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1 C.L "BLTCH OTER- Governor RJCHARD M. ARMSTRONG- Drector D A H 0 D E P A R T M E N T 0 F HEALTH &WELFARE DEBRA RANSOM, R.N.,R.H..T., Chef BUREAU OF FACLTY STANDARDS 3232 Elder Street P.O. Box Bose, D PHONE 20~ FAX = CERTFED MAL: September 4, 204 Crag Johnson, Admnstrator Boundary County Nmsng Home 6640 Kanksu Street Bonners Fen;, D Provder #: Dear Mr. Johnson: On August 2, 204, a Recertfcaton and State Lcensme survey was conducted at Boundary County Nmsng Home by the daho Department of Health and Welfare, Dvson of Lcensng and Certfcaton, Bureau of Faclty Standards to determne fyom faclty was n complance wth state lcensure and federal partcpaton requrements for nmsng homes partcpatng n the Medcare and/or Medcad programs. bs survey found that your faclty was not n substantal complance wth Medcare and/or Medcad program partcpaton requrements. bs survey found the most serous defcency to be an solated defcency that consttutes no actual harm wth potental for more than mnmal harm that s not mmedate jeopardy, as documented on the enclosed CMS-2567, whereby sgnfcant correctons are requred. Enclosed s a Statement of Defcences and Plan ofconecton, Form CMS-2567, lstng Medcare and/or Medcad defcences and a smlar State Form lstng lcensme health defcences. n the spaces provded on the rght sde of each sheet, answer each defcency and state the date when each wll be completed. NOTE: The alleged complance date must be after the "Date Survey Completed" (located n feld X3) and on or before the "Opportunty to Correct" (lsted on page 3). Please provde O:NLY ONE completon date for each federal and state tag n column (XS) Completon Date to sgnfy when you allege that each tag wll be back n complance. Waver renewals may be requested on the Plan of Correcton. After each defcency has been answered and dated, the admnstrator should sgn both the Form

2 Crag Johnson, Admnstrator September 4, 204 Page 2 of4 CMS-2567 and State Form, Statement of Defcences and Plan of Correcton n the spaces provded and retnm the orgnals to ths offce. Your Plan of Correcton (PoC) for the defcences must be submtted by September 7,204. Falure to submt an acceptable Poe by September 7, 204, may result n the mposton of cvl monetary penaltes by October 7, 204. The components of a Plan of Correcton, as requred by CMS nclude: \Vhat correctve acton(s) wll be accomplshed for those resdents found to have been affected by the defcent practce; How you wll dentfy other resdents havng the potental to be affected by the same defcent practce and what conectve acton(s) wll be taken; \Vhat measures wll be put n place or what systemc change wll you make to ensure that the defcent practce does not recur; How the conectve acton(s) wll be montored to ensure the defcent practce does not recur,.e., what qualty assurance program wll be put nto place. Ths montorng wll be revewed at the follow-up survey as par of the process to verfy that the faclty has corrected the defcent practce. Montorng must be documented and retaned for the follow-up survey. n your Plan of Conecton, please be sure to nclude: a. SpecfY by job ttle who wll do the montorng. * t s mportant that the ndvdual dong the montorng have the approprateexperence and qualfcatons for the task. * The montorng cannot be completed by the ndvdual( s) whose work s under revew. b. Frequency of the montorng;.e., weekly x 4, then q 2 weeks x 4, then monthly x 3. * A plan for "random" audts wll not be accepted. * ntal audts must be more frequent than monthly to meet tbe requrement for the follow-up. c. Start date of the audts; nclude dates when conectve acton wll be completed n column (X5). f the faclty has not been gven an opportnnty to con ect, the faclty must determne the date complance wll be acheved. f CMS has ssued a letter gvng notce of ntent to mplement a denal of payment for new Medcare/Medcad admssons, consder the effectve date of the remedy when determnng your target date for achevng complance.

