Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 2, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to honor residents' Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, and to assess pharmaceutical services related to controlled medication security.
Complaint Details
The complaint investigation found substantiated issues with honoring DNR/DNI orders and medication security, affecting a few residents.
Findings
The facility failed to honor DNR and DNI orders for one resident, resulting in inappropriate initiation of CPR. Additionally, the facility failed to ensure controlled medications were properly tracked and secured, with incomplete narcotic accountability records noted.
Deficiencies (2)
Failure to honor residents' Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, leading to inappropriate CPR initiation on Resident #5.
Failure to ensure controlled medications were tracked and kept secure, with incomplete narcotic accountability record signatures.
Report Facts
Date of survey: Sep 2, 2025
Narcotic accountability record period: 1
Number of medication carts reviewed: 1
Number of licensed nurse signatures missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Stated two nurses should have signed the narcotic accountability record and confirmed DNR status of Resident #5 |
| LPN #1 | Licensed Practical Nurse | Entered Resident #5's room with incorrect POST document and initiated CPR |
| Admissions Nurse | Stated two nurses should have signed the narcotic accountability record and confirmed Resident #5 was DNR |
Inspection Report
Routine
Deficiencies: 14
Date: Jan 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, medication administration, infection control, food safety, and staff competencies at Life Care Center of Idaho Falls.
Findings
The facility was found deficient in honoring residents' advance directives, maintaining a safe and homelike environment, ensuring accurate resident assessments and care plans, following PASARR screening requirements, administering medications properly, maintaining infection control practices, ensuring food safety, and employing qualified staff for food and nutrition services. Several residents' care plans and assessments were inaccurate or incomplete, and environmental hazards and unsafe practices were observed.
Deficiencies (14)
Failed to honor residents' Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, causing actual harm to Resident #24.
Failed to ensure residents were provided with a safe, clean, and homelike environment, including unsafe water temperatures and unclean areas.
Failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information for 8 residents.
Failed to refer residents for PASARR Level II evaluations when diagnosed with major mental illness for 4 residents.
Failed to follow a resident's comprehensive person-centered care plan for Resident #41, including use of two staff members for bed mobility.
Failed to revise residents' care plans to reflect current needs and interventions for 4 residents.
Failed to ensure medications were administered according to professional standards for Resident #222, including failure to notify physician of medication refusals.
Failed to ensure services provided met professional standards of quality for Residents #12 and #65, including lack of wound care orders and oxygen orders.
Failed to ensure residents were free from accident hazards; Resident #30 had a medical device plugged into a power strip, which is unsafe.
Failed to ensure nurses and nurse aides had appropriate competencies; licensed nurses did not follow standing orders for oxygen for Resident #41.
Failed to ensure medications were stored appropriately; Residents #51 and #58 had medications accessible without proper assessment or care planning.
Failed to ensure food was stored in a safe and sanitary manner; expired foods, undated items, and pest infestation were observed in the kitchen.
Failed to ensure infection control prevention practices; oxygen supplies were not stored properly, catheter bags were on the floor, and glucometers were not cleaned according to policy.
Failed to ensure glucometers were calibrated consistently; solution tests were not done daily as required.
Report Facts
Residents reviewed for advanced directives: 18
Resident rooms observed for environment: 48
Residents reviewed for MDS accuracy: 18
Residents reviewed for PASARR screening: 7
Residents reviewed for care plan compliance: 18
Residents observed for medication administration: 10
Residents observed for infection control: 18
Residents observed for glucometer cleaning: 2
Medication refusals by Resident #222: 11
Expired yogurts found: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Stated residents can self-administer medications only after assessment; noted Resident #23 should have had Biofreeze care planned; stated nursing staff should have followed oxygen standing orders for Resident #41. | |
| DON | Director of Nursing | Notified about Resident #24's DNR status; stated PASARR Level II evaluations were missing for several residents; confirmed care plan and medication administration deficiencies; stated physician should have been notified after medication refusals; stated oxygen standing orders were not followed; stated oxygen supplies should be stored properly; stated expired foods should not be present; stated Resident #51 should not have medications left at bedside. |
| LPN #3 | Used glucometer on Resident #12 and cleaned it improperly; unaware of proper glucometer cleaning policy. | |
| RN #2 | Used glucometer on Resident #41 and cleaned it improperly; unaware glucometer needed to remain wet for 2 minutes. | |
| Maintenance Director | Stated resident should not have medical device plugged into power strip; stated pest control contractor visits monthly. | |
| Food Service Director | Acknowledged not meeting regulatory requirements for Certified Dietary Manager; stated expired foods and undated items should not be present; stated pest control contractor had recently treated facility. | |
| Registered Dietician | Acknowledged Food Service Director's lack of certification; present during food safety inspection. | |
| LPN #4 | Stated glucometer solution tests should be done daily by night shift. | |
| CNA #8 | Stated catheter bag should not be on the floor. | |
| RN #1 | Stated catheter bag should not be on the floor. | |
| LPN #2 | Stated Resident #65's oxygen is as needed but should have orders. | |
| LPN #6 | Observed Resident #12's wounds and performed wound care without physician orders. | |
| Wound Nurse | Stated wound supplies should not be left out in Resident #58's room. |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to assess the accuracy of Minimum Data Set (MDS) assessments and to evaluate the facility's compliance with respiratory care requirements, specifically regarding the use of a Bilevel Positive Airway Pressure (BIPAP) machine for residents.
