Life Care Center of Idaho Falls

Based on record review, staff interview, and policy review 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 2 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: The facility's Inventory Control of Controlled Substances policy, revision date 08/01/24, documented.1. Procedure 1.1 Facility should ensure the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift.and document the results on a Controlled Substance Count Verification/Shift Change Sheet. 2. Facility should ensure facility staff count all Schedule III-IV controlled substances in accordance with facility policy and applicable law. On 3/18/26 at 8:17 AM, observed during the Hall 2 medication cart audit, the Narcotic Card Item…

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 policy review, record review, and staff interview, it was determined the facility failed to ensure residents were assessed appropriately for adequate indications for the use of opioid pain medications. This was true for 1 of 4 residents (Resident #74) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse consequences or increased risk of death. Findings include:The facility's Pain Management policy dated 12/2/25, documented the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Assess pain every shift and record on eMAR. Always indicate which pain scale was used and document the type of pain the resident is experiencing. Resident #74's physician order for medication for mild pain documented Acetaminophen Tablet 325 MG, give 2 tablets by mouth every 8 hours as needed for mild acute pain for 30 Days, not to exceed 3000 mg/day.Resident #74…

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, staff interviews, policy review, and manufacturer manual it was determined the facility failed to ensure biologicals were labeled when opened, and medications were properly stored in a locked compartment. This was true for the facility. These deficient practices created the potential for use of expired biologicals, and undetected access to medications by unauthorized personnel. Findings include: The facility's Storage and Expiration Dating of Medications and Biologicals policy, revision date [DATE], documented Procedure 11. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates. The Assure Prism Blood Glucose Monitoring System Quality Assurance / Quality Control (QA/QC) Reference Manual documented, .when you first open a control solution bottle, record the discard date (date opened plus 3 months) in the space provided on the label. The facility's General Dose Preparation and Medication Administration…

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 interviews, it was determined the facility failed to ensure infection control and prevention practices were maintained for residents' Durable Medical Equipment (DME). This was true for 1 of 1 resident (Resident #71) reviewed during environmental observations. This failure had the potential to impact residents by placing them at risk for cross contamination and infection. Findings include:The facility's Infection Prevention and Control Program (IPCP) and Plan revised 6/2/25, documented under Implementing Strategies to Achieve the Goals.4. Methods to reduce the risks associated with procedures, medical equipment, and medical devices, including the following:a. Appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipmentResident #71 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation, heart failure, and hypertension.On 3/16/26 at approximately 8:45 AM, observed Resident #71 operating her power…

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 honor residents Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders. This was true for 1 of 1 resident (Resident #5) whose record was reviewed for code status. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented. Findings include:Resident #5 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic kidney disease and diabetes.A facility investigation documented on [DATE], Resident #5 was found unresponsive by CNA staff and nursing staff were notified. Nursing staff performed an assessment and determined Resident #5 was a DNR. LPN #1 then entered Resident #5's room with a POST document in hand and stated she was a full code and CPR was started. This POST document was later found to be for a different resident and not Resident #5. Nursing staff called 911 for an ambulance.…

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 1 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 9/2/25 at 12:19 PM, during Hall 2 medication cart review, observed the narcotic accountability record, dated 9/1/25 to 9/2/25, with 1 licensed nurse signature not documented. On 9/2/25 at 12:32 PM, RN #1 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 9/2/25 at 12:40 PM, the Admissions Nurse stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on observation, food code review, and staff interview, it was determined the facility failed to ensure food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA (Food Drug Administration) 2022 Food Code, Section 3-501.17 documented ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. During the initial kitchen inspection conducted on 1/6/25 at 7:00 AM, the following was observed: Walk-in refrigerator: - 8 individual yogurts with expired dates of 12/28/24 - A sandwich wrapped in cellophane labeled GC and dated 1/4/25 - An open…

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 Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 8 of 18 Residents (#4, #6, #12, #29, #40, #54, #58, and #65) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/2024, documents section K0520 Nutritional Approaches, was to be checked if a resident receives nutrition from a feeding tube. The RAI, revised 10/1/2024, documents section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determines a resident has a serious mental illness and/or mental retardation, or related condition. 1. Resident #4 was admitted to the facility on [DATE], with 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, record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 4 of 18 residents (#12, #23, #59, and #65) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Care Planning-Baseline, Comprehensive, and Routine Updates policy, revision date 11/25/24, documented the facility would monitor the individual's progress and adjusts interventions to their care plan as needed. 1. Resident #12 was initially admitted to the facility on the 10/14/24, and readmitted to the facility on [DATE], with multiple diagnoses including bipolar disorder (a major mental mood disorder) and post-traumatic stress disorder (a major mental illness). Resident #12's care plan, dated 11/22/24, documented she had clostridium…

