents residing in the facility who ate food prepared in the facility's kitchen. The cockroach infestation created the potential for harm. Finding include:On 10/23/25 at 10:12 PM the kitchen of the facility was observed, the kitchen door was not locked, when the door was opened, a cockroach was observed scurrying from under the dishwashing area toward the ice machine. There was a strong chemical odor in the kitchen. Parts of the kitchen were draped in thin plastic sheathing, and the floor was noted to be damp in areas. A cockroach was observed on its back flailing it's legs in the walkway between the food service tray line and the coffee preparation area. Brown, coffee ground like droppings were observed behind kitchen equipment on a countertop. Live cockroaches were observed crawling on the floor, in kitchen cabinets and drawers, on packaged food products, and under the oven. Dead…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 a) ensure resident care plans were revised to reflect current needs and interventions and b) ensure residents and their representatives were encouraged to participate in care planning and attend care conferences. This was true for 4 of 16 residents (Resident #8, #11, #21, and #27) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed. Findings include. The facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, documented assessments of residents are ongoing, and care plans are revised as information about the resident and resident condition changes. 1. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including surgical aftercare, Alzheimer's disease with early onset, and dementia. Resident #8's care plan revised 3/13/25, documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to provide a minimum of 12 hours of in-service education per year for 2 of 2 CNAs (#2 and #3) reviewed for sufficient and competent CNA staffing. This failure placed residents at risk of receiving care from staff who are not adequately trained to meet residents' needs. Findings include: 1. On 4/3/25 at 12:46 PM, review of CNA #2's employee file documented her hire date was 3/22/19. Review of CNA #2's Employee In-service Hours form documented she had 9.5-hours of in-service time for 2024. Review of CNA #2's Employee In-service Hours form documented she had completed two in-services for 2025. No time was documented for the two in-services. CNA #2's employee file did not document that she had completed 12-hours of in-services for the 2024/2025 evaluation period. 2. On 4/3/25 at 1:50 PM, review of CNA #3's employee file documented her hire date was 1/13/10. Review of CNA #3's Employee In-service Hours form documented she had 4 hours of in-service time documented for 2024. CNA #3's Employee In-service Hours form documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 informed consent was obtained prior to initiation of psychotropic medications for 1 of 16 residents (Resident #8) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including surgical aftercare, Alzheimer's disease with early onset, and dementia. On 12/31/24, a physician order documented Resident #8 was to start Seroquel (an antipsychotic medication that affects brain activities associated with mental processes) 25 mg one time a day for dementia with behavioral disturbance. On 1/29/25, the Pharmacist documented It would be suggested to assess the risks versus benefits for continued use of Quetiapine (generic Seroquel) 25 mg at bedtime…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility whose environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified and b) residents were injured due to unsafe areas in the facility. Findings include: The facility Maintenance policy revised December 2009, documented the function of the maintenance personnel was to maintain the building in good repair and free from hazards. On 3/31/25 at 11:20 AM, observed a thick layer of dust and dirt on the ceiling air exchange vent in the North hallway. On 3/31/25 at 1:58 PM, observed the floor by the copy room with a 7-inch by ¾- inch area missing tiles. On 4/1/25 at 1:54 PM, observed the floor in the main dining room, in front of the counter with condiments a 2-inch by 1/3-inch piece of flooring sticking up. On 4/1/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 the MDS assessment accurately reflected resident's status. This was true for 1 of 16 residents (Resident #6) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: Resident #6 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including heart failure and diabetes. Resident #6's Physician order dated 5/29/24, documented Level of Care: Hospice. Resident #6's care plan dated 8/29/24, documented Resident #6 had a terminal prognosis and was on hospice. Resident #6's Quarterly MDS dated [DATE], documented under section O, K1. Hospice No. Resident #6's Quarterly MDS dated [DATE], documented under section O, K1. Hospice No. On 4/2/25 at 9:54 AM, the DON stated Resident #6 was on hospice and she did not know why his MDS did not reflect that.