Life Care Center of Sandpoint

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the kitchen was cleaned, the resident freezer was cleaned, and staff food was not stored with resident food. These deficiencies had the potential to affect the 71 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on observation, policy review, record review, CDC guidance review, and interviews it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment, and to help prevent the transmission of communicable diseases and infection. Specifically the facility did not perform a facility wide testing for COVID 19 as advised by their local Health Department, personal protective equipment (PPE) was not don properly, hand hygiene was not performed during residents' cares, and medical equipment was not stored in a sanitary manner.

Inspectors wroteBased on policy review, record review, and staff interviews, it was determined the facility failed to ensure residents were offered and/or administered the appropriate pneumococcal vaccine as indicated. Additionally, the facility failed to ensure residents' refusals to receive pneumococcal vaccinations were addressed each year. This was true for 5 of 5 residents (#3, #7, #8, #60 and #78) reviewed for pneumococcal immunizations. This deficient practice placed residents at risk of developing pneumococcal pneumonia a potentially life-threatening condition.

Inspectors wroteBased on record review, CDC guidance and interviews, it was determined the facility failed to ensure COVID vaccinations were offered, administered, and re-offered to the residents. This was true for 4 of 4 residents (#7, #8, #60 and #78) whose COVID vaccinations were reviewed. This deficient practice placed residents at risk of severe illness, hospitalization, and death due to SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus - the virus that cause the COVID-19 illness) and had the potential to all affect all residents in the facility.

Inspectors wroteBased on observation, staff interview, and policy review, it was determined the facility failed to ensure residents were treated with dignity when eating in the dining room. This was true for 1 of 16 resident's (Resident #49) observed during dining observation. This deficient practice had the potential to cause psychosocial harm if the resident felt he was not as important as other residents, and physical harm if his nutritional needs were not met.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure residents had a homelike environment. This was true for 1 of 18 resident's (Resident #32) who were observed for homelike environment. Resident #32's room was observed to be soiled and unkept. This deficient practice created the potential for psychosocial harm if residents were not provided with the same homelike environment as other residents, and potential harm if the residents lived in unsanitary conditions.

Inspectors wroteBased on the review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure a residents' Minimum Data Set (MDS) assessment included accurate information. This was true for 2 of 3 residents (#7 and #10) who were reviewed for accuracy of assessments. This deficient practice had the potential for negative consequences if residents were not monitored due to inaccurate assessments.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to refer residents with a diagnosed mental disorder to the appropriate state-designated authority for a re-evaluation and determination. This was true for 1 of 3 residents (Resident #3), reviewed for PASRR level II evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority.

Inspectors wroteBased on record review, staff interview, and observation it was determined the facility failed to update resident's care plans and provide care conferences. This was true for 2 of 18 residents (#6 and #11), whose care plans were reviewed for accuracy and care conference planning. This deficient practice had the potential to cause harm if a resident's care plan was not updated to reflect current medical conditions, or if their care plan was not discussed with residents or their representatives.

Inspectors wroteBased on observation, record review, Incident and Accident report, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 18 sampled residents (Resident #35) reviewed for quality of care. These failed practices had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to provide respiratory care for 1 of 2 residents (Resident #8) reviewed for respiratory care. This deficient practice created the potential for harm if respiratory care was not provided. Findings Include:Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dissection of thoracoabdominal aorta (a severe medical emergency characterized by a tear in the inner lining of the aorta, the main artery that carries blood from the heart through the chest and abdomen), asthma, and dementia. On 7/24/25 at 2:23 PM, it was observed with the RCM, Resident #8's humidifier reservoir was empty, his nebulizer tubing was not stored correctly, and his oxygen tubing was not dated. On 7/24/25 at 2:25 PM, the RCM stated oxygen tubing was replaced weekly, and should have been dated when it was changed. [...]

