**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, it was determined the facility failed to ensure residents were initially assessed to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #10). This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include:Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. On 7/6/25 at 1:51 PM, observed in Resident #10's room [ROOM NUMBER] tubes of Cortisone-10 cream on her overbed table. Resident #10 stated she self-administers the medication when she needs it. Resident #10's medical record had not contained a self-administration assessment for the Cortisone-10 cream.On 7/8/25 at 2:15 PM, the DON stated Resident #10 should have been assessed for the Cortizone-10 cream to allow her to have it in her room to self-administer and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure the MDS assessment accurately reflected the resident's status. This was true for 1 of 1 resident (Resident #10) whose MDS, care plan, and nursing assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and cared for or monitored due to inaccurate assessments. Findings include:Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. Review of Resident #10's Level I PASRR dated 10/6/23, and Level II PASRR dated 10/10/23, and noted PTSD was listed as a diagnosis. Review of Resident #10's MDS dated [DATE], 1/18/25, 10/18/24, 7/20/24, 4/19/24, 1/18/24, and 10/18/23 which documented under I6100 Post Traumatic Stress Disorder (PTSD) was marked NO.On 7/7/25 at 1:20 PM, the DON stated once PTSD is listed on the PASSR's it should have been documented in each MDS and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement resident's comprehensive person-centered care plan. This was true for 1 of 1 resident (Resident #10) whose care plan was reviewed. This deficient practice of not developing and implementing care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly. Findings include: Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. Resident #10's comprehensive person-centered care plan had not documented PTSD diagnosis with goals and interventions.On 7/8/25 at 2:19 PM, the DON stated Resident #10's PTSD diagnosis should have been care planned and was not.

**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 update care plans when changes occur to resident's care. This was true for 2 of 14 residents (#12 and #34) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided as resident's needs changed. Findings include:The facility's policy, Comprehensive Care Plans and Conferences dated 9/5/24, documented resident’s care plans must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe), congestive heart failure, and repeated falls. On 3/3/25, Resident #12 had a fall when his quad-cane bent during a transfer, resulting in a laceration and skin tear. The incident report documented an intervention to replace the quad-cane. On 4/19/25, a PT (Physical Therapy) Evaluation and Plan of Treatment documented Resident #12’s prior level of functioning required minimum to maximum assist for self-cares using a hemi-walker, power wheelchair, and manual wheelchair. The evaluation did not document the use of a quad-cane. On 4/23/25, a PT treatment encounter note documented Resident #12 was to ambulate short distances with staff using a hemi-walker. The treatment encounter note did not document the use of a quad-cane. Resident #12’s care plan, with a last review completed date of 7/2/25, documented he requires 1 person transfer assistance with a quad-cane. The care plan did not document the use of a hemi-walker. On 7/8/25 at 4:30 PM, the DON stated the quad-cane was replaced with a hemi-walker after Resident #12’s fall on 3/3/25. The care plan should have been updated to change the quad-cane to hemi-walker but was not. Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body) and cellulitis of right lower limb (a bacterial infection affecting the skin and underlying tissues of the right leg, causing redness, swelling, pain, and warmth). On 7/6/25 at 2:53 PM, observed Resident #34’s left leg was very red and swollen and was not wearing Tubi grips. Resident #34’s physician order dated 3/12/25, documented Apply edema wear (Tubi grips size F) to bilateral lower extremity. Apply from base of toes to 1 below the knee. To prevent rolling, turn over the top of edema wear making a 3 cuff. Edema wear is washable but must hang to dry. It may be removed for skin care and assessment, then replaced. Resident #34’s Weekly Skin Assessment 6/25/25 and 7/3/25, documented SEVERE edema to bilateral lower extremities. Resident noncompliant with Tubi grips and foot elevation. Resident #34’s comprehensive person-centered care plan had not documented the use of Tubi grips daily. On 7/8/25 at 2:17 PM, the DON stated Resident #34’s Tubi grips should have been care planned and were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility standing orders, record review and staff interview, it was determined the facility failed to follow facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 3 of 4 Residents (#34, #41, and #43) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include: The facility standing orders and protocols documented BM (Bowel Movement) Step 1: Lactulose 10GM/15ML: 30 ml PO daily PRN for no bowel movement X 72 hrs +. If no results within 8 hrs proceed to step 2: BM Step 2: Dulcolax Suppository 10mg: give one Suppos rectally PRN daily for NO BM X 72 Hrs +. If no results within 8hrs proceed to step 3. BM Step 3: Fleet Enema 7-19 GM/118 ml: Give one Enema rectally PRN daily for NO BM X 72 Hrs+. If no results within 8 hours Notify MD for further instructions. a. Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body) and cellulitis of right lower limb (a bacterial infection affecting the skin and underlying tissues of the right leg, causing redness, swelling, pain, and warmth). Resident #34 had a BIMS of 15. Review of Resident #34's medical record contained a signed facility standing order for bowel care.On 7/7/25 at 9:47 AM, Resident #34's medical record had documented bowel movement (according to B&B CNA task) on 6/12/25 at 8:20 PM, and not again until 6/16/25 at 12:20 PM, 87 hours later. Resident #34's physician's orders dated 8/19/24, related to bowel care were as follows:- Lactulose Solution 10 GM/15ML Give 30 ml by mouth as needed for No BM x72 hours Step ONE. If no results within 8 hours, proceed to step TWO, - Step TWO, Dulcolax Suppository 10 MG (Bisacodyl) Insert 10 mg rectally as needed for constipation - if no results from Lactulose Step TWO. If no results within 8 hours, proceed to Fleet enema, step THREE, - Step THREE Fleet Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 application rectally as needed for constipation - no results from suppository Step THREE. If no results, notify MD.Resident #34's MAR documented Lactulose, Dulcolax, and Fleet Enema were not given during the month of June 2025. Resident #34's medical record contained no documentation that the physician had been notified after 87 hours without a BM.Resident #34 was documented as eating 75 to 100 percent of his meals 6/8-13/25. On 6/14 Breakfast - 51 to 75%, Lunch - 100%, Dinner - 26 to 50%On 6/15 all meals eaten at 51 to 75%.Resident #34's medical record documented no behavioral related issues or refusals of care related to toileting during June or July 2025.On 7/8/25 at 2:20 PM, the DON stated nursing staff should have followed physician's orders and the facility standing order for Resident #34's bowel care and had not. b. Resident #41 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including fracture of left and right femur and heart failure.Resident #41 had a BIMS of 15.Review of Resident #41's medical record contained a signed facility standing order for bowel care.Resident #41's had documented bowel movement (according to B&B CNA task) on 6/11/25 at 3:46 PM, and not again until 6/14/25 at 9:32 PM, 77 hours later.Resident #41's had documented bowel movement (according to B&B CNA task) on 6/18/25 at 9:08 PM, and not again until 6/22/25 at 1:12 AM, 76 hours later.Resident #41's had documented bowel movement (according to B&B CNA task) on 6/27/25 at 1:51 AM, and not again until 6/30/25 at 9:59 PM, 92 hours later.Resident #41's physician's orders related to bowel care were as follows:- Lactulose Solution 10 GM/15ML dated 6/13/23, Give 30 ml by mouth as needed for No BM x72 hours Step ONE. If no results within 8 hours, proceed to step TWO, - Step TWO, Dulcolax Suppository 10 MG (Bisacodyl) dated 7/5/23, Insert 10 mg rectally as needed for constipation - if no results from Lactulose Step TWO. If no results within 8 hours, proceed to Fleet enema, step THREE, - Step THREE Fleet Enema 7-19 GM/118ML (Sodium Phosphates) dated 6/13/23, Insert 1 application rectally as needed for constipation - no results from suppository Step THREE. If no results, notify MD.Resident #41's MAR documented Dulcolax was given on 6/11/25, while Lactulose and Fleet Enema were not given during the month of June 2025. Resident #41's medical record contained no documentation that the physician had been notified of BM related issues during the month of June 2025.Resident was documented as eating the following percentage of his meals of the following dates.- 6/11/25 - Dinner 26 to 50%- 6/12/25 - Lunch 51 to 75%, Dinner 76 to 100%- 6/13/25 - None listed- 6/14/25 - None listed - 6/18/25 - Lunch 50 to 75%, Dinner 76 to 100%- 6/19/25 to 6/20/25 Lunch 76 to 100%, Dinner 76 to 100% - 6/27/25 - to 6/30/25 Dinner 76 to 100% Resident #41's medical record documented no behavioral related issues or refusals of care related to toileting during June or July 2025.On 7/8/25 at 2:20 PM, the DON stated nursing staff should have followed physician's orders and the facility standing order for Resident #41's bowel care and had not. c. Resident #43 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and need for assistance with personal cares.Resident #43 had a BIMS of 15.Review of Resident #43's medical record contained a signed facility standing order for bowel care.On 7/7/25 at 9:49 AM, Resident #43's medical record had documented bowel movement (according to B&B CNA task) on 6/19/25 at 12:59 PM, and not again until 6/23/25 at 1:22 PM, 96 hours later. Resident #43's physician's orders dated 9/22/23, related to bowel care were as follows:- Lactulose Solution 10 GM/15ML Give 30 ml by mouth as needed for No BM x72 hours Step ONE. If no results within 8 hours, proceed to step TWO, - Step TWO, Dulcolax Suppository 10 MG (Bisacodyl) Insert 10 mg rectally as needed for constipation - if no results from Lactulose Step TWO. If no results within 8 hours, proceed to Fleet enema, step THREE, - Step THREE Fleet Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 application rectally as needed for constipation - no results from suppository Step THREE. If no results, notify MD.Resident #43's MAR documented Lactulose, Dulcolax, and Fleet Enema were not given during the month of June 2025. Resident #43's medical record contained no documentation that the physician had been notified after 96 hours without a BM.Resident #43 was documented as eating 75 to 100 percent of her meals 6/20-22/25.Resident #43's medical record documented no behavioral related issues or refusals of care related to toileting during June 2025.On 7/8/25 at 2:20 PM, the DON stated nursing staff should have followed physician's orders and the facility standing order for Resident #43's bowel care and had not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, 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 (#34 and #43) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include: a. Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body) and cellulitis of right lower limb (a bacterial infection affecting the skin and underlying tissues of the right leg, causing redness, swelling, pain, and warmth).On 7/6/25 at 2:52 PM, observed Resident #34 was not using his oxygen concentrator located in his room. Resident #34 stated he uses it when he feels he needs it.Resident #34's physician's order dated 1/27/25, documented oxygen at 3 liters per minute continuously via nasal canula. Document every shift.Resident #34's care plan documented OXYGEN SETTINGS: O2 via nasal cannula at 3 LPM continuously and humidified. Date Initiated: 9/13/2024 Resident's medical record documented the following:Date & Time O2 SpO2 Staff- 7/7/25 at 7:07 96.0% Room Air RN #1 - 7/6/25 at 22:48 91.0% Room Air RN #1 - 7/6/25 at 22:47 91.0% Room Air RN #1 - 7/6/25 at 16:08 93.0% Room Air LPN #1 - 7/6/25 at 6:52 94.0% Room Air LPN #4 - 7/5/25 at 9:42 94.0% Room Air LPN #3 - 7/5/25 at 7:14 94.0% Room Air MAC #2 - 7/4/25 at 11:45 96.0% Room Air LPN #2 - 7/4/25 at 11:45 96.0% Room Air LPN #2 - 7/4/25 at 1:01 92.0% Room Air MAC #3 - 7/4/25 at 1:01 92.0% Room Air MAC #3 - 7/3/25 at 6:50 97.0% Room Air LPN #2 - 7/3/25 at 6:49 97.0% Room Air LPN #2 - 7/2/25 at 23:21 92.0% Room Air MAC #3 - 7/2/25 at 23:21 92.0% Room Air MAC #3 - 7/2/25 at 6:38 93.0% Room Air RN #1 - 7/1/25 at 23:54 91.0% Room Air MAC #3 - 7/1/25 at 23:54 91.0% Room Air MAC #3 - 7/1/25 at 14:29 91.0% Room Air LPN #6- 7/1/25 at 14:29 91.0% Room Air LPN #6 - 7/1/25 at 6:37 97.0% Room Air RN #1 On 7/8/25 at 2:25 PM, the DON stated nursing staff should have contacted Resident #34's physician to either cancel or update the oxygen order and had not.b. Resident #43 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and need for assistance with personal cares.Facility BiPAP / CPAP Administration policy dated 9/3/24, documented humidifier reservoir should be filled daily with sterile or distilled water to the fill-line. Each day when the patient is removed from the machine the reservoir should be emptied and left to air dry. Once weekly, the reservoir should be washed with warm soapy water and rinsed well, then left to air dry. Weekly cleaning should be documented in the patient record.On 7/6/25 at 1:17 PM, observed Resident #43's CPAP nasal pillows sitting on the bed side table uncovered. Resident #43 stated it had been a while since the facility staff had cleaned the mask and she had never seen staff clean the humidifier.Resident #43's TAR documented CPAP / BiPAP: Clean PAP nasal mask with warm soapy water and allow to air dry every dayshift. Order date 10/2/23. There was no documentation that Resident #43's CPAP mask had been cleaned on 6/19/25.RN #2 and LPN #5 documented in June 2025, they had cleaned the CPAP mask per physician's order and the care plan.RN #1 and LPN #2, #3, #4 documented in July 2025, they had cleaned the CPAP mask per physician's order and the care plan.On 7/8/25 at 2:24 PM, the DON stated she interviewed the nurses regarding the cleaning of Resident #43's CPAP mask. The nurses were not cleaning the mask or humidifier according to the physician's order and care plan and should have been.

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 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:On 7/8/25 at 8:57 AM, during Sawtooth Hall medication cart audit, observed the narcotic accountability record, dated 5/3/25 to 7/8/25, with 3 licensed nurse signatures not documented. On 7/8/25 at 9:01 AM, LPN #1 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 7/8/25 at 9:10 AM, during Sun Valley Hall medication cart audit, observed the narcotic accountability record, dated 5/28/25 to 7/8/25, with 5 licensed nurse signatures not documented. On 7/8/25 at 9:36 AM, RN #1 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 7/8/25 at 3:37 PM, the DON stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

**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 were secure and inaccessible to unauthorized staff and residents. This was true for 1 of 19 Residents (Resident #28). This failure created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include:The facility’s Storage and Expiration Dating of Medications and Biologicals policy revision date 8/1/24, documented the following: - the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is not accessible by residents and visitors. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis, lumbar region (condition where spaces narrow, putting pressure on the spinal cord and nerves) and diabetes. On 7/8/25 at 8:47 AM, the following was observed in Resident #28’s room; LPN #1 administered oral medications to resident then left insulin pen on resident’s overbed table when leaving the room to get a needle for the insulin pen. LPN #1 reentered resident’s room and administered the insulin. On 7/8/25 at 8:54 AM, LPN #1 stated she should not have left the insulin pen at Resident #28's bedside. On 7/8/25 at 10:05 AM, the DON stated medications should not have been left at Resident #28's bedside unattended. The facility's General Dose Preparation and Medication Administration policy dated 12/1/07, documented the facility staff should ensure that medication carts are always locked when out of site or unattended. On 7/7/25 at 1:48 PM, observed an unattended and unlocked medication cart next to the nurses’ station. MAC #1 stated the medication cart should have been locked when I was not at the cart. On 7/7/25 at 2:27 PM, the DON stated the medication carts are to be locked when staff are not next to the cart.

Based on observation, interview, Department of Health and Welfare - Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: Department of Health and Welfare - Idaho Administrative Rules 16.03.02. Environmental Sanitation 108. Garbage and Refuse 03a. All containers used for storage of garbage and refuse shall be constructed of durable, nonabsorbent material and shall not leak or absorb liquids. Containers shall be provided with tight-fitting lids unless stored in vermin-proof rooms or enclosures, or in a waste refrigerator.U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled.On 7/6/25 at 10:30 AM, observed various trash cans in the kitchen food prep area were not sealable, with round holes cut in the center to keep open.On 7/6/25 at 10:35 AM, the Food Services Manager stated she was not aware of the requirement to have closed garbage can lids in the food prep areas.

**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 accurate and complete clinical records were maintained for each resident. This was true for 1 of 1 resident (Resident #12) whose records were reviewed. This deficient practice resulted in incomplete documentation and created the potential for harm if inappropriate care and/or treatments were provided to the resident. Findings include:Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe), congestive heart failure, and repeated falls.A physician's order dated 1/30/25, documented Resident #12's inappropriate sexual comments towards staff were to be documented on the TAR and include number of episodes, intervention, and outcome.A care plan dated 2/21/25, documented Resident #12 makes sexually inappropriate comments to staff and a behavior tracking document is in place for this behavior.On 7/8/25 at 9:30 AM, the DON with the Executive Director present stated Resident #12 did not receive a shower on 6/14/25, 6/28/25, and 7/2/25 due to his inappropriate sexual comments towards staff. The Administrator stated Resident #12 has had these behaviors for a long time and was documented in his medical record.A review of Resident #12's TAR and progress notes from 2/1/25 - 7/8/25, did not document any sexually inappropriate comments or behaviors.On 7/9/25 at 11:45 AM, the DON stated Resident #12's inappropriate sexual behaviors towards staff should have been documented on the TAR and a behavior note written on 6/14/25, 6/28/25, and 7/2/25, but was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 2022 FDA Food Code, resident and staff interviews, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This deficient practice had the potential to affect all residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The 2022 FDA Food Code states hot food will be maintained at 135 degrees F (Fahrenheit) or above and cold food will be maintained at 41 degrees F or below. The following comments were obtained during resident interviews. On 7/6/25 at 2:45 PM, Resident #46 stated meals are cold, with over or undercooked vegs that are often tasteless and mushy. On 7/6/25 at 2:52 PM, Resident #34 stated food is always cold and horrible, poorly fixed. Turkey and rice in last night’s dinner was horrible and tasted old. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including Multiple Sclerosis (disease in which the immune system attacks the protective covering of the nerve cells) and depression. On 7/6/25 at 10:04 AM, Resident #6 stated food is not good. The meat is tough, and the vegetables are soggy most of the time. The meal quality is worse on the weekends. On 7/8/25 at 3:00 PM, Resident #6 stated lunch was not too good, and the hot food was often cold. On 7/8/25 at 1:12 PM, a lunch meal taste tray was provided and the following issues with the quality of the food and temperatures are listed below. - The chicken temp was 135 degrees F, the chicken did have an acceptable temp but there was a strong spicy taste in the gravy that took away from the meal. - The pudding was 65.1 degrees F which should have been much colder and the taste was off. - The peas were 132.2 degrees F and acceptable. - The carrots were 129 degrees F, these were overcooked, mushy, and had a foul taste to them. The Holding Temperature log for the pudding on 7/8/25 lunch was 53 degrees F and should have been 41 degrees or lower. On 7/9/25 at 9:02 AM, the Facility Food Service Manager stated the holding temp for that dessert should have been 50 degrees F or colder and was not. On 7/9/25 at 9:02 AM, observed the kitchen Holding temperature logs for each meal were not legible for the following dates. - June 14, 15, 16, 21, 22, 23, 2025 all dinner meals. On 7/9/25 at 9:35 AM, the Facility Food Services Manager stated those Hold Temperature logs should have legible data entered and they were not on those dates.