3 Crag Johnson, Admnstrator September 4, 204 Page 3 of4 The admnstrator must sgn and date the frst page of both the federal survey report, Form CMS-2567 and the state lcensme survey repott, State Form. All references to federal regulatory requrements contaned n ths letter are found n Ttle 42, Code of Federal Regulatons. Remedes wll be recommended for mposton by the Centers for Medcare and Medcad Servces (CMS), f your faclty has faled to acheve substantal complance by September 25, 204 (Opportunty to Correct). nformal dspute resoluton of the cted defcences wll not delay the mposton of the enforcement actons recommended (or revsed, as approprate) on September 25, 204. A change n the serousness of the defcences on September 25, 204, may result n a change n the remedy. The remedy, whch wll be recommended f substantal complance has not been acheved by September 25, 204 ncludes the followng: Denal of payment for new admssons effectve November 2,204. [42 CFR (a)] f you do not acheve substantal complance wthn three (3) months after the last day of the survey dentfyng noncomplance, the CMS Regonal Offce and/or State Medcad Agency must deny payments for new admssons. We must recommend to the CMS Regonal Offce and/or State Medcad Agency that your provder agreement be termnated on February 2, 205, f substantal complance s not acheved by that tme. Please note that ths notce does not consttute formal notce of mposton of alternatve remedes or termnaton of your provder agreement. Should the Centers for Medcare & Medcad Servces determne that termnaton or any other remedy s warranted, they wll provde you wth a separate formal notfcaton of that determnaton. f you beleve these defcences have been corrected, you may contact Lorene Kayser, L.S.W., Q.M.R.P. or Davd Scott, R.N., Supervsors, Long Term Care, Bmeau of Faclty Standards, 3232 Elder Street, Post Offce Box 83720, Bose, daho, ; phone number: (208) ; fax number: (208) , wth your wrtten credble allegaton of complance. f you choose and so ndcate, the PoC may consttute your allegaton of complance. We may accept the wrtten allegaton of complance and presume complance untl substantated by a revst or other means. n such a case, nether the CMS Regonal Offce nor the State Medcad Agency wll mpose the prevously recommended remedy, f approprate. f, upon the subsequent revst, your faclty has not acheved substantal complance, we wll recommend that the remedes prevously mentoned n ths letter be mposed by the CMS Regonal

4 Crag Johnson, Admnstrator September 4, 204 Page4 of4 Offce or the State Medcad Agency begnnng on August 2, 204 and contnue untl substantal complance s acheved. Addtonally, the CMS Regonal Offce or State Medcad Agency may mpose a revsed remedy(es), based on changes n the serousness of the noncomplance at the tme of the revst, f approprate. n accordance wth 42 CFR , you have one opportunty to queston cted defcences through an nformal dspute resoluton process. To be gven such an oppmtunty, you are requred to send your wrtten request and all requred nformaton as drected n nformatonal Letter #200 l-l 0. nformatonal Letter #200-0 can also be found on the nternet at: tabd/4 34!Default.aspx go to the mddle of the page to nformaton Letters secton and clck on State and select the followng: BFS Letters (06/30) Long Term Care nfonnal Dspute Resoluton Process DR Request Form Ths request must be receved by September 7,204. f your request for nfomal dspute resoluton s receved after September 7, 204, the request wll not be granted. An ncomplete nformal dspute resoluton process wll not delay the effectve date of any enforcement acton. Thank you for the comteses extended to us durng the survey. f you have any questons, comments or concerns, please contact Lorene Kayser, L.S.W., Q.M.R.P. or Davd Scott, R.N., Supervsors, Long Term Care at (208) Sncerely, W~!~~~ QMRP, S"Peccoo Long Term Care LKK/lj Enclosures

