Bear Lake Memorial Skilled Nursing Facility

Inspectors wroteBased on observation, interview, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods, and use proper hand hygiene when serving food. 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.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of psychotropic medications for 1 of 12 residents (Resident #6) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 2 of 12 residents (#30 and #35) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention.

Inspectors wroteBased on observation and resident and staff interviews, it was determined the facility failed to ensure residents were provided with a safe and clean, homelike environment that did not pose any safety risks. This was true for 1 of 6 resident room doors (room [ROOM NUMBER]) whose room doors were opened. This deficient practice created the potential for diminished quality of life and psychosocial distress for residents when their room doors do not open correctly or fully to allow entrance or exit of the room.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 2 of 12 residents (Resident #7and Resident #23) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 12 Residents (#1 and #35) reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when physicians were not contacted regarding residents not having a BM within the last 72 hours.

Inspectors wroteBased on observation, facility policy review, record review, and interviews, it was determined the facility failed to provide respiratory services consistent with professional standards of practice. This was true for 3 of 3 residents (#4, #11 and #27) whose SpO2 documentation and respiratory equipment was observed. This failure created the potential for residents' oxygen status and health to be affected and respiratory equipment to malfunction and possibly catch fire.

Inspectors wroteBased on record review and staff interviews, it was determined the facility failed to have an RN on duty for at least 8 consecutive hours a day. This was true for 1 of 3 days reviewed for RN coverage. This created the potential for harm if routine and/or emergency nursing services went unmet and had the potential to affect all residents residing at the facility.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was maintained for 18 months after it had been posted. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased 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 inthe facility.

Inspectors wroteBased on observation, interviews, and facility policy review, it was determined the facility failed to ensure medications were secured in a locked medication cart, and of expired medications were removed. This was observed in 2 of 2 medication carts. This failure created the potential for residents to obtain prescribed medications used for other residents, presented the risk for cross-contamination of products, and receive expired medications with decreased efficacy.

Inspectors wroteBased on observation, policy review, and staff interviews, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff did not remove dirty gloves, perform hand hygiene, and redon gloves before continuing to serve residents food. This deficient practice had the potential to contaminate served food items and make residents ill.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment. This was true for 1 of 2 medication carts whose sharps containers were overfilled. This failure had the potential for injury and infections.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the physician responded to the Pharmacist's recommendations to review the need for antibiotics ordered prophylactically (to potentially prevent) urinary tract infections (UTIs) for two of five residents (Resident (R) 3 and R4) reviewed for unnecessary medications out of 17 sampled residents. This had the potential for both residents to experience adverse medication reactions.

Inspectors wroteBased on record review, interview, review of the Centers for Disease Control (CDC) guidance on Antibiotic Stewardship, and review of facility's policy, the facility failed to ensure two of five residents (Resident (R) 3 and R4) reviewed for unnecessary medications out of a sample of 17 residents had appropriate clinical indications for the use of an antibiotic. This had the potential for adverse drug reactions for both residents.

Inspectors wroteBased on observation, policy review, staff interview, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 2 residents (#3 and #28) reviewed for pressure ulcers. Resident #3 was harmed when she developed a suspected deep tissue injury that worsened to a Stage IV (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) pressure ulcer to her sacrum (bottom of the spine). Resident #28 was harmed when she developed an unstageable pressure ulcer to her sacrum and suspected deep tissue injuries to her right heel and left calf.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure bowel care interventions were developed and implemented for 3 of 3 residents (#14, #15, and #17) reviewed for bowel care. This deficient practice placed residents at risk of harm related to complications from constipation or impaction.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure an RN was on duty 8 hours a day 7 day a week to provide care and treatment to the residents. This was true for 4 of the 21 days reviewed. This affected 8 of 8 (#1, #3, #13, #14, #15, #17, #28, and #33) residents residing in the facility and had the potential to affect the other 26 residents residing in the facility. This created the potential for harm if residents' nursing needs went unmet.

Inspectors wroteBased on resident representative and staff interview, policy review, and record review, it was determined the facility failed to provide a financial record, or quarterly statement, to 2 of 2 residents (#3 and #28) whose personal fund accounts were reviewed. This failure created the potential for harm if concerns, including inaccuracies, about the personal fund accounts were not addressed.

Inspectors wroteBased on record review, review of billing records, and staff interview, it was determined the facility failed to ensure residents were provided advance notice of the reason their Medicare Coverage A was being terminated during their stay in the SNF and how to appeal the termination process. This deficient practice was true for 2 of 3 residents (#2 & #19) reviewed for notice of Medicare non-coverage (NOMNC). This failure created the potential for residents to experience financial distress and psychological harm when residents were not informed of how to appeal the ending of their Medicare coverage.

Inspectors wroteBased on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure comprehensive care plans were developed and implemented to address the diabetic and range of motion needs of residents. This was true for 2 of 12 residents (#1 and #33) whose care plans were reviewed. These deficient practices created the potential for the residents to receive inappropriate or inadequate care with subsequent decline in health.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised as care needs changed. This was true for 2 of 12 residents (#3 and #13) reviewed for care plan revision. This failure had the potential for the residents to receive inappropriate or inadequate care with subsequent decline in health.