Based on observation, interview, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, 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 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 7/6/25 at 10:11 AM, observed the following issues in the Walk-in Refrigerator. - a large container of cooked turkey in liquid, partially covered with plastic wrap that was down in the liquid and not properly covered.- several trays of desserts and drinks that were not dated.- various zip-lock type bags containing peanut butter and jelly sandwiches, which were not dated.On 7/6/25 at 10:15 AM, observed the following issues in the Walk-in Freezer.- a large cardboard box of green beans, opened to the air and not properly covered.- a large cardboard box of chicken opened to air not properly covered.- a large cardboard box of hamburger patties opened to air not properly covered.On 7/6/25 at 10:22 AM, the Food Service Manager stated the food items should have been properly covered and dated when opened and were not.On 7/6/25 at 10:25 AM, reviewed the kitchen dish washer logs noting they were not completed with some missing data in July on the following dates: July 4 and 5 breakfast and lunch.On 7/6/25 at 10:27 AM, reviewed the kitchen sanitizing bucket PPM log which was missing data on July 3, 4 and 5 at the following times, 7 AM, 9 AM, 11 AM, and 1 PM.The Food Service Manager stated those dates should have been documented as completed and were not.On 7/6/25 at 12:27 PM, observed containers of lemonade and iced tea that were not labeled or dated, were being served in the dining room for lunch by the DON. The DON stated the containers don't have dates on them, but they just came from the kitchen.

**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 informed consent was obtained prior to initiation of medications for 1 of 5 residents (Resident #25) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medication was prescribed, the expected benefits, and the risks associated with the medications. Findings include: The facility's policy, Psychotropic Medication Management, undated, documented the following: *Psychotropic drug is defined in the regulations at §483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior. *The resident's medical record must include documentation of adequate indications for a medication's use and the diagnosed condition for which a medication is prescribed. *Involvement of the resident, his or her family, and/or the resident representative in the medication management process. (A consent is required for each medication). *Selection of medication(s) based on assessing relative benefits and risks to the individual resident. The facility's Pharmacy Services and Procedures Manual for the policy on Psychotropic Medication Use, revised 1/1/22, stated Facility staff should inform the resident and/or resident representative of the initiation, reason for use and risks associated with the use of psychotropic medications, per facility policy or applicable state regulations. These policies were not followed. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder and dementia. Resident #25's physician orders documented she was to receive the following medications: *Donepezil (medication to treat confusion related to dementia) 5 mg, one tablet by mouth at bedtime, ordered on 3/16/22. *Zoloft (antidepressant) 50 mg, one tablet by mouth once a day for depression, ordered on 3/16/22. *Seroquel (antipsychotic) 25 mg, 0.5 tablet by mouth at bedtime for adjunctive treatment related to major depressive disorder, ordered on 4/5/22. Resident #25's Psychoactive Medication Informed Consent for Seroquel and Zoloft, dated 3/16/22, signed by her representative documented the side effects of the medications. The consent did not include the reason why the medications were prescribed to her and the expected benefits of the medications. A consent for Resident #25's Donepezil was not in Resident #25's record. The Drugs.com website, accessed 5/12/22, stated Donepezil is used to help improve mental function in people with Alzheimer's disease. On 4/28/22 at 9:03 AM, the DON stated Resident #25's informed consent for Seroquel and Zoloft had missing information. The DON stated the reasons the medications were prescribed and expected benefits of the medications should be included in the informed consent. The DON stated the facility did not obtain consent from Resident #25 or her representative for Donepezil because it was not a psychotropic medication.

**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 resident's contact isolation was addressed on the baseline care plan. This was true for 1 of 5 residents (Resident #243) reviewed for baseline care plans. This failure created the potential for spread of infection if residents' contact isolation intervention was not initiated. Findings include: The facility's Baseline Care Plan policy, revised 5/19/21, directed staff to develop a baseline care plan within 48 hours of admission to provide an initial set of instructions needed to provide an effective and person-centered care of the resident that meets professional standards of care. This policy was not followed: Resident #243 was admitted to the facility on [DATE], with multiple diagnoses including Methicillin Resistant Staphylococcus Aureus Infection (MRSA - an infection caused by Staphylococcus bacteria that are resistant to commonly used antibiotics). A physician order, dated 4/20/22, directed staff to place Resident #243 on contact precautions (masks, gowns and gloves must be used by health care providers when in the infected patient's room) in addition to standard precautions due to his MRSA infection to his left foot. Resident #243's Baseline Care Plan, dated 4/20/22, did not include documentation he was to be placed on contact isolation precautions as ordered by the physician. On 4/27/22 at 12:21 PM, the DON reviewed Resident #243's baseline care plan. The DON stated Resident #243's baseline care plan did not include he was to be placed in contact isolation. The DON stated the baseline care plan should include contact isolation as an intervention for Resident #243's MRSA infection.

**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 medications were administered in a manner that was consistent with physician's orders and professional standards of practice. This was true for 3 of 6 residents (#20, #31, and #38) reviewed for medication administration. This failure created the potential for adverse effects for Resident #20 and Resident #38 should they experience a life-threatening situation due to low or high blood sugar, and for Resident #31 when he received doses in excess of physician orders for nasal spray. Findings include: The Nursing 2019 Drug Handbook stated the eight rights of medication administration were right drug, right patient, right dose, right time, right route, right reason, right response, and right documentation. The facility's General Dose Preparation and Medication Administration policy, revised 1/1/22, documented the facility staff should verify the correct medication, dose, route, rate, time, and resident before administrating a medication. The facility's Medication Administration Times policy, revised 1/1/22, documented medications should be administered to the resident following the scheduled time determined by the facility's pharmacy committee and/or Physician/Prescriber. The policy stated medication must be given within 60 minutes before the designated times of administration and should be completed by 60 minutes after the designated times of administration. These policies were not followed. 1. The Drugs.com website, accessed 5/12/22, stated, Insulin glargine is a long-acting insulin that starts to work several hours after injection [to lower blood glucose] and keeps working evenly for 24-hours. The website stated insulin glargine may be given at any time of the day; however, once a time is chosen, it is best to inject it within three hours of that time every day. The website stated low blood sugar may happen with this medicine. Very low blood sugar could lead to seizures, passing out, long lasting brain damage, and sometimes death. The Mayo clinic website, accessed on 5/12/22, stated, Blood sugar that's either too high or too low for too long may cause various serious conditions, all of which can lead to a diabetic coma. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, dementia, and hyperglycemia (high blood sugar.) Resident #20's physician orders, dated 6/11/21, documented Resident #20 was to receive 10 units of insulin glargine (long-acting insulin) 2 times a day in the morning at 7:00 AM and before sleep at 8:00 PM. On 2/20/22 the facility revised the order for the insulin glargine morning dose to be administered at 7:30 AM. Resident #20's MAR documented the insulin glargine was given late as follows: * Greater than 181 minutes to 240 minutes in the morning on 1/4/22, 1/24/22, 3/8/22. * Greater than 121 minutes to 180 minutes in the morning on 1/12/22, 1/13/22,1/17/22, 2/12/22, 2/26/22, 3/2/22, 3/5/22, 3/10/22, 3/19/22, 3/22/22, 3/24/22, 3/30/22, 4/16/22, 4/25/22, 4/26/22. * Greater than 121 minutes to 180 minutes before sleep on 1/15/22. * Greater than 61 minutes to 120 minutes in the morning on 1/1/22, 1/7/22, 1/9/22, 1/14/22, 1/16/22, 1/21/22, 2/2/22, 2/7/22, 2/15/22, 2/22/22, 2/23/22, 2/25/22, 3/1/22, 3/4/22, 3/9/22, 3/11/22, 3/20/22, 3/29/22, 4/4/22, 4/6/22, 4/8/22, 4/9/22, 4/14/22, 4/18/22. * Greater than 61 minutes to 120 minutes before sleep on 1/4/22, 3/3/22, 4/20/22. On 04/27/22 at 2:40 PM, the RDCS said the acceptable administration time for insulin glargine was 1 hour before and after the scheduled time in the MAR. If given past the 1 hour of the scheduled time, it was considered being given late. On 4/28/22 at 8:15 AM, when asked, the DON said there was no documentation why Resident #20's insulin was given late. She stated the nurse was to notify Resident #20's physician and document if insulin glargine was given late. 2. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (when the lungs are unable to absorb enough oxygen to supply the body tissues and organs). Resident #31's physician's order, dated 12/1/21, documented the following: *fluticasone Propionate Suspension (a nasal steroid spray) 50 mcg, one spray in each nostril once a day for nasal congestion. On 4/27/22 at 8:04 AM, LPN #1 administered two sprays of fluticasone nasal spray to each of Resident #31's left nostril and right nostril. On 4/27/22 at 8:13 AM, LPN #1 was asked how many fluticasone sprays Resident #31 should receive in each nostril. LPN #1 reviewed the physician's order and stated one spray in each nostril. LPN #1 stated she thought it was two nasal sprays in each nostril because Resident #31 always wanted to receive two nasal sprays in his nostril. 3. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (when the lungs are unable to absorb enough oxygen to supply the body tissues and organs), and diabetes mellitus. a. The Drugs.com website, accessed on 5/12/22, documented when insulin Lispro is used as a mealtime insulin, it should be taken within 15 minutes before a meal or immediately after a meal. A physician's order, dated 1/22/22, documented Resident #38 was to receive insulin Lispro Solution (fast-acting insulin) 55 units before meals for diabetes. The facility provided a document, updated 10/4/21, documenting breakfast was served between 7:25 AM and 8:10 AM. On 4/27/22 at 9:43 AM, LPN #1 administered 55 units of insulin Lispro to Resident #38's right abdomen. On 4/27/22 at 11:29 AM, Resident #38 stated she had her breakfast at about 8:45 AM, approximately 1 hour before her insulin was administered. On 4/27/22 at 10:59 AM, LPN #1 was asked when Resident #38 should receive her insulin Lispro. LPN #1 reviewed Resident #38's insulin order and stated Resident #38's insulin Lispro should be given before her meals. When asked if she administered Resident #38's insulin Lispro before her meals, LPN #1 stated she did not. Resident #38's insulin Lispro was not given before her meal as ordered by the physician. b. A physician's order, dated 1/22/22, documented Resident #38 was to receive one inhalation orally of Advair Discus Aerosol Powder Breath Activated (used to control wheezing and shortness of breath) 100-50 mcg every 12 hours for chronic respiratory failure. The order included special instructions for Resident #38 to rinse her mouth out with water and spit back into the cup after administration. The Drugs.com website, accessed on 5/4/22, stated the mouth should be rinsed with water without swallowing after inhalation of Advair Discus to help reduce the risk of oral fungus. On 4/27/22 at 9:43 AM, Resident #38 was observed to take one inhalation of Advair Discus orally and gave the inhaler back to LPN #1. LPN #1 then gave Resident #38 her oral medications and asked to drink her water mixed with Miralax (laxative). Resident #38 did not rinse her mouth after inhaling the Advair Discus. On 4/27/22 at 10:59 AM, LPN #1 stated she did not ask Resident #38 to rinse her mouth after taking the Advair Discus. LPN #1 stated she should have told Resident #38 to rinse her mouth with water and spit it out. The facility failed to follow physician orders for Resident #31 and Resident #38.