5 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES "-ND PlAN OF CORRECTON (X) PROVDERSUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG t-kn =U: Uts/Ltf/LU4 OMB NO NAME OF PROVDER OR SUPPLER B. WNG STREET ADDRESS, CTY, STATE. ZP CODE 08/2/204 BOUNDARY COUNTY NURSNG HOME 6640 KANKSU STREET BONNERS FERRY, D (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGUlATORY OR LSC DENTFYNG NFORMATON) D PREFX PROVDERS PlAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) {X5) COMPLETON F 000 NTAL COMMENTS The followng defcences were cted durng the annual Federal recertfcaton survey of your faclty. The surveyors conductng the survey were: Amy Barkley, RN, BSN, Team Coordnator and Susan Gotlobt, RN. The survey team entered the faclty on 8/8/204 and exted the faclty on 8/2/4. Survey defntons: CNO = Chef Nursng Offcer F (b)(3), 483.0(d)(2) NFORMED OF SS=D HEALTH STATUS, CARE, & TREATMENTS The resdent has the rght to be fully nformed n language that he or she can understand of hs or her total health status, ncludng but not lmted to,, hs or her medcal condton. The resdent has the rght to be fully nformed n advance about care and treatment and of any changes n that care or treatment that may affect : the resdents well-beng. : Ths REQUREMENT s not met as evdenced by: Based on record revew and staff ntervew, t was determned the faclty faled to ensure that 2 (# 5, 6) of 2 sampled resdents wth dementa, who were revewed for the use of antpsychotcs, were provded rsk versus benefts to nclude the potental for death. The defcent practce had the potental to cause more than mnmal harm when resdents # 5 and # 6 had a dagnoss of ~ dates ndcated are F 000 for the year 204. psclamer: Plan of correcton s beng ~ubmtted n accordance wth ~pecfc regulatory requrements. rt shall not be construed as an ~dmsson of any defcency cted. F 54 F-54 Correctve Acton: Resdent #5 and #6 Rsk/Beneft form completed to nclude "potental rsk of death caused by cardovascular dsease or nfecton" dentfcaton of Resdents wth Potental to be affected: : All resdents recevng any antpsychotc were revewed for approprate documentaton of rsk/beneft of ant-psychotc medcaton. Those resdents whose Rsk/Beneft consent form : dd not nclude "rsk of death caused by cardovascular dsease or nfecton" were updated to nclude these rsks and approprate consent receved from respons.ble party after revew of added rsks. Systemc changes: "Ant-psychotc medcaton form was created and mplemented to lst possble sde effects/rsks to nclude: 09/6/4 laboratory DRECTORS OR PR~~DERSUPPLER REPRESENTATVES SGNATURE ~-aal~ TTLE (X6) /</9/,;Jur 7 Any defcency statement mdfng-v(lh an astersk (*} denotes a defcency whch the nsttuton m~y be excused from correctng provdng t ~s determned that other safeguards provde suffcent protecton to the patents. (See nstructons.) Except for nursmg homes, the fndngs stated above are dsclosable 90 days followng the date of survey whether or not a plan of correcton s provded. For nursng homes, the above fndngs and plans of correcton are dsc/osable 4 days followng the date these documents are made avalable to the faclty. f defcences are cted, an approved plan of correcton s requste to contnued program partcpaton. FORM CMS-2567(02-99) Prevous Versons Obsolete Event D:4E3U Faclty ld: MDSD0070 f contnuaton sheet Page of

6 Ut:-AK Mt:N Vr Ht:AL H ANU HUMAN :St:KVL;t::S CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDERSUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG OMB NO NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) F 54 Contnued From page dementa and were not provded the nformaton that the drug Seroquel could cause death. Fndngs ncluded: *Nursng 204 Drug Handbook, page 77. Seroquel: "Black Box Warnng. Drug snt ndcated for use n elderly patents wth dementa-related psychoss because of ncreased rsk of death from CV (carda vascular) dsease or nfecton.". Resdent# 6 was admtted to the faclty on 9/25/3 wth dagnoses that ncluded Alzhemers dsease, psychotc mood dsorder, congestve heart dsease, and anxety. The resdents current physcan recaptulaton, orders, dated 