Findings
The facility failed to ensure accurate MDS assessments for two residents, including incorrect documentation of BIPAP use and discharge status. Additionally, the facility did not have a physician order for the use and settings of a BIPAP machine for one resident, creating potential risk for respiratory distress.
Deficiencies (2)
Failure to ensure residents' Minimum Data Set (MDS) had correct assessment information for 2 of 5 residents, including omission of BIPAP machine use and incorrect discharge coding.
Failure to obtain a physician order for a resident's use of a Bilevel Positive Airway Pressure (BIPAP) machine, including missing documentation of mode, pressure settings, mask type, oxygen requirements, and frequency of use.
Report Facts
Residents reviewed for MDS accuracy: 5
Residents affected: 2
Residents reviewed for BIPAP therapy: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Stated no physician orders existed for BIPAP application or settings for Resident #44 |
| Director of Nursing | Director of Nursing | Stated Resident #44 should have pulmonologist orders for BIPAP settings |
| Executive Director | Executive Director | Confirmed the BIPAP order was missed and should have been entered into Resident #44's record; stated facility followed RAI manual for MDS documentation |
| MDS Coordinator | MDS Coordinator | Acknowledged errors in MDS assessments for Residents #44 and #65 |
Inspection Report
Routine
Deficiencies: 7
Date: May 24, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, bathing preferences, environmental safety, care planning, activities of daily living assistance, medication administration, and food preferences.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity during dining, failure to honor bathing preferences and schedules, inconsistent water temperatures in showers, incomplete care plans regarding oxygen and bathing needs, inadequate bathing assistance, failure to follow bowel care medication orders, and failure to provide appropriate meal alternatives according to resident preferences.
Deficiencies (7)
Failure to maintain or enhance residents' dignity during dining when residents seated at the same table were served meals at different times.
Failure to ensure residents' preferences for bathing schedules were honored.
Failure to ensure comfortable water temperatures were maintained for residents during showers.
Failure to ensure comprehensive resident-centered care plans included the use of oxygen and bathing needs.
Failure to ensure residents received bathing assistance consistent with their needs.
Failure to ensure professional standards of practice were followed for bowel care medication administration.
Failure to provide appropriate meal alternatives to accommodate resident allergies, intolerances, and preferences.
Report Facts
Residents reviewed for bathing preferences: 10
Residents reviewed for comfortable environment: 10
Residents reviewed for care plans: 18
Residents reviewed for bathing assistance: 2
Residents reviewed for bowel care: 9
Days without bowel movement: 12
Days without bowel movement: 6
Days without bowel movement: 5
Days without bowel movement: 6
Days without bowel movement: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Mentioned in relation to Resident #29's care plan and bathing schedule. | |
| CNA #1 | Mentioned regarding bathing assistance and resident refusals. | |
| Regional Director of Clinical Services | RDCS | Interviewed about bathing schedules, dignity policy, and food preferences. |
| Administrator | Interviewed about care plans, bathing schedules, and food service issues. | |
| Maintenance Director | MD | Interviewed about water temperature issues. |
| LPN #2 | Mentioned regarding bowel care medication administration. | |
| LPN #3 | Discussed bowel care medication administration failures. |
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