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 40 medications (5%) which affected 2 of 7 residents (#31 and #38) whose medication administration was observed during the medication pass. This failed practice placed residents at risk of not receiving medications as ordered by their physician and the potential for harm when Resident #31 received doses in excess of physician orders for a nasal spray and potential to affect the therapeutic level and effectiveness of Resident #38's insulin when it was administered after meals instead of before meals as ordered by her physician. Findings include: The Nursing 2019 Drug Handbook stated the eight rights of medication administration were right drug, right patient, right dose, right time, right route, right reason, right response, and right documentation. 1. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (when the lungs are unable to absorb enough oxygen to supply the body tissues and organs). Resident #31's physician's order, dated 12/1/21, documented he was to receive fluticasone Propionate Suspension (a nasal steroid spray) 50 mcg, one spray in each nostril once a day for nasal congestion. On 4/27/22 at 8:04 AM, LPN #1 administered two sprays of fluticasone nasal spray to each of Resident #31's left nostril and right nostril. On 4/27/22 at 8:13 AM, LPN #1 was asked how many fluticasone sprays Resident #31 should receive in each nostril. LPN #1 reviewed the physician's order and stated one spray in each nostril. LPN #1 stated she thought it was two nasal sprays in each nostril because Resident #31 always wanted to receive two nasal sprays in his nostril. 2. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including diabetes mellitus. A physician order, dated 1/22/22, documented Resident #38 was to receive insulin Lispro Solution (fast-acting insulin) 55 units before meals for diabetes. On 4/27/22 at 9:43 AM, LPN #1 administered 55 units of insulin Lispro to Resident #38's right abdomen. On 4/27/22 at 10:59 AM, LPN #1 was asked when Resident #38 should receive her insulin Lispro. LPN #1 reviewed Resident #38's insulin order and stated Resident #38's insulin Lispro should be given before her meals. When asked if she administered Resident #38's insulin Lispro before her meals, LPN #1 stated she did not. On 4/27/22 at 11:29 AM, Resident #38 stated she had her breakfast at about 8:45 AM, approximately 1 hour before her insulin was administered. Resident #38's insulin Lispro was not given before her meal as ordered by the physician.

**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 had comprehensive, resident-centered care plans which included individualized, resident-centered interventions and goals. This was true for 3 of 24 residents (#7, #21, and #25) whose care plans were reviewed. This failure placed residents at risk for negative outcomes if services were not provided, or provided incorrectly, due to lack of information in their care plans. Findings include: The facility's care plan policy, revised 5/10/21, stated the facility developed a comprehensive person-centered care plan, consistent with residents' rights. The care plan was developed by the Interdisciplinary Team and described the services to be furnished to attain or maintain each resident's highest practicable physical, mental and psychosocial well-being. This policy was not followed. 2. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder and anxiety disorder. Resident #7's physician orders directed staff to monitor and document Resident #7's specific behaviors as follows: *Monitor and document behavior for anger and agitation towards others, ordered 11/19/20. *Monitor and document behavior for delusions, ordered 1/11/21. *Monitor and document behavior for perseveration and fixation on health issues, ordered 5/19/21. Resident #7's care plan for depression and anxiety, initiated 9/20/19, included interventions directing staff to administer her medications as ordered by the physician and observe her for signs and symptoms of depression and anxiety: anger, agitation, social isolation, and tearfulness. Resident #7's care plan did not include interventions to monitor her specific target behaviors, including delusions, perseveration, and fixation on health issues as ordered by the physician. On 4/29/22 at 9:50 AM, the RDCS said Resident #7's care plan did not include all of the physician's orders for monitoring behavior. 3. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including insomnia and stroke. A physician order, dated 3/15/22, directed staff to monitor and document Resident #21's behaviors for statements of hopelessness and negative verbalization related to self or situation. Resident #21's care plan for psychotropic medication use, initiated 4/3/22, documented Resident #21 was prescribed medication related to depression. The care plan directed staff to administer his medication as ordered by the physician and observe him for effectiveness and side effects of the medication every shift. Resident #21's care plan did not include interventions to monitor his specific behaviors for statements of hopelessness and negative verbalization related to self or situation, as ordered by the physician. On 4/29/22 at 9:50 AM, the RDCS said Resident 21's care plan did not include the physician's orders for monitoring his behaviors. The RDCS said the care plan should monitor each resident's defined behaviors based on the physician's order. 1. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder and dementia. A physician's order, dated 3/16/22, directed staff to monitor and document Resident #25's behavior for self-isolation/lack of interest. A care plan, initiated 4/3/22, documented Resident #25 was prescribed psychotropic medications related to depressive disorder and staff were directed to administer her medications as ordered by the physician and observe her for any side effects of the medications every shift. Resident #25's care plan did not include the physician's order to monitor her behavior for self-isolation and lack of interest. On 4/28/22 at 3:39 PM, the DON stated Resident #25 was being monitored for negative mood such as self-isolation. The DON stated she did not see documentation in Resident #25's care plan for behavior monitoring.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure measures were in place to prevent possible cross-contamination from dirty to clean areas in the kitchen. This had the potential to affect the 41 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: The facility's Food and Nutrition policy, Prevention of Cross-Contamination, revised 12/17/21, documented all Food and Nutrition Services associates were trained in infection control techniques to prevent the contamination of food and the spread of infection to ensure food was stored, prepared, distributed and served in accordance with professional standards for food safety, and per federal, state and local requirements. The Idaho Food Safety and Sanitation Manual, Page 33, revised 2/2018, stated hands must be washed after handling garbage, dirty dishes or soiled equipment, and before handling food or clean food-contact surfaces of equipment or utensils. These policies and guidelines were not followed. On 4/25/22 at 11:35 AM, Kitchen Staff (KS) #1 was observed washing pots and pans in the 3-compartment sink. KS #1 rinsed food off the dishes, washed dishes in soapy water, rinsed dishes in clean water, dipped dishes in sanitizing solution, removed dishes from the sanitizing solution, and set them on a rack to dry. KS #1 did not perform hand hygiene after washing and rinsing dirty dishes and before removing clean dishes from the sanitizing solution. On 4/25/22 at 12:30 PM, KS #1 was observed continuing to wash pots and pans. KS #1 did not perform hand hygiene after washing and rinsing dirty dishes and before removing clean dishes from the sanitizing solution. On 4/25/22 at 12:30 PM, the Registered Dietitian (RD) stated hand hygiene should be performed between the handling of dirty and clean dishes. She stated dishes should be washed, rinsed and placed in the sanitizer. She stated hands should be washed before dishes were removed from the sanitizer and set to dry or put away. On 4/25/22 at 12:32 PM, KS #1 stated he was employed at the facility for about 3 to 4 months. KS #1 stated he washed dishes, rinsed them, sanitized them, and set them to dry. KS #1 stated during his orientation and training he was not instructed to wash hands between dirty and clean dishes. KS #1 stated KS #2 trained him on the dishwashing procedure. KS #1 pointed to the poster on the wall above the dish sink as his guide for the proper way to pre-rinse soiled dishes, wash, rinse, sanitize, and set dishes to air dry. The poster on the wall did not indicate hand hygiene should be performed after washing and rinsing dirty dishes and before removing clean dishes from the sanitizer. On 4/25/22 at 12:34 PM, KS #2, stated he trained KS #1 on the dishwashing procedure. KS #2 stated dishes should be washed, rinsed, and placed in the sanitizer. KS #2 stated hand hygiene should be performed prior to taking dishes out of the sanitizer and setting them to dry. KS #2 stated he provided that information to KS#1 when he trained him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, resident interview, and staff interview, it was determined the facility failed to ensure the dignity of the residents was maintained. This was true for 2 of 3 residents (#16 and #50) who wore wrist bands and were reviewed for dignity. This failure created the potential for psychosocial harm and well-being should resident's self-worth and self-esteem be negatively affected. Findings include: The facility's policy Ready, Set, Go! Rehabilitation Program, undated, documented all residents on rehabilitation services will be given a colored wrist band when they are initially evaluated by therapy. These wrist bands will help all staff know what level of assistance to provide for residents during their stay at the facility. As residents progress in their therapy, their wrist bands will be changed by therapy staff. A red wrist band indicates residents are only walking with therapy staff and all transfers require assistance from a staff member. A yellow band indicates residents can walk with staff members in their room and within the facility. They may need assistance with a walker, cane, or crutches. These residents must have staff with them if they are walking or transferring. A green wrist band indicates residents can walk independently in their room and in the facility without assistance from staff. 