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 facility policy, Idaho Administrative Code, and the State Operations Manual, observation, and interviews, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 7 of 48 resident rooms and other areas throughout the facility which were observed. This deficient practice created the potential for diminished quality of life and resident safety. Findings include: The facility's Water Temperature Inspection policy dated 1/15/24, documented satisfactory temperature range is maintained per state regulations. Idaho Administrative Code 16.03.02 section 120.13.c, documented the temperature of hot water at plumbing fixtures used by residents is between 105 degrees F and 120 degrees F. State Operations Manual Appendix PP pg 342, documents water temperature of 124 degrees F will cause a 3rd degree burn to occur within 3 minutes, and water temperatures of 120 degrees F will cause a 3rd degree burn to occur within 5 minutes. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 4 of 7 residents (#12, #51, #60, and #219) reviewed for Pre-admission Screening and Resident Review (PASARR) 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. Finding include: The facility's Pre-admission Screening and Resident Review (PASARR) policy revision date 9/26/24, documented a positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. 1. Resident #12 was initially admitted to the facility on the 10/14/24, and readmitted to the facility on [DATE], with multiple diagnoses including bipolar disorder…

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, interview, and record review, the facility failed to follow a resident's comprehensive person-centered care plan. This deficient practice had the potential to affect 1 of 18 resident's (Resident #41) health and wellbeing. Findings include: Resident #41 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including hemiplegia, hemiparesis, and seizures. Resident #41's care plan dated 11/27/24, documented under Bed Mobility: Dependent, Resident #41's bones are fragile, use 2 staff members. Resident #41's medical chart listed under tasks, ADL - bed mobility, the following dates documented that one CNA or NA assisted Resident #41 with mobility in her bed; - 12/27/24 at 6:25 PM, CNA #1 - 12/28/24 at 12:09 AM, CNA #2 - 12/29/24 at 6:51 PM, NA #2 - 12/30/24 at 11:47 AM, CNA #3 - 12/31/24 at 1:36 PM, NA #1 and 6:47 PM, CNA #4 - 1/2/25 at 11:43 PM, CNA#5 - 1/5/25 at 3:52 PM, CNA #6 - 1/8/25 at 4:39 PM, CNA #7 On 1/9/25 at 11:23 AM, the DON stated the CNAs and NAs…

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, policy review and staff interview, it was determined the facility failed to ensure medications were administered according to professional standards of practice. This was true for 1 of 10 residents (Resident #222) observed during medication administration. These failed practices created the potential for residents to experience adverse effects when their medications were not administered according to the physician's order. Findings include: The facility's Refusal of Care or Treatment policy, dated 11/28/22, documented if a resident refuses medication or treatment, the facility, will: - notify the resident and/or the resident representative of the risks versus benefits of the refusal. - explore the reason for the refusal and possible alternatives with the resident and/or resident representative. - refer to the Omnicare Resident Medication Rights policy which documented the facility should notify the physician of a resident's refusal of medication/treatment for periods greater…

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 2 of 12 residents (#12 and #65) reviewed for quality of care. Residents were at risk for adverse outcomes when they did not have physician orders to provide care to meet residents' needs. These failed practices had the potential to adversely affect residents whose care and services were not followed according to accepted standards of practice. Findings include: 1. Resident #12 was initially admitted to the facility on the 10/14/24, and readmitted to the facility on [DATE], with multiple diagnoses including bipolar disorder (a major mental mood disorder) and post-traumatic stress disorder (a major mental illness). On 1/6/25 at 11:58 AM, a wound was observed to Resident #12's left knee. On 1/7/25 at 8:10 AM, Resident #12's medical record did not document orders for the wounds on her left knee. On 1/8/25 at 10:38 AM, observed with LPN #1 present, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the State Operations Manual, observation, and staff interview, it was determined the facility failed to ensure residents were free from accident hazards for 1 of 18 residents (Resident #30) whose room was observed for environmental safety. This deficient practice had the potential to cause physical harm if a power strip used to plug in a medical device was to overheat and cause a fire. Findings include: The State Operations Manual, Appendix PP revised 8/8/24, documented power strips may not be used as a substitute for adequate electrical outlets in a facility and are not designed to be used with medical devices in patient care areas. Resident #30 was admitted to the facility on [DATE], with atrial fibrillation (irregular rapid heart rhythm that can lead to blood clots in the heart). A physician order dated 10/9/23, documented Resident #30 was to use sequential compression devices (inflatable sleeve to prevent blood clots) to bilateral lower extremities two times a day for lymphedema…