8//4, documented:, *Quetapne Fumarate (Seroquel) 2.5 mg :(mllgrams) po (by mouth) at 0:00 (AM). *Quetapne Fumarate (Seroquel) 50 mg po at 700 (5 PM). The resdents Psychoactve Medcaton nformed Consent form dated /7/4, whch was sgned by the resdents daughter, documented: B. WNG PREFX D STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) F 5 l 54: (Contnue)!rsk of death caused by cardovascular ~sease or nfecton" prnted on the form ~or revew pror to consent (nstead of ~andwrtten) ~esponsble Party:CNO/Desgnee =ompleton Date: 09/0/204 08/2/204 (X5) COMPLETON Qualty Montorng: 09/6/4 Every resdents recevng ant-psychotcs wll dscuss Rsk/adverse sde-effects of! antpsychotcs ncludng rsk of death from tardovascular dsease or nfecton wth tesdent or responsble party pror to ~vng/refusng consent of ant-psychotc. ~esponsble Party: CNO/Chef Nursng \)ffcer/nursng Staff [ frequency of Montorng:. f Every resdent admtted wth antpsychotc medcatons f Every resdent wth antpsychotc medcatons?rdered fbehavoral Management Monthly Revew pff all resdents recevng antpsychotcs.! \ Medcaton nterventon Recommended: -"Seroquel (on admt) 25 mg at 7 p.m., 2.5 mg at 0 A.M. orally." *Purpose the Psychoactve Medcaton s ndcated: -Possble Sde Effects/Rsks dentfy source used for Revew-! "dzzness, extrapyramdal symptoms, sezures." Note: The educaton for the sde effects of, Seroquel, whch ncluded death, was not provded : to the resdent or famly member. FORM CMS-2557(02-99) Prevous Ve(sons Obsolete Event J0:4E3U../hf) c s;. ~c-:~ tf-- o Eacltt 0: MDS00070 f contnuaton sheet Page 2 of

7 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES A..ND PLAN OF CORRECTON (X) PROVDER/SUPPLERCLA DENTFCATON NUMBER: {X2) MULTPLE CONSTRUCTON A BULDNG OMB NO NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D SUMMARY STATEMENT OF DEFCENCES PREFX (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) F 54 Contnued From page 2 B. WNG STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D /2/204 D PROVDERS PLAN OF CORRECTON (XS) PREFX (EACH CORRECTVE ACTON SHOULD BE COMPLETON CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) F 54 *Statement of consent: The consent secton of the form for the use of the Seroquel had 3 areas to check wth dfferent optons whch ncluded consent for use, consent for temporary use, or no consent for the use of the medcaton. None of the three boxes were checked. On 8/20/4 at 4:0 PM, the surveyor asked the CNO (Chef Nurse Offcer) f the faclty had documentaton that t had provded the rsk of death when the nformed consent for Seroquel ) had been provded to the resdents famly. The CNO stated she had spoken to the Bureau of F acttes Chef (daho Department of Health and Welfare] about that about 2 weeks pror. The CNO stated she had brought the nformaton back to the facltys Medcal Drector, and he was workng on t. The nformed consent for the resdent was revewed wth her and she agreed the rsk of death was not on t. The CNO stated she would look to see f t was documented n the chart. On 8/20/4 at 5:45 PM, the CNO stated to the surveyor she had not found documentaton that the faclty provded the rsk of death wth the use. of Seroquel n the resdents paperwork. The surveyor revewed the requrement to nform the resdent and/or guardan of the rsk of death wth the use of Seroquel and the CNO stated she was not aware of the requrement for dementa resdents. 2. Resdent #5 was admtted to the faclty on 6/3/3 wth dagnoses that ncluded, non-azhemers dementa, psychotc dsorder, and schzophrena. FORM CMS-2567(02-99) Prevous Versons Obsolete! j Faclty D: MDS00070 tc"c> o/ Jjtf f contnuaton sheet Page 3 of