Inspectors wroteBased on record review, policy review, and resident and staff interviews, it was determined the facility failed to ensure post dialysis assessments were completed and accurate. This was true for 1 of 2 residents (Resident #15) who received dialysis. This created the potential for Resident #15 for adverse outcomes such as blood loss and infection from the access site.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 3 of 7 residents (#9, #15, and #81) reviewed for medication errors. This deficient practice created the potential for harm if residents received the wrong dosage of medications.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure pharmacy labels matched the physician's order. This was true for 1 of 8 residents (Resident #15) whose medications administration was observed. This failure created the potential for harm should Resident #15 be administered the wrong dose of her medications.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure accurate clinical records were maintained for each resident. This was true for 1 of 18 residents (Resident #42) whose record was reviewed. This deficient practice created the potential for Resident #42 to experience harm if she received inappropriate care and/or treatment.

Inspectors wroteBased on record review, facility job description review, and staff interview, it was determined the facility failed to ensure there was a qualified dietary manager. This failed practice created the potential to negatively affect all residents in the facility who ate food which was prepared in the facility's kitchen.

Inspectors wroteBased on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to ensure a resident was assessed for safety to self-administer an over-the-counter supplement medication. This was true for 1 of 1 resident (Resident # 32) reviewed for self-administration of medications. This failure created the potential for adverse outcomes if Resident #2 received too much or too little of the medication.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 17 residents (Resident #24) reviewed for accuracy of MDS assessments. This deficiency created the potential for residents to not have their care needs met due to inaccurate assessments.

Inspectors wroteBased on observation, policy review, record review, and resident and staff interview, the facility failed to ensure a resident was provided toileting assistant and incontinence care. This was true for 1 of 1resident (Resident #44) reviewed for activities of daily living. This failure had the potential to lead to urinary tract infections, skin rashes, skin infections, pressure sores or increased incontinence.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure there was an ongoing activity program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was true for 1 of 3 residents (Resident #41) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lacked meaningful activities throughout the day.

Inspectors wroteBased on observation, record review, review of a facility risk management report, and resident staff interview, it was determined the facility failed to ensure a resident's care plan was followed to prevent accidents. This was true for 1 of 4 residents (Resident #24) reviewed for accidents. This resulted in the potential for more than minimal harm to Resident #24 when she was transfered and sustained increased pain to her left knee due to lack of adequate supervision during a transfer.

Inspectors wroteBased on observation, policy review, record review, and resident and staff interview, the facility failed to ensure a resident's food preference was accommodated. This was true for 1 of 2 residents (Resident #21) reviewed for dietary preferences. This deficient practice created the potential for harm if residents experienced dissatisfaction, hunger and/or weight loss from not having meal preferences accommodated.

Inspectors wroteBased on observation, policy review, review of the 2017 FDA Food Code, and staff interview, it was determined the facility failed to ensure food was maintained according to safe practices. This failed practice placed 19 of 19 residents (#3, #4, #18, #20, #29, #37, #38, #42, #43, #49, #50, #67, #68, #69, #74, #77, #80, #81, #85, #187, #191, and #192) who ate snacks or foods from the unit refrigerators and the 72 other residents who ate food from the refrigerators, at risk for adverse health outcomes. This failed practice increased residents' risk of developing food borne illnesses.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure resident care plans included their code status. This was true for 8 of 8 residents (#29, #42, #43, #67, #68, #69, #74, and #85) reviewed for care plan revision. This deficient practice had the potential for harm if resident wishes for end of life care were not honored.

Inspectors wroteBased on record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure residents were provided assistance with bathing and toileting consistent with their needs. This was true for 4 of 9 residents (#20, #38, #74, and #81) reviewed for bathing. This practice created the potential for harm if the lack of assistance for personal hygiene and toileting led residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, or otherwise compromise their physical and/or sense of psychosocial well-being.