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 facility standing order policy, observation, and staff interview, it was determined the facility failed to ensure licensed nurses performed tasks which they had the knowledge, skills, and competencies. This was true for 3 of 4 licensed nurses observed. This had the potential for adverse effects for all residents when the facility's standing orders were not followed. Findings include: The facility's Standing Orders, dated 2/15/24, documented for oxygen saturations less than 88%, titrate supplemental oxygen 1-4 liters per minute via nasal cannula or mask. Resident #41 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including hemiplegia, hemiparesis, and seizures. Resident #41's medical record documented the following SpO2 (peripheral oxygen saturation, is a measurement of the amount of oxygen in your blood) with no documented follow-up to address the low SpO2. - 8/8/24 at 4:50 PM, SpO2 was 86% RA, RN #2 - 8/9/24 at 8:03 AM, SpO2 was 85% RA, RN #3 - 8/9/24 at 1:04…

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 medications available for residents were stored appropriately. This was true for 2 of 4 residents (#51 and #58), whose rooms were inspected. This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include: The facility's Self Administration of Medications policy, revision date 10/13/21, documented the facility would: - ensure that each resident who requested to self-administer medication would be assessed by the interdisciplinary team to determine if the resident is safe to self-administer medications. - after the interdisciplinary team and primary physician review the assessment and determined the resident can safely self-administer, or self-administer and store medications at bedside, a physician's order would be obtained and the care plan for the resident would reflect the self-administration. - allow bedside medication storage to be…

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 review of the State Operations Manual, interview, and record review, it was determined the facility failed to employ a qualified director of food and nutrition services. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. Findings include: The State Operations Manual Appendix PP, revised 8/8/24, documented the director of food and nutrition services must at a minimum meet one of the following qualifications: - be a Certified Dietary Manager; or - a Certified Food Service Manager; or - has similar national certification for food service management and safety from a national certifying body; or - has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or - has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than…

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 prevention practices were maintained to provide a safe and sanitary environment for 4 of 18 residents (#22, #51, #59, and #222) observed for oxygen and respiratory equipment use, and 2 of 2 residents (#12 and #41) observed for proper cleaning of glucometers. These failures put residents at risk for cross contamination and infection. Findings include: 1. The facility's Oxygen Administration (Safety, Storage, Maintenance) policy, revision date 10/11/24, documented: - oxygen and respiratory supplies are stored in a bag labeled with resident's name when not in use. - clean exterior of concentrators weekly. - external filter should be checked daily and all dust should be removed. Filters should be washed with soap and water once a week and as needed. The following was observed for proper storage of oxygen supplies: a) On 1/6/25 at 8:28 AM, observed Resident #51's oxygen concentrator with white substance on the top and white fuzz covering the filter. b) On 1/7/24 at…

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 the review of records and staff interview, it was determined the facility failed to ensure glucometers were calibrated to maintain accuracy of results for 2 of 4 medications carts (Hall 300 and Hall 400) observed. The Assure Prism Blood glucose Monitoring System manual documented control solution tests are used to check the meter and the test strips to ensure they are working properly. The control solution test should be done: - when using the meter for the first time. -whenever a new bottle or box on individually wrapped test strips is opened. - if the meter or test strips do not function properly. - if the resident's symptoms are inconsistent with the blood glucose test results and you feel that the meter or test strips are not working properly. - if the meter is dropped or damaged. On 1/8/25 at 2:50 PM, the glucometer solution test logbooks were reviewed and revealed the following: - Hall 400 glucometer solution test was not consistently done for the month of December 2024 to January 2025. - Hall 300 glucometer solution test was not consistently done for the month 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 observation, record review, and resident and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 2 of 5 residents (#44 and #65) reviewed for accuracy of MDS assessments. This deficiency created the potential for residents to not have their care needs met due to inaccurate assessments. Findings include: 1. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), and acute and chronic respiratory failure. During an observation in Resident #44's room on 3/5/24 at 11:24 AM, a BIPAP machine (A type of ventilator that helps with breathing for some medical problems. It delivers positive air pressure when you breathe in and out, but higher pressure when you breathe in) was on the bedside table next to Resident #44's bed, and the tubing and mask were placed in a basket…

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, observation,and resident and staff interview, the facility failed to ensure a physician order was obtained for a resident's use of a Bilevel Positive Airway Pressure (BIPAP) machine. This was true for 1 of 2 residents (Resident #44) reviewed for continuous positive airway pressure therapy devices. This failure caused the potential for Resident #44 to receive incorrect airway pressure therapy and put her at risk of respiratory distress. Findings include: The facility's CPAP/BIPAP Administration Policy, reviewed 9/28/23, documented when CPAP (Continuous Positive Airway Pressure) or BIPAP is ordered, the following must be included in the written order: 1. Mode (i.e., CPAP, BIPAP, CPAP Auto set etc.), 2. Pressure setting, 3. Size and type of mask (i.e., small, nasal, or full-face mask.), 4. Liters of oxygen (if ordered.), and 5. Frequency of use (example- at night when sleeping and with naps as tolerated). Resident #44 was admitted to the facility on [DATE], with multiple…

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.