8 .DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDERSUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG OMB NO NAME OF PROVDER OR SUPPLER B. WNG STREET ADDRESS, CTY, STATE, ZP CODE 08/2/204 BOUNDARY COUNTY NURSNG HOME 6640 KANKSU STREET BONNERS FERRY, D (X4) D SUMMARY STATEMENT OF DEFCENCES PREFX (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) F 54 Contnued From page 3 D PROVDERS PLAN OF CORRECTON (X5) PREFX (EACH CORRECTVE ACTON SHOULD BE COMPLETON CROSS REFERENCED TO THE APPROPRATE DEFCENCY} F 54 The resdents current physcan recaptulatons orders dated 8//4, documented: *Quetapne Fumarate (Seroquel) 2.5 mg (mllgrams) po (by mouth) at 8:00 (AM). *Quetapne Fumarate (Seroquel) 25 mg po at 900 (7 PM). The resdents Psychoactve Medcaton nformed Consent form dated 24/3, whch was sgned by the resdents daughter, documented: *Medcaton nterventon Recommended: -"Seroquel25 mg /2 tab(let) = 2.5 mg twce daly." *Purpose the Psychoactve Medcaton s ndcated: -Possble Sde Effects/Rsks dentfy source used for Revew- : "dzzness, extrapyramdal symptoms, sedaton, j postural hypotenson." ; *Statement of Consent: - The box checked was: " do desre the use of the medcaton(s) ndcated above and do consent to ther use." : Note: The educaton for the sde effects of Seroquel, whch ncluded death, was not provded : to the resdent or famly member. On 8/20/4 at 4:0 PM, the surveyor revewed the Psychoactve medcaton nformed consent for the resdent wth the CNO, and asked f the faclty had provded the nformaton for the use of Seroquel and death. The CNO sad the nformaton was not on the form and stated she would look for t n the chart. FORM CMS-2567(02-99) Prevous Versons Obsolete Event D:4E3U Faclty ld: MD$ f contnuaton sheet Page 4 of!

9 UCt"l-\r\ Vt:l~ V nc-\l n -\~U nuvf-\~ ~t:kv\_..t:v CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PlAN OF CORRECTON (X) PROVDERSUPPLER/CLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A. BULDNG OMB NO NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGUlATORY OR LSC DENTFYNG NFORMATON) B. WNG D PREFX STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D PROVDERS PlAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) 08/2/204 (X 5 COMPLETON F 54 Contnued From page 4 F 54 On 8/20/4 at 5:45PM, the CNO stated she had not found documentaton that the faclty provded the rsk of death wth the use of Seroquel n the resdents paperwork. On 8/2/4 at 3:30 PM the Admnstrator and the CNO were nformed of the fndngs. No addtonal nformaton was provded. F (h) FREE OF ACCDENT SS=D HAZARDS/SUPERVSON/DEVCES The faclty must ensure that the resdent envronment remans as free of accdent hazards as s possble; and each resdent receves adequate supervson and assstance devces to prevent accdents. Ths REQUREMENT s not met as evdenced by: Based on observaton, staff/resdent ntervew, and record revew t was determned the faclty dd not ensure the followng: - A cabnet, n the beauty parlor wth potentally hazardous lquds was locked; - Efferdent tablets were not accessble to a resdent wth a known hstory of dssolvng and drnkng Efferdent; and - A resdent wth three reported cgarette burns receved ncreased supervson whle smokng. Ths was true for 2 of 9 sampled resdents (# & #5), and all ambulatory resdents n the faclty. Ths faled practce had the potental for harm f Resdent #5 drank the Efferdent and other resdents drank the potentally hazardous lquds : F 323 F323- Hazardous Materals n 09/25/4 Beauty Room Acton Plan: All hazardous materals removed from cabnet. - Beauty room cabnet assessed and lock remedated - Sgn appled to cabnet door "cabnet doors must be lockedjr - Beauty Room Door handle replaced wth self-lockng handle [ - Sgn posted on door Keep doot closed when room not n use n - All rooms conta~nng potentafly hazardous materals assessed for self-lockng door handles - Self lockng door handles, present on all other rooms ) contanng potentally hazardfus materals Qualty Montorng: Beauty Room] wll be checked Q shft to nsute door s closed and locked. Staft to ntal log sheet. ~~ rrequency: Q Shft X month """",,,,,, """ "[ FORM CMS-2567(02-99) Prevous Versons Obsolete Event ld: 4E3U Faclty ld: MDS00070 f contnuaton sheet Page 5 of 7,.-\.--f - ~ f"_-;r ~ l