Inspectors wroteBased on observation, staff interview, resident interview, review of nurse staffing information, review of daily assignment sheets, policy review, review of resident appointment schedules, review of Resident Council Meeting Minutes, and review of the Facility Assessment, it was determined the facility failed to ensure sufficient numbers of staff were provided to meet the supervision, bathing, nutrition and hydration, and nursing oversight needs of residents. This deficient practice directly impacted 13 of 18 residents (#4, #20, #35, #38, #34, #39, #43, #46, #49, #50, #64, #74, and #81) reviewed for sufficient staffing and had the potential to negatively impact the other 78 residents residing in the facility. [...]

Inspectors wroteBased on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented for hand hygiene during perineal care (peri-care) and wound care, equipment cleaning, and care of urinary catheters and reservoir (urine collection bag). This was true for 4 of 19 residents (#20, #37, #45, #56, #74) reviewed for infection prevention practices. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents' records included a copy of the residents' advance directive or there was documentation of their decision not to formulate an advance directive. This was true for 3 of 12 residents (#37, #38, and #74) reviewed for advance directive information. This failed practice created the potential for harm should the resident's wishes not be followed due to lack of direction and documentation in their record.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure a resident was provided personal privacy during a physical assessment. This was true for 1 of 22 residents (Resident #81) reviewed for privacy. This practice created the potential for psychosocial harm if residents experienced a lack of self-esteem and embarrassment due to disregard of personal privacy, and confidentiality during a physical assessment.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, homelike environment. This was true for 2 of 22 residents (#43 and #191) whose environment was observed. This deficient practice created the potential for harm if residents were embarrassed by odors and dirty equipment and/or felt the lack of cleanliness was unacceptable, disrespectful, or undignified.

Inspectors wroteBased on staff interview and record review, it was determined the facility failed to ensure information was provided to the receiving hospital for emergent situations for 2 of 3 residents (#3 and #49) reviewed for transfers. This deficient practice had the potential to cause harm if the resident was not treated in a timely manner due to lack of information.

Inspectors wroteBased on staff interview, review of admission agreement paperwork, and record review, it was determined the facility failed to ensure transfer notices were provided in writing to residents upon transfer. This was true for 3 of 3 residents (#3, #49, and #287) reviewed for transfers. This deficient practice had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed-hold notice was provided to a resident and/or their representative upon transfer to the hospital. This was true for 3 of 3 residents (#3, #49, and #287) who were reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room.

Inspectors wroteBased on record review, hospice and facility agreement review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included delineation of care and responsibilities between hospice/palliative care agency and facility services. This was true for 1 of 1 resident (Resident #81) reviewed for hospice services. This failure created the potential for harm if residents were to receive inadequate or inappropriate care which negatively impacted the resident's quality of end-of-life care.

Inspectors wroteBased on observation, staff interview, policy review, and Activity Calendar review, it was determined the facility failed to ensure there was a variety of activities scheduled to meet the needs of residents with cognitive impairment. This was true for 1 of 2 residents (Resident #74) reviewed for activities. This created the potential for residents to become bored and foster an increase in negative behaviors when not provided with meaningful engaging activities.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, it was determined the facility failed to ensure adequate supervision was provided. This was true for 1 of 6 residents (Resident #74) reviewed for accidents and supervision. This failure had the potential for harm if residents sustained injuries from accidents and incidents.

Inspectors wroteBased on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure residents were consistently provided adequate nutritional and hydration interventions. This was true for 2 of 4 residents (#20 and #74) reviewed for weight loss and hydration concerns. This failure created the potential for harm if residents became dehydrated and they experienced unplanned weight loss.

Inspectors wroteBased on observation, record review, facility policy review, and staff interview, it was determined the facility failed to ensure residents received oxygen therapy per physician orders, and failed to ensure staff changed, dated, and stored residents' oxygen tubing per facility policy. This was true for 2 of 2 residents (#38 and #46) reviewed for oxygen therapy. This failure created the potential for harm if residents' respiratory needs were not met, and from respiratory infections due to the growth of pathogens (organisms that cause illness) in oxygen tubing.