1. Resident #16 was readmitted to the facility on [DATE], with multiple diagnoses including history of transient ischemic attack (a brief episode of neurological dysfunction), cerebral infarction (stroke), difficulty walking, generalized muscle weakness, unsteadiness, gait and mobility abnormalities, and repeated falls. Resident #16's physical therapy notes, dated 8/3/18, documented he was issued and educated regarding the red wrist band. Resident #16 was agreeable for staff to assist with all mobility. Resident #16's significant change MDS assessment, dated 9/12/18, documented his cognition was intact, and family or significant other participated in the assessment. The MDS assessment documented Resident #16's functional status required one and two person assist with ADLs, and a history of falls. On 11/27/18 at 9:47 AM, Resident #16 was observed in his room sitting in his wheelchair watching television. Resident #16 was observed with a red wrist band on his left arm. At that time, Resident #16 stated he had the red wrist band on his arm because he had a history of falling and would rather not have to wear the wrist band. On 11/30/18 at 10:53 AM, the DOR stated she had been here since June 2018. The DOR stated the Ready, Set, Go! Program had been used by the facility for awhile and the residents usually really liked the program. The DOR stated the resident may refuse to use the wrist band. The DOR stated she did not know Resident #16 still had a wrist band and was no longer on Rehab. The DOR stated the bands were used to communicate between physical therapy and nursing staff. 2. Resident #50 was admitted to the facility on [DATE], with multiple diagnoses including generalized muscle weakness. Resident #50's care plan, dated 11/8/18, directed staff to provide extensive one to two person assistance with transfers, mobility, and ambulation in therapy. Resident #50's admission MDS assessment, dated 11/14/18, documented his cognition was moderately impaired, and family or significant other participated in the assessment. The MDS assessment documented Resident #50's functional status required one and two person assistance with ADLs. Resident #50's care plan conference, dated 11/19/18, documented he was not making much progress, and there was concern for potential for injury. Resident #50's care plan conference did not address applying a wrist band. On 11/26/18 at 6:53 PM, Resident #50 was observed in his room lying in bed with his wife present. Resident #50 was observed with a red wrist band on his left arm. Resident #50 stated the red band on his left wrist was not something he wanted to wear by choice. On 11/29/18 at 11:37 AM, LPN #4 stated Resident #50's wrist band was for the staff and resident to know if residents were able to move independently. The green wrist band was for independent, red was for assistance needed, and yellow was for a fall risk. LPN #4 stated residents could refuse to have the wrist band in place and it should be care planned. On 11/29/18 at 3:12 PM, the Administrator stated she did not know any residents in the facility were wearing wrist bands, except one that had a green wrist band, and she did not know that the residents did not want to wear the wrist bands. The Administrator also stated for the residents who received physical therapy and wore wrist bands, it gave the residents something to celebrate when they achieved the green wrist band.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, it was determined the facility failed to ensure residents were provided the opportunity to participate in the care planning process for the development and implementation of their person-centered plan of care. This was true for 1 of 24 residents (Resident #49) who were reviewed for care planning. The failure created the potential for harm if residents' care was provided inconsistent with their needs and preferences. Findings include: Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (an irregular heart rhthym). He was readmitted on [DATE], following a brief hospitalization related to the atrial fibrillation and had a coronary angioplasty with stent placement. An angioplasty is a minimally invasive procedure to unblock arteries. Resident #49's annual MDS assessments, dated 11/13/18, documented his hearing and vision were adequate and his speech was clear, he understood others and they understood him, and he was independent in cognitive skills for daily decision making. On 11/27/18 at 9:54 AM, Resident #49 said he had not participated in any care planning or care conference meetings. There was no documentation of care planning/conference meetings in Resident #49's record. On 11/29/18 at 5:48 PM, the RSD said there were no care conferences for Resident #49 since he was admitted in 2017.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, review of the facility's admission packet, and policy review, it was determined the facility failed to ensure residents were provided written information regarding Advance Directives in a language they could understand and assisted them to formulate Advance Directives. This was true for 1 of 24 residents (Resident #1) who were reviewed for Advance Directives. The failure increased the risk Resident #1's health care preferences would not be honored if she became incapacitated and unable to communicate her wishes. Findings include: The facility's Advance Directives policy, dated 2/2018, documented The resident has a right to execute or refuse to execute an advance directive, which stipulates how decisions regarding his or her medical care are made. Residents have the right to self-determination regarding their medical care. This includes .to direct his or her own medical treatment, including withholding or withdrawing life sustaining treatment. The State Operations Manual defined an 'Advance directive' is 'a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.' Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advance directive. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including a pelvic fracture, generalized muscle weakness, acute kidney failure, and major depressive disorder. Resident #1's quarterly MDS assessments, dated 8/22/18, documented her preferred language was Spanish and she needed or wanted an interpreter to communicate with health care staff and the physician. She understood others and they understood her and her cognition was modified independent (some difficulty in new situations only). Resident #1's Baseline Care Plan and Initial Discharge Plan, dated 5/24/18, documented her Advance Directive was DNR (Do Not Resuscitate). Resident #1's comprehensive care plan for Advance Directives, dated 5/24/18, also documented was a DNR. The care plan also stated her sons will make all health care decisions if she became incapacitated. Resident #1's record included a POST form that documented she was a DNR and wanted limited additional interventions of intravenous (IV) fluids, antibiotics, and blood products. She signed the POST on 5/14/18, and the physician signed it on 5/29/18. No other Advance Directive information was found in Resident #1's record. A Progress Note by the LSW, dated 11/5/18, documented In looking through [Resident #1's name] chart noted she does not have a living will or DPOA [Durable Power of Attorney] for healthcare, and her family states she has not filled one out before. SW [Social Worker] sent email to Office on Aging inquiring about if they have these documents in Spanish for resident to look at in case she would like to fill one out. Awaiting to hear back from them. There were no other Social Service notes. On 11/28/18 at 3:13 PM, the LSW said she contacted the Office on Aging on 11/5/18 to request Advance Directive information in Spanish and she received it the next day. She said she called Resident #1's son soon after that and told him she received the Advance Directive information in Spanish. The LSW said she did not document the conversation with Resident #1's son and she did not talk with Resident #1. She said the son lived and worked in another town and he had not been back to the facility in awhile. The LSW said Resident #1 was interviewable and she could have talked to her with a Spanish speaking staff member to interpret.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, home health provider staff interview, resident representative interview, it was determined the facility failed to ensure appropriate information was communicated to a home health care provider upon the discharge of a resident. This was true for 1 of 5 residents (Resident #157) who were reviewed for discharge from the facility. The deficient practice created the potential for harm if home health services were not provided as ordered for the resident. Findings include: Resident #157 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including Lewy Body dementia (abnormal protein deposits), congestive heart failure, chronic pain, abnormalities of gait and mobility, muscle weakness, dysphagia (difficulty swallowing), and severe protein-calorie malnutrition. A physician's order, dated 4/14/17, documented May discharge home with home health physical therapy [PT], occupational therapy [OT], and nursing. Resident #157's Discharge summary, dated [DATE], documented she was returning home with home health services per her request. Resident #157's Initial Discharge Planning record, dated 1/23/17, documented she had previously used in-home care and services from an agency. It was the same home health care provider documented in the Discharge Summary. A social services progress note, dated 4/19/17, by the RSD documented Resident #157 was discharged to home on 4/15/17, she worked with PT, OT, and speech therapy during her stay in the facility, and she met all of her goals for discharge. A home evaluation was completed prior to discharge, tube feedings were discontinued and, the RSD documented home health was arranged following discharge of Resident #157. On 11/29/18 at 5:28 PM, the RSD said she asked residents if they received home health care in the past and which agency provided the care. She said she normally sent a face sheet, History and Physical by the physician, the MARs and TARS, physician orders, including the discharge order, and the last physician visit note by fax to the home health provider. When asked how she knew the home health provider received the referral information for Resident #157, the RSD said she watched the fax machine to see the confirmation page but she did not retain the fax confirmation. The RSD reviewed Resident #157's clinical record and said she did not document what she faxed to the home health provider and there were no copies of what she faxed to the home health care provider in the record. The RSD said she did not find documentation she communicated by phone or in person with the home health provider. On 11/30/18 at 11:58 AM, the Business Manager of the home health care provider said they did not receive any referral information for Resident #157 in 2017. The Business Manager said all referrals for their home health services went through the business office and they kept all referral information whether the person was admitted or not. She said the last time the home health care provider received a referral for Resident #157 was in 2016. On 11/30/18 at 3:53 PM, Resident #157's representative said home health care was not provided after her discharge from the facility on 4/15/17, and she was hospitalized 10 days later. The representative said she contacted the home health care provider later and they said they never received any referral information in April 2017.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, it was determined the facility failed to ensure the baseline care plan included communication as a potential barrier for 1 of 3 residents (Resident #1) who were non-English speaking and who were reviewed. The failure created the potential for harm if the care and services provided did not meet her needs or was contrary to her wishes due to lack of direction regarding her preferred language. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including a pelvic fracture, generalized muscle weakness, acute kidney failure, and major depressive disorder. Resident #1's most recent MDS assessment, dated 8/22/18, documented her preferred language was Spanish and she preferred a spanish interpreter to communicate with health care staff and the physician. Resident #1's Baseline Care Plan and Initial Discharge Plan, dated 5/24/18, did not document her preferred language or identify interventions for communication. On 11/26/18 at 3:40 PM, LPN #1 said Resident #1 spoke only Spanish. LPN #1 confirmed the facility had access to an interpreter twenty-four hours per day, seven day per week, and some of the staff spoke Spanish. On 11/27/18 at 9:03 AM, Resident #1 was observed talking in Spanish with a staff member. On 11/27/18 at 2:26 PM, Resident #1 was interviewed with the assistance of NA Student #1 interpreting Spanish. Resident #1 said only one staff member spoke Spanish, and the other staff did not use the interpreter service. On 11/30/18 at 4:20 PM, the UCC reviewed Resident #1's Baseline Care Plan. She said Resident #1's preferred language was not included in the Baseline Care Plan but it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure the care plan was revised to reflect a resident's current status and needs. This was true for 1 of 24 residents (Resident #1) whose care plans were reviewed. The failure to revise Resident #1's care plan when her dialysis access device site changed created the potential for harm if her care was not provided and/or decisions were made based on inaccurate information. Findings include: Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure. On 11/27/18 at 2:55 PM, Resident #1 said she had just returned from dialysis. She showed the surveyor her dialysis access device in her right upper arm, and where she had a previous access device on her left upper chest. A clean, dry, and intact dressing was on the right arm access site. Resident #1 said the facility staff did not check her access device after dialysis and she was the one who removed the dressing 4 hours after dialysis. Resident #1's care plan, dated 8/22/18, included approaches regarding dialysis/renal failure. Interventions on the care plan included: * Check the left subclavian (chest wall) dialysis access device site for signs and symptoms of infection, pain, or bleeding, daily and as needed. * Remove the dialysis access device site dressing 4 hours after return from dialysis. * No bandaids on fistula (right upper arm). Resident #1's record included vascular surgeon office visit note. The notes documented the following: * 9/10/18 - .She is status post creation of a right upper arm primary AV [arterial/venous] fistula. She is currently dialyzing through a left IJ [internal jugular] tunneled dialysis catheter .Her right upper arm access has not been struck yet .On physical exam, her access is a nice thrill .I looked at her fistula with duplex scan .and [it] should be ready to access .contact dialysis and told him to start using her fistula . * 10/24/18 - .her dual-lumen tunneled hemodialysis catheter .was removed in its entirety . On 11/30/18 at 11:15 AM, the DON said Resident #1's left subclavian dialysis access device was removed and the dialysis access device was now in her right upper arm. She said the care plan was not updated to include the new dialysis access device and the removal of the old device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, it was determined the facility failed to ensure activities met the interests and supported the physical, mental, and psychosocial well-being of each resident. This was true for 1 of 24 residents (Resident #1) who were reviewed for activities. This failure created the potential for residents to become bored or depressed when she was not provided with meaningful engagement throughout the day. Findings include: Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including a pelvic fracture, generalized muscle weakness, acute kidney failure, and major depressive disorder. Resident #1's quarterly MDS assessment, dated [DATE], documented her preferred language was Spanish and she needed or wanted an interpreter to communicate with health care staff. Her hearing and vision were adequate and her speech was clear. Her cognition was modified independent (some difficulty in new situations only). It was very important to her to listen to music that she liked, be around animals, do favorite activities, and participate in religious services or practices. It was somewhat important to have things to read, keep up with the news, and do things with groups of people. Resident #1's comprehensive care plan included the following problems and interventions: * Communication barrier related to her speaking Spanish with a minimal understanding of English, dated [DATE]. Staff were directed to use alternative communication tools, family contact and some staff as translators, a picture recognition book, Gestures, watching Spanish speaking channels on television, and speaking with other Spanish speaking residents. * Alteration in her mood related to depression, dated [DATE]. Staff were directed to use a translator, encourage interest in favorite past times and interactions with peers. Resident #1's care plan documented on [DATE], she enjoyed doing her favorite activities, which included crafts and fingernail care/polish, are very important to her. The activities staff were directed to translate the morning activity paper and use Google translate during activities. Resident #1's Activities Evaluation, dated [DATE], documented current events/news was very important to her, as were family/friend visits, knitting/crocheting, and music. It was documented she wanted staff to take her to fingernail care/polish and craft activities, and she loved cooking and crocheting. On [DATE] at 3:35 PM, Resident #1 was in her room sitting in her wheelchair looking toward the window. No lights were on in her room. When the surveyor knocked at her door, she smiled and waved the surveyor into her room. She said she did not speak English in Spanish and nodded her head up and down when the surveyor spoke in English. On [DATE] at 2:26 PM, Resident #1 was in her wheelchair in her room. She was wearing her coat. NA Student #1 assisted with interpreting, and Resident #1 said she just returned from dialysis. She said she did go to some activities but she did not participate because she did not understand or know how to do the activity. She said she would like to do more activities but many of the staff only spoke English and she did not understand them. On [DATE] at 11:32 AM, the Activities Director (AD) said all residents were given a printed list of the activities for that day, and her assistant translated the daily activities lists to Spanish for Resident #1. The AD accompanied the surveyor to Resident #1's room and pointed out the translated activity list for Wednesday, [DATE]. The AD said the facility previously used an online program called Activities Connection and Resident #1 really enjoyed reading the daily chronicles in Spanish. The AD said the Activities Connection subscription had expired recently and she was waiting for approval to renew the subscription. The AD said all activities were conducted in English and she and her assistant previously used Google translator on their cell phones to translate for Resident #1 at the beginning of an activity. The AD stated it was difficult to translate and conduct the activity at the same time. On [DATE] 5:30 PM, the AD provided Resident #1's Individual Resident Daily Participation records for September, October, and [DATE] which documented the following: * [DATE]: - She actively participated in a beauty/barber activity three times ([DATE], [DATE], and [DATE]). - She listened to the radio, watched television, and read her Bible daily from [DATE] to [DATE]. - She actively participated in a social activity/party three times ([DATE], [DATE], and [DATE]). - She actively participated when a family/friend visited twice ([DATE] & [DATE]). There was no documentation Resident #1 participated in activities with animals/pets, arts/crafts, current events/news, or knit/crochet. * [DATE]: - She actively participated in a beauty/barber activity once ([DATE]). - She actively participated in a social activity/party once ([DATE]). - She read her Bible daily from [DATE] to [DATE] and [DATE] to [DATE], and on [DATE] and [DATE]. - She watched television five times ([DATE], [DATE], [DATE], [DATE] and [DATE]. There was no documentation Resident #1 participated in activities with animals/pets, arts/crafts, current events/news, or knit/crochet. * [DATE]: - She actively participated in a beauty/barber activity once ([DATE]). - She actively participated when a family/friend visited three times ([DATE], [DATE], and [DATE]). - She activity participated in a music activity once ([DATE]). - She did not read her Bible, listen to the radio, or watch television. - She activity participated when a staff member made daily visits 5 times ([DATE], [DATE], [DATE], [DATE], and [DATE]). There was no documentation Resident #1 participated in activities with animals/pets, arts/crafts, current events/news, or knit/crochet. On [DATE] at 11:30 AM, the AD said there was one other Spanish speaking resident in the facility but that resident did not come out of his room very much. She said the facility did not have a policy regarding activities for residents with a communication barrier. She said she checked to see if the facility had a policy regarding cell phone use. She said the facility did have a cell phone use policy and cell phone use for resident needs was approved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, resident interview, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 5 of 25 residents (#39, #46, #50, #258, and #260) who were reviewed for standards of practice. This failure created the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include: 1. The Nursing 2018 Drug Book included specific recommendations for crushing medications. One recommendation stated crushing certain oral medications may alter the drug's effect causing overdose or other adverse reactions. Before crushing a medication, always check with the pharmacist and established references. The facility's Oral Medication Administration policy, dated 11/2017, documented staff will check for specific prescriber orders to crush medications. Crush medications, if indicated, for a resident only after referring to the Medications Not To Be Crushed List. For products that appear on the Medications Not To Be Crushed List, check with the pharmacist regarding a suitable alternative and request a new prescriber order if appropriate. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including dysphagia (difficulty swallowing), right side hemiplegia and hemiparesis (paralysis and weakness) related to cerebral infarction (stroke), and generalized muscle weakness. Resident #39's admission MDS assessment, dated 10/29/18, documented her cognition was intact and family or significant other participated in the assessment. The MDS assessment documented Resident #39's nutrition required a mechanically altered diet. On 11/27/18 at 8:50 AM, LPN #7 was observed administering medication to Resident #39 that was not crushed. The medications included Eliquis 5 mg, Prozac (antidepressant)10 mg, calcium carbonate 200 mg/500 mg, docusate sodium (stool softener) 100 mg, and amlodipine (blood pressure medication)10 mg. All medications were given with water and Resident #39 was observed having difficulty swallowing the medication. On 11/27/18 at 4:38 PM, LPN #6 was observed administering medication to Resident #39 that was crushed. The medications included calcium carbonate 200 mg/500 mg and docusate sodium 100 mg. LPN #6 observed Resident #39 had regular water at the bedside and stated to Resident #39 even though she was reevaluated by the SLP to start regular water, she should have nectar thick water until there was an order submitted by the SLP. LPN #6 then removed the water and replaced it with nectar thick water. LPN #6 stated she was not sure why LPN #7 did not crush the medications in the morning. LPN #6 stated LPN #7 should have known to crush Resident #39's medications before administering them. LPN #6 stated she was crushing Resident #39's medications for awhile and knew to administer crushed medications during nursing shift report. LPN #6 stated she thought there was a documented order or record that designated medications to be crushed. LPN #6 provided the MAR and physician orders from Resident #39's record, there was no documentation directing staff to crush medications and provide nectar thick water. On 11/28/18 at 10:00 AM, LPN #3 stated he gave uncrushed medication to Resident #39 on that day and the last time, about 4 days ago, he gave her crushed medications. LPN #3 stated pill packs, provided by the pharmacy did not document which medications should be crushed. On 11/28/18 at 10:10 AM, the DON stated she did not know why there was not an order for crushed medications for Resident #39. The DON stated the process for new orders was to document in the resident's record and MAR, then the resident's electronic record was updated as time permitted, and it could take up to a month. The DON stated when residents had issues with dysphagia, nursing staff should notify the physician or the SLP. On 11/28/18 at 1:30 PM, the DON stated staff were to crush medications by direction of a physician's order and it would be documented on the MAR. On 11/28/18 at 2:41 PM, Resident #39 stated she usually received her medications crushed, and there was only one medication she took as a whole pill. On 11/30/18 at 9:00 AM, the SLP stated based on her understanding Resident #39 was taking crushed medications for at least two weeks and probably longer than that. The SLP stated during an assessment she evaluated a resident's ability to swallow by initiating a number of test trials with items such as candy pieces. The SLP stated she evaluated Resident #39 and determined she was able to swallow some pills but not all pills, the bigger pills were more difficult for her to swallow. The SLP stated the DOR and UCC instructed her to not recommend or order medications to be crushed unless she could recommend all medications could be crushed. The SLP made the recommendation to have some of Resident #39's medications crushed, and they told her she could not do that because it was either all or none. At 11/30/18 at 11:45 AM, the Administrator stated she expected there was a physician's order to crush medications. The Administrator stated she did not know what the facility's policy for crushing medications was, and she was not sure if the order could be submitted by the SLP or by nursing staff. 2. Resident #46 was admitted to the facility on [DATE], with diagnoses including atherosclerotic heart disease, atrial fibrillation (irregular heart rhythm), muscle weakness, and wounds to BLE. Review of Resident #46's quarterly MDS assessment, dated 11/10/18, documented he was cognitively intact. A physician order, dated 9/28/18, documented Resident #46 was to have tubigrip stockings(compression stockings to reduce edema in the lower extremities) twice daily, on in morning and off at bedtime for edema. Resident #46's record included a Progress Note, dated 11/2/18, which documented the RN noted 3+ pitting edema to his bilateral feet/ankles. The RN documented Resident #46 was educated about the importance of elevating his BLE, as well as compliance with the tubigrips. The progress note documented the physician was notified and agreeable with the plan of care. At the bottom of the progress note the physician added a hand-written statement which documented OK. Make sure compliant with compression stockings. Resident #46's November 2018 TAR documented he was to wear compression stockings to both legs daily. The TAR documented the facility did not apply the compression stockings as ordered by the physician on 11/15/18, 11/16/18, 11/18/18, 11/23/18, 11/27/18, and 11/28/18. On 11/28/18 at 10:55 AM, Resident #46 stated a CNA had removed the stockings and told him they [stockings] were too nasty to wash. Resident #46 stated the CNA had not replaced the stockings, and there were several occasions where the staff failed to apply the compression stockings. At the time of the interview, Resident #46 was not wearing the compression stockings and he stated, I have edema and need them on. On 11/29/18 at 9:50 AM, LPN #2 stated it was the responsibility of the CNAs to apply the stockings. On 11/29/18 at 10:00 AM, CNA #1 stated it was the nurse's responsibility to apply the compression stockings because it was a treatment. On 11/29/18 at 10:25 AM, the DON stated the compression stockings could be applied by either the CNAs or the LPNs. The DON stated the CNAs should notify the LPN if the resident refused or if there was a problem, and the LPN should document the conversation. The DON stated if the CNA failed to apply the stockings it fell to the LPNs to ensure the orders were followed. The DON reviewed the November TAR for Resident #46 and confirmed it was blank with no documentation to indicate the compression hose were applied as ordered for the above listed dates. 3. The Centers for Disease Control and Prevention (CDC) website, updated on 8/15/18, and accessed on 12/3/18, included specific recommendations for hypoglycemia. One recommendation was keeping blood glucose levels as close to target as possible to help prevent complications. The CDC also stated regular blood glucose monitoring was the most important intervention to manage diabetes. The CDC website stated with low blood glucose levels the brain does not get enough glucose and stops functioning as it should. The facility's Hypoglycemic Reaction policy, dated 10/2014, included directions and guidelines for the care of the resident experiencing a hypoglycemic reaction. The policy stated the nurse must use good clinical judgment in the treatment of the resident based on the blood glucose value, resident specific parameters of blood glucose ranges, and the consciousness of the resident. The policy further stated staff will document in the record the signs and symptoms, assessment, blood glucose values, attempts to give oral carbohydrates, glucagon injection location, the resident's response, and notification of physician and family. Resident #50 was admitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus with other diabetic kidney complications, long term use of insulin, and hypertension. Resident #50's admission MDS assessment, dated 11/14/18, documented his cognition was moderately impaired, and family or significant other participated in the assessment. The MDS assessment documented Resident #50 received insulin medication on a routine basis. Resident #50's physician orders, dated 11/7/18, documented he was prescribed Humalog (insulin) and sliding scale insulin. The American Diabetes Association defines sliding scale as a set of instructions for adjusting insulin on the basis of blood glucose test results, meals, or activity levels. Resident #50's care plan, dated 11/8/18, identified his Type 2 diabetes mellitus and the order for Humalog insulin and sliding scale therapy. The care plan identified hypoglycemic goals and directed staff to perform blood sugar checks and monitor signs and symptoms of hypoglycemia. Resident #50's MAR documented on 11/15/18, he had a blood sugar value of 65, and on 11/21/18, he had a blood sugar value of 60. Resident #50's November 2018 Blood Glucose Protocol record did not document an intervention on 11/15/18 or 11/21/18. The Blood Glucose Protocol documented the following: - Notify physician for blood sugars less than 60 or greater than 400 unless specified by sliding scale. Follow facility clinical protocol. - If the resident's blood sugar is less than 80, resident is awake with an intact gag reflex, and can swallow, give 15-20 grams of fast acting glucose. (Ex: 120 cc juice, glucose gel, 4 tsp sugar mixed in liquid.) Repeat blood sugar in 15 minutes. If blood sugar less than 80 repeat 15-20 grams of fast acting glucose. Repeat blood sugar in 15 minutes. Repeat above steps until resident is stable and blood sugar is at or above 80. Follow up with meal or significant snack. (document amount consumed) Recheck blood sugar in 15 minutes. If not responding to treatment give glucagon and call MD. - If the resident is unconscious or cannot ingest sugar treatment: Give glucagon 1 mg subcutaneous (into soft tissue) or intramuscular (into the muscle). Recheck blood glucose in 15 minutes or sooner if condition worsening. If resident is responding: give 15-20 gram of fast acting glucose, (ex: 120 cc juice, glucose gel or 4 tsp sugar). Recheck blood sugar in 15 minutes, if blood sugar is greater than 80 follow up with a meal or significant snack (document amount consumed). If resident fails to respond, call Emergency Services, physician and family. On 11/29/18 at 11:25 AM, LPN #4, with the RDCS present, stated he followed the hypoglycemic protocol and verbalized the entire protocol description from the MAR. After reviewing Resident #50's record, LPN #4 confirmed he had a low blood glucose on 11/15/18 and 11/21/18, and he sometimes had a low blood sugar at night. LPN #4 then reviewed the sliding scale numbers and parameters for Resident #50, which documented for a blood sugar less than 149, hold the insulin. LPN #4 stated the sliding scale indicated a value at which insulin should not be given and no other interventions. LPN #4 stated he would not follow the hypoglycemic protocol on the MAR, and that was the reason why there was not an intervention on the hyperglycemic protocol sheet and a recheck blood sugar was not done. On 11/29/18 at 12:45 PM, the DON, with the UCC and RDCS present, stated the hypoglycemic protocol should be individualized for each resident. The DON stated Resident #50 should have had an intervention and blood sugar check after 15 minutes and documented on the protocol sheet. The DON stated the sliding scale should not be used as the number for intervention of blood sugars less than 60 or 80. 4. The American Association for Respiratory Care (AARC) website, updated on 10/24/16, and accessed on 12/3/18, stated the body needs oxygen to keep the blood adequately saturated in order for cells and tissues to get enough oxygen to function properly. The website included the recommendation for supplemental oxygen when the oxygen saturation falls below 89 percent, or when the arterial oxygen pressure falls below 60 mmHg (millimeters of mercury). The facility's Oxygen Therapy policy, dated 2/20/15, directed staff to ensure all patients who require supplementary oxygen receive therapy that is appropriate to their clinical condition. a. Resident #258 was admitted to the facility on [DATE], with multiple diagnoses including pneumonia due to haemophilus influenzae (bacterium that can cause a severe infection), acute and chronic respiratory failure with hypoxia (lack of oxygen), insomnia, other lung disorders, and dysphagia (difficulty swallowing). Resident #258's admission MDS assessment, dated 11/29/18, documented she received oxygen therapy. Resident #258's physician orders, dated 11/21/18, documented she was prescribed an oxygen flow rate of 4 liters via nasal cannula or by mask to keep oxygen saturation greater than or equal to 90% and to check oxygen saturation levels as needed for shortness of breath. On 11/26/18 at 4:24 PM, Resident #258's cognition was observed to be intact. She was sitting in her recliner and received an oxygen flow rate of 3 liters via nasal cannula. Resident #258 stated she should have been receiving 4 liters of oxygen via nasal cannula. On 11/26/18 at 6:00 PM, the UCC stated checked Resident #258's oxygen setting from the wall concentrator and stated the oxygen flow rate was set at 3 liters via nasal cannula. The UCC then reviewed the physician's orders for Resident #258 and stated the oxygen flow rate should have been set at 4 liters via nasal cannula. The UCC then changed the settings to an oxygen flow rate of 4 liters. b. Resident #260 was admitted to the facility on [DATE], with multiple diagnoses including obstructive sleep apnea, chronic obstructive pulmonary disease, and muscle weakness. Resident #260's physician orders, dated 11/19/18, documented she was prescribed continuous oxygen at 2 liters via nasal cannula. Resident #260's November 2018 MAR documented she was to receive 2 liters of oxygen via nasal cannula to maintain an oxygen saturation greater than or equal to 92% and document every shift. On 11/26/18 at 4:51 PM, Resident #260's cognition was observed to be intact. She was lying in bed and had an oxygen flow rate of 1 liter via nasal cannula. The humidifier was not bubbling. Resident #260 stated she should have been receiving 2 liters of oxygen via nasal cannula. On 11/26/18 at 6:15 PM, the UCC checked Resident #260's oxygen setting on the wall concentrator and stated the oxygen flow rate was set on 1 liter via nasal cannula. The UCC then reviewed the physician's orders for Resident #260 and stated the oxygen flow rate should have been set at 2 liters via nasal cannula. The UCC then changed the settings to an oxygen flow rate of 2 liters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, review of the facility/dialysis provider agreement, and review of facility policy, it was determined the facility failed to ensure physician orders and the care plan related to dialysis care and services were updated and implemented when the access device site changed, and that pre and post-dialysis assessments were consistently completed for 1 of 1 resident (Resident #1) who was reviewed for dialysis. The failure created the potential for harm if undetected complications went untreated or there was a delay in treatment. Findings include: The facility/dialysis provider agreement, made and entered into on 10/18/07, documented, .Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to Center [dialysis provider]. This information, shall include . Treatment presently being provided to the Designated Resident, including medications and any changes in a patient's condition . Any other information that will facilitate the adequate coordination of care, as reasonably determined by Center .Facility will provide for the interchange of information useful or necessary for the care of the Designated Resident . The facility's Dialysis policy, revised 11/28/16, documented, The dialysis patient shall receive consistent care pre and post-dialysis. The shunt site shall be checked on a daily basis . and, on the Day of Dialysis, facility staff were to complete and send the dialysis form with the resident and after dialysis they were to, 1. Obtain vital signs .2. Follow routine dialysis instructions on dialysis transfer form .5. Monitor shunt site on a routine basis . Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure. Resident #1's dialysis/renal failure care plan, dated 8/22/18, included approaches to: * Check her left subclavian dialysis access device site for signs and symptoms of infection, pain, or bleeding daily and as needed * Communicate her care in collaboration with the dialysis center * Remove the dialysis access device site dressing 4 hours after her return from dialysis Resident #1's physician orders,dated 9/25/18, included the following: * The left subclavian access site dressing to be changed by the dialysis provider after dialysis on Tuesday, Thursday, and Saturday; * Facility staff to observe the left subclavian access device site every shift for signs and symptoms of infection (redness, swelling, pain, drainage, etcetera) and document + if present / - if not present and notify the dialysis provider if needed. * Lidocaine cream 3% - rub on right arm port site one hour before dialysis 3 times weekly. On 11/27/18 at 9:03 AM, Resident #1 was observed near an exit in her wheelchair wearing a coat and talking with the transportation staff member. The transportation staff member said she was going to take Resident #1 to dialysis. On 11/27/18 at 2:55 PM, Resident #1 said she had just returned from dialysis. She showed the surveyor her dialysis access device in her right upper arm, and where she had a previous access device on her left upper chest. A clean, dry, and intact dressing was on the right arm access site. Resident #1 said the facility staff did not check her access device after dialysis and she was the one who removed the dressing 4 hours after dialysis. Resident #1's clinical record included Pre/Post Dialysis Communication records. These records had 3 sections with instructions for facility staff to complete pre-dialysis and post-dialysis assessments. The dialysis center was to complete the second section. The pre and post-dialysis sections included areas to document vital signs (temperature, blood pressure, pulse, and respirations), weight in pounds with a box to check if she refused to be weighed, the condition of the access/site, whether thrill and bruit (thrill, or vibration, indicates arterial and venous blood flow and patency; bruit, or a swishing sound, indicates patency) were present or not, and the signature/title of the person completing each section. Resident #1's Pre/Post Dialysis Communication records for November 2018 documented the following: * She was not weighed, and there was no documentation she refused to be weighed, for the pre-dialysis assessments on 11/1/18, 11/3/18, 11/6/18, 11/10/18, 11/15/18, 11/17/18, 11/20/18, 11/22/18, 11/24/18, 11/27/18, and 11/29/18. * Her pulse was not checked on 11/29/18, pre-dialysis. * She was not monitored post-dialysis, this section was blank, on 11/1/18, 11/3/18, 11/6/18, 11/13/18, 11/15/18, 11/17/18, 11/20/18, 11/24/18, 11/27/18, and 11/29/18. * She was not weighed and there was no documentation of a refusal for post-dialysis on 11/10/18 and 11/22/18. * The condition of her access site and the thrill and bruit were not assessed post-dialysis and the staff member did not document their signature/title on 11/15/18. * Thrill was not assessed post-dialysis on 11/22/18. Resident #1's vascular surgeon office visit notes documented the following: * 9/10/18 - .She is status post creation of a right upper arm primary AV [arterial/venous] fistula. She is currently dialyzing through a left IJ [internal jugular] tunneled dialysis catheter .Her right upper arm access has not been struck yet .On physical exam, her access is a nice thrill .I looked at her fistula with duplex scan .and [it] should be ready to access .contact dialysis and told him to start using her fistula . * 10/24/18 - .her dual-lumen tunneled hemodialysis catheter .was removed in its entirety . On 11/29/18 at 4:58 PM, RN #1 said Resident #1 returned to the facility sometime around 2:00 PM but she had not seen her yet. The RN said she removed the dressing off her left arm access device between 4 to 6 hours after her return to the facility and she checked for the bruit at that time. She said nurses removed the dressing, not the resident. Regarding the pre and post dialysis communication form, RN #1 said she had not been completing the post dialysis section because she did not know it needed to be completed. On 11/30/18 at 10:00 AM, the DON reviewed Resident #1's dialysis communication forms and said the nurses were not consistently completing the dialysis communication forms. She said however, the facility's Registered Dietitian (RD) and the dialysis center RD had decided the facility would use the weights obtained at the dialysis center. On 11/30/18 at 11:15 AM, the DON said Resident #1's left subclavian dialysis access device was removed and the access device was in her right upper arm now. She said the care plan and MAR were being updated to reflect the change. The DON said she did not find documentation of communication between the facility RD and the dialysis center RD regarding monitoring Resident #1's weight. She said Resident #1's weight should have been obtained and monitored pre and post-dialysis, but confirmed it was not.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration to residents. This was true for 1 resident (#4), 2 of 2 medication storage rooms, and 1 of 4 medication carts reviewed for storage and labeling medication. This failure had the potential for harm should residents receive expired medications with decreased efficacy, potency, and safety. Findings include: The U.S. Food and Drug Administration (FDA) website, updated on 9/6/18, and accessed on 12/3/18, included specific recommendations for expired medication. One recommendation documented the medicine expiration date was a critical part of deciding if the product was safe to use and would work as intended. The expiration date reflects the time period during which the product was expected to remain stable, or retain its identity, strength, quality, and purity, when it was properly stored according to its labeled storage conditions. The FDA recommended the safest route to always use medications that are not expired. The facility's Medication Storage policy, dated 11/2017, directed staff to ensure outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy. On 11/27/18 at 9:00 AM, LPN #7 was observed administering medications to residents, and the medication storage room on the Sawtooth Floor of the facility was reviewed for storage and labeling concerns. Medications were not appropriately labeled and stored, and were expired. Examples include: - The medication storage room had 2 opened and partially used Vashe Wound Solution. The containers were not labeled with a resident's name and were placed among other new supplies. LPN #7 acknowledged the Vashe containers were opened and unlabeled, and then threw them away. - 20 containers of Jevity 1.2 CAL were observed in the medication storage room with an expiration date of 10/19/18. LPN #7 acknowledged the expired Jevity 1.2 CAL and stated it would be taken care of by the Central Supply Director (CSD). On 11/27/18 at 9:13 AM, the CSD stated she knew about the expired Jevity but she forgot about it. She was going to throw it out, but let it lapse because she did not have anyone to take care of it. The CSD stated she did not know about the Vashe being opened and it would be taken care of. On 11/28/18 at 1:47 PM, LPN #2 reviewed the medication in the refrigerator of the medication storage room on the Shoshone Falls Floor of the facility. The medication refrigerator contained Lorazepam 2mg/1ml oral for Resident #4 with an expiration date of 9/14/18. LPN #2 acknowledged the expired date and said she would take care of it. On 11/28/18 at 1:47 PM, LPN #2 reviewed the medication cart on the Shoshone Floor of the facility. One opened and partially used Vashe Wound Solution container was in the cart and was not labeled with a resident's name. LPN #2 stated Vashe was used for a single resident but they were no longer using it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to implement the antibiotic stewardship protocol for 1 of 2 residents (Resident #50) who were reviewed for antibiotic use. This deficient practice created the potential for harm should residents receive ineffective or unnecessary treatment for a suspected urinary tract infection. Findings include: Review of the Antibiotic Stewardship protocol, dated 3/2017, documented nurses are to complete a suspected UTI (Urinary Tract Infection) SBAR (Situation, Background, Assessment, Recommendation) document before contacting the physician for orders. Resident #50 was admitted to the facility on [DATE], with multiple diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms. Resident #50's physician orders, dated 11/28/18 at 9:30 AM, documented Start Ceftin (a medication to fight bacteria) 250 milligrams by mouth BID (twice daily) x 10 days if not already started on something. Review of Resident #50's preliminary urine culture report, dated 11/29/18 at 4:00 PM, identified the presence of yeast. Resident #50's physicians orders, dated 11/29/18 at 4:10 PM, directed staff to discontinue the Ceftin and start Diflucan (an antifungal medication) 100 mg by mouth daily for 14 days. Resident #50's record did not document a UTI SBAR was completed after a UTI was suspected. On 11/30/18 at 12:21 PM, RN #5 stated the best practice was for the physician to get the preliminary culture report back before prescribing an antibiotic. RN #5 stated if a resident had discomfort, then Pyridium (a medication that helps to alleviate urinary tract symptoms) could be prescribed until the report was obtained. On 11/30/18 at 12:33 PM, RN #5 confirmed the antibiotic stewardship protocol was not followed for Resident #50.