10 .DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PlAN OF CORRECTON (X) PROVDER/SUPPLER/CLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A. BULDNG t--<:n t:.u: UtlU~/ZU4 OMB NO NAME OF PROVDER OR SUPPLER B. WNG STREET ADDRESS, CTY, STATE, ZP CODE 08/2/204 BOUNDARY COUNTY NURSNG HOME 6640 KANKSU STREET BONNERS FERRY, D (X4)D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (X5) COMPLETON F 323 Contnued From page 5 and requred emergency medcal servces. Addtonally, Resdent # was at rsk for harm f he were to drop a lt cgarette or hot ash on hmself and receve a second or thrd degree burn.!. Resdent # was admtted to the faclty wth multple dagnoses to nclude chronc pan, neurogenc bladder, quadrplega, c-spne njury, and spastcty. The resdents most recent Quarterly MDS dated 6/ 0/4 coded the followng: - Cogntvely ntact wth a BMS score of 3. - Extensve assst of two people for bed moblty, transfers, and dressng. - ndependent wth locomoton on and off the unt. ; - Supervson wth one person assst for eatng. ~ - Functonal lmtaton n blateral upper and lower [ extremtes.. The resdents Self-Care Defct care plan documented the followng: - 8/3/, "Resdent able to smoke ndependently after set up wth adaptve equpment and protectve cover worn around neck to protect chest and lap." -6/8/4, "Do not assst hm [Resdent #] to smoke, such as puttng hand to mouth for cgarette smokng." The resdents Safe Smokng Assessment dated 2/28/ documented the followng: - "RSDT [resdent] alert and orented and able to make hs own decsons." - Needs assstance [wth]lghtng cg[arette] but has tool made for smokng ndependence once lt. A Confdental Qualty Management Occurrence FORM CMS-2567(02-99) Prevous Versons Obsolete Event D:4E3U F 323 F323- Faclty dentfcaton ofl 09/25/4 root cause for cgarette burns: Root cause for cgarette burns: Resdent s unable to safely manage any aspect of smokng actvty ndependently due to physcal and sensory mparments related to c-spne njury. Acton Plan: Prevent resdent! from recevng burns n the future: - Resdent \ Jll be provded wth! choce of electronc cgarette or tobacco cgarette. f resdent requests electronc! cgarette staff to escort and set-up ncludng smokng apron!. - Resdent may smoke ndependently. - f resdent requests tobacco cgarette resdent wll be provded smokng apron. Staff wll escort and set-up cgarette utlzng Remote Smoker Ashtrayn (see photos) and provde drec~ supervson for the entre duraton of smokng actvty. - Fre extngusher and frst-a d blanket mounted on pllar for mmedate access n the event of emergency. - Smokng Apron has been replaced wth one that provdes protecton of the neck and che st {ash fell down front of resdenlt between apron and shrt) ). Faclty 0: MDS00070 f contnuaton sheet Page 6 of

11 CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PlAN OF CORRECTON (X) PROVDERSUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG form APPROVED OMB NO NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4)D PREFX F SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGUlATORY OR LSC DENTFYNG NFORMATON) Contnued From page 6 report dated /22/4 documented the followng: "Noted em cgarette burn on left medal thgh." nvestgaton -"No sgn of nfecton noted. Resdent unaware when ths happened. t was not there on /20/4 when catheter flushed. Resdent! wears smokng apron every tme he goes out to smoke. t appears to be placed approprately when observed t."! A Confdental Qualty Management Occurrence report dated 6/27/4 documented the followng: "Probable cgarette burn top of Rght thgh." Addtonal descrpton of event - "Resdent denes knowng about burn, or when t happened." Need for addtonal montorng due to njury, medcaton - "Montor daly for s/sx [sgns and symptoms] of nfecton. Patent/Resdent ntervew- "RSDT [resdent] not concerned about wound and knows rsks of contnung to smoke." Care plan updated, "No." j Follow-up by department manager/drector "Staff remnded to make sure smokng apron s tucked n at the sdes, between w/c [wheelchar], and legs." A Confdental Qualty Management Occurrence report dated 84 documented the followng: "Resdents cgarette fell, landng