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to refer residents with an exempted hospital stay and have a diagnosed mental disorder to the appropriate state-designated authority for a re-evaluation and determination. This was true for 1 of 3 residents (Resident #8), reviewed for PASRR level II evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including surgical aftercare, Alzheimer's disease with early onset, and Major Depressive Disorder. On 11/25/24, a BLTC Medicaid reviewer documented on Resident #8's PASRR Level II 30-day exemption rehabilitation. If the participant stays (30 days) past admission, please submit most current MDS, MD orders, social notes, and psych info to BLTC. If discharged , please notify BLTC. Review of Resident #8's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 professional standards of nursing practice were followed for 1 of 17 residents (Resident #28) reviewed for quality of care. Resident #28 was at risk for adverse outcomes when her physician order was not written correctly. This failed practice had the potential to adversely affect residents whose care and services were not followed according to accepted standards of practice. Findings include: Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including peripheral vascular disease (when the arteries become narrow or blocked, reducing blood flow to the affected areas) and left leg, above the knee amputation. On 3/31/25 at 10:41 AM, observed Resident #28's right lower extremity with a Tubigrip stocking (a tubular elastic bandage used to provide tissue support and compression). Her left lower leg had been amputated. Resident #28's Physician order dated 11/19/24, documented, Tubigrip to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interview, the facility failed to ensure interventions were put in place and followed to prevent additional falls for 2 of 16 residents (#1 and #6) reviewed for falls. This failure increased the potential for additional falls and potential injury for residents with a history of falls. Findings include: 1. Resident #1 was initially admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses including cerebral infarction (when blood flow to the brain is blocked, causing tissue death to the brain) and traumatic brain injury. Review of the facility's Incident and Accident reports dated 6/22/24, documented the staff were transferring Resident #1 to the bed when his knees buckled, and he was lowered to the ground. Review of the facility's Incident and Accident reports dated 2/10/25, documented NA #1 was transferring Resident #1 to the bed, when his legs buckled, and she lowered him to the ground. Review of Resident #1's care plan did not document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 4/1/25 at 1:55 PM, during North hall medication cart audit, observed the narcotic accountability record, dated 3/2/25 to 4/1/25, with one licensed nurse signature not documented. On 4/1/25 at 1:57 PM, LPN #1 stated the nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure the attending physician acted upon Pharmacy recommendations for 1 of 16 residents, (Resident #8) whose medication regimens were reviewed for psychotropic medication. This deficient practice placed residents with dementia at an increased risk of death. Findings include: The facility's Medication Regimen Review Policy dated April 2024, documented the attending physician is to document in the medical record any medication irregularity and what, (if any) action was taken to address it. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including surgical aftercare, Alzheimer's disease with early onset, and dementia. On 12/31/24, a physician order documented Resident #8 was to start Seroquel (a medication that affects brain activities associated with mental processes) 25 mg one time a day for dementia with behavioral disturbances. On 1/29/25, the Pharmacist documented on the MRR report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the FDA Black Box Warning, record review, and staff interview, the facility failed to ensure the medical necessity for psychotropic medication administration. This was true for 1 of 16 residents (Resident #8) reviewed for unnecessary medications. This failure created an increased risk of mortality when residents diagnosed with dementia were prescribed antipsychotic medications. Findings include: The FDA documented elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel (an antipsychotic drug) is not approved for elderly patients with dementia related psychosis. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including surgical aftercare, Alzheimer's disease with early onset, and dementia. On 12/31/24, a physician order documented Resident #8 was to start Seroquel 25 mg one time a day for dementia with behavioral disturbance. On 2/28/25, the Pharmacist documented on the MRR report to the attending…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 medications (5.41% error rate) which affected 1 of 3 residents (Resident #142) whose medication administrations were observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication. Findings include: The following was observed during the medication pass: Resident #142's physician order documented insulin sliding scale; administer Lantus insulin, 10 Units subcutaneously and Lispro insulin, 2 Units subcutaneously. On 4/2/25 at 7:35 AM, observed LPN #1 remove Lantus insulin pen from the medication cart and dial the Lantus insulin pen to 1 Unit to prime and then dialed to 10 Units as ordered. On 4/2/25 at 7:36 AM, observed LPN #1 remove Lispro insulin pen from the medication cart and dial the Lispro insulin pen to 1 Unit to prime then dialed to 2 Units as ordered. LPN #1 did not prime the insulin pens with the required 2 Units of insulin before dialing the ordered dose.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined the facility failed to ensure controlled medications were stored and kept secure from potential theft and/or diversion. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 4/1/25 at 1:37 PM, observed bottle of lorazepam liquid (Schedule IV controlled medication) stored in the medication refrigerator door rack. On 4/1/25 at 1:48 PM, RN #1 stated the medication refrigerator and the medication room door is locked. She stated there is no other locked, permanently affixed, compartment inside the medication refrigerator for controlled medications.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of the Idaho Food Code, it was determined the facility failed to ensure food was stored properly, dated when opened, equipment was stored in a sanitary condition, and ensure infection control protocol was followed during meal tray delivery. This deficient practice had the potential to affect all 39 residents who received meals prepared in the facility's kitchen. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-eat, Time/Temperature Control for Safety Food, Date Marking . held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . The NSF Machine Operational Requirements for the dishwasher documented: Wash temperature recommended 120 degrees Fahrenheit, minimum 120 degrees Fahrenheit. Rinse temperature recommended 140 degrees Fahrenheit, minimum 120 degrees Fahrenheit. Required 50 PPM Available Chlorine. 1. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform proper hand hygiene. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The following was observed for hand hygiene: On 3/31/25 at 11:55 AM, observed 12 residents served their meal in the dining room. Hand hygiene was not offered or performed for the residents prior to receiving their meal. On 3/31/25 at 12: 06 PM, observed RN #1 serve 3 residents their meal to them in their room. Hand hygiene was not offered or performed for the residents. On 3/31/25 at 12:36 PM, CNA #1 stated they usually wash the resident's hands with wash clothes before and after they eat but today, they did not, and they should have. On 4/3/25 at 12:11 PM, IP stated the residents should be offered hand hygiene before meals, in the dining room and in their rooms.

Based on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 39 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 3-305.11(A) documented food should be protected from contamination and stored in a clean, dry location where it was not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. On 5/30/24 at 3:45 PM, during an inspection of the dry food pantry, the following was observed: - The bottom shelves were measured at 4.25 inches. Individual bags of potato chips, tortilla chips, paper goods, single use cups, and plastic silverware were stored on the bottom shelves. - A layer of dust was observed on one of the upper shelves where a television was placed above an active…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 3 of 12 residents (Resident #6, #36, and #38) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. Findings include: The facility's Residents' Rights Regarding Treatment and Advanced Directives policy, revised September 2022, documented on admission the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. Should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff. Any decision-making regarding resident's choices will be documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 2 of 6 residents (#6 and #30) reviewed for transfer. 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. Findings include: The facility's Transfer or Discharge policy, dated October 2022, documented the Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. The following resident records did not include documentation the resident or their representative was provided a Notice of Facility Bed-Hold: a. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy (a chemical imbalance in the blood that damages the brain) and hypertension. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact 1 of 1 resident (Resident #38) reviewed for catheter care, by placing him at risk for cross-contamination and infection. Findings include: The facility Catheter Care, Urinary policy, revised February 2024, directed staff to be sure the catheter tubing and drainage bag are kept off the floor. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a chronic disease of the central nervous system) and adult failure to thrive (general decline in health in older adults). On 5/28/24 at 11:38 AM, Resident #38 was observed lying in his bed and his foley catheter (a semi-flexible plastic tube inserted into the bladder and the other end is attached to a bag that collects urine--used when a person cannot urinate normally)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital. This was true for 2 of 6 residents (#6 and #30) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include: The facility's Transfer or Discharge policy, dated October 2022, documented should a resident be transferred or discharged for any reason: A. The following information is communicated to the receiving facility or provider: -The basis for the transfer or discharge -Contact information of the practitioner responsible for the care of the resident -Resident representative information including contact information -Advanced directive information -All special instructions or precautions for ongoing care, as appropriate -Comprehensive care plan goals -All other information necessary to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 appropriate assessments for assistive devices were completed for 2 of 2 residents (#1 and #38). This deficiency created the potential for injury if the residents were not assessed and monitored appropriately. Findings include: The HALO Safety Ring Instructions, undated, included a warning, ENTRAPMENT MAY OCCUR. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. (A HALO Safety Ring is a bed mobility device that increases environmental independence, prevents mattress movement, and is considered a type of bed rail.) 1. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including a traumatic brain injury, spastic hemiplegia of his nondominant side (a condition that causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body), muscle weakness, and a history of falls. On 5/28/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 residents', PASARR Level I (Preadmission Screening and Resident Review) had correct information and if residents' PASARR Level I indicated the resident had been identified with possible indicators of mental illness and required further screening, a PASARR Level II was to be completed. This was true for 2 of 2 residents (#6 and #30) whose PASARR records were reviewed. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to lack of screening. Findings include: The facility's Behavioral Assessment, Intervention and Monitoring policy, revised February 2024, documented if the PASARR Level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability, or related condition, he or she will be referred to the state PASARR representative for the Level II (evaluation and determination)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and staff interview, it was determined the facility failed to ensure respiratory equipment was changed as indicated. This was true for 1 of 4 residents (Resident #7) reviewed for respirator care. This created the potential for respiratory infections due to growth of pathogens (organisms that cause illness) in respiratory treatment equipment. Findings include: Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and kidney disease. A quarterly MDS assessment, dated 5/9/24, documented Resident #7 had severe cognitive impairment and received oxygen therapy. A physician's order, dated 4/1/24, directed staff to change Resident #7's oxygen tubing and humidifier and clean concentrator filter, twice a month, on the 1st and the 15th, during the night shift. On 5/28/24 at 12:42 PM, Resident #7 's concentrator humidifier (container of water attached…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 informed consent was given by the resident or their representative for the use of bed rails. This was true for 2 of 2 residents (#1 and #38) reviewed for having bed rails. This failure created the potential for harm when the resident did not understand the risks associated with the use of bed rails. Findings include: The facility was unable to provide the policy and procedure for the use of assistive devices and the requirement of obtaining informed consent prior to the use of assisted devices. The facility stated they followed the manufacturer's HALO Safety Ring Instructions for installation. 1. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including a traumatic brain injury and spastic hemiplegia of his nondominant side (a condition that causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body), muscle weakness, and a history of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine. This was true for 1 of 5 residents (Resident #20) whose records were reviewed for pneumococcal vaccinations. This failure created the potential for residents to have an increased risk of pneumococcal (bacterial) pneumonia and the potential for severe illness or death. Findings include: The Centers for Disease Control and Prevention (CDC) website, dated 9/22/23, and accessed on 6/4/24, included recommendations for pneumococcal vaccinations for all adults 65 years or older as follows: - If you never received any pneumococcal vaccine, the CDC recommends receiving one dose of PCV20 or PCV15. - If you have previously received PCV13 at any age and PPSV23 at less than [AGE] years of age, the CDC recommends receiving PCV20 at least five years after administration of PCV13 or PPSV23. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses including paranoid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 regularly inspect bed rails to identify areas of possible entrapment. This was true for 2 of 2 residents (#1 and #38) who were reviewed for the use of bed rails. This failure created the potential for injury or harm if a resident was to become trapped by unmonitored equipment. Findings include: The HALO Safety Ring Instructions, undated, included, Regularly check the HALO device to identify areas of possible entrapment, immediately cease using the bed until entrapment risk is fixed. 1. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including a traumatic brain injury and spastic hemiplegia of his nondominant side (a condition that causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body), muscle weakness, and a history of falls. On 5/28/24 at 1:00 PM, Resident #1 was observed with an assistive device called a HALO safety ring attached to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of grievance logs, and resident and staff interviews, it was determined the facility failed to ensure all call lights were functioning. This was true for 2 of 2 residents (#7 and #30) reviewed for call lights. This had the potential for harm if residents were unable to summon staff assistance by activating the call light. Findings include: The facility's Call System, Resident policy, dated September 2022, documented residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. 1. Resident #7 was originally admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and kidney disease. Resident #7's care plan, revised 2/3/24, directed staff to provide a safe environment: call light in reach and answer call light promptly. A quarterly MDS assessment, dated 5/9/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.