n small gap at the top of hs protectve apron. Receved small 0.5 em lght burn to skn. Care for area gven." Follow-up by department manager/drector- "Encouraged hm to change to E-cgarette, note added to Bran to montor apron - makng certan top edge s hgh under chn and no gaps reman for hs cgarette to drop nto." SWNG D PREFX STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D PROVDERS PlAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) F-323 (cant) F 323 Montor effectveness of acton -plan: 08/2/204 ~aff to document on log shee~ choce of cgarette that was! set-up and ntal log sheet. - Safe smokng assessment to be completed \ lth each MDS assesfment to nclude safe demonstraton of remote smoket ashtray and electronc cgaret te Frequency:! - Documentaton of smokng: every smokng actvty - Safe Smokng Assessment - Quarterly, Annual and Change of Status dentfy and Montor resdents! skn for burns: : - Skn assessment to be cornplet~d weekly and wth bathng. Responsble Party:Lcense Nurse: Montor when smokng: - nterdscplnary staff membefs assgned to supervse Smokng Agreement: Reve\ Ted \ lth! Resdent - Copy of Faclty"Tobacco Freel t Workplace u revewed and understands and agrees to ab e by the polcy - (Yes) - Resdent, understands the need, to wear a smokng apron for safety - (Yes) (X5) COMPLETON Note: "Bran" refers to the facltys 24 hour FORM CMS-2567(02-99) Prevous Versons Obsolete Event t0:4e3u...-/ \\ ;7 9}:_!)d\.-vM-,..- (/ c) Faclty D: MDS00070 f contnuaton sheet Page 7 of / (jl(

12 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDER/SUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG PRNTED: 08/29/204 OMB NO NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME WNG STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D /2/204 (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (XS) COMPLETON F 323 Contnued From page 7 nursng report. On 8/9/4 at 9:00 AM the resdent was observed to have a dark green fleece sweatshrt on. The sweatshrt was observed to have 2 cgarette burn holes down the front of t rangng n sze from pn hole to quarter. On 8/2/4 at 9:00AM the CNO was asked for the facltys smokng polcy and procedure. The CNO stated the faclty was a non-smokng faclty and therefore there was no polcy. The surveyor stated that Resdent # smoked. The CNO stated he was grandfathered when the faclty decded to prohbt smokng. On 8/2/4 at 2:30 PM, LN # was asked f the faclty completed a Safe Smokng Assessment on the resdent after all or any of the three dentfed burns. LN # stated she was unable to fnd a current Safe Smokng Assessment and the. faclty had not completed the assessment after any of the dentfed burns. On 8/2/4 at 3:00PM, the CNO and LN # were ntervewed. LN # stated the faclty has counseled the resdent multple tmes on smokng cessaton and the resdent declned. The surveyor asked what changes were made to the resdents smokng nterventons after each burn, and how dd the faclty montor the effectveness and modfy those nterventons. The CNO stated there have been no changes made to the resdents smokng nterventons snce August of 20 because the resdents ablty to smoke ndependently after set-up had not changed. The surveyor asked f the faclty had ncreased supervson of the resdent whle he smokes. The CNO stated staff s not currently provdng F323(cont) F Resdent wll comply wth arranged smokng schedule - (No) * Resdent unable to set-up/l~ht hs own cgarettes.. - Resdent understands that, smokng near resdents wth oxygen n use s prohbted -! (Yes) - - Resdent understands needs fo~ restrctons on smokng durn~ nclement \ leather - (Yes) r Resdent agrees to respect others rght to use the pato wthout smoke - (Yes) ~ - Resdent understands that refusal to abde by ths agreement could result n dscharge from ths faclty! - - (No) * Resdent unable to set-up/ lght cgarettes. Montorng of adherence to agreement: Not-applcable as resdent s unable to smoke wthout staff assst to pato, set-up of cgarette/smokng actvty. FORM CMS-2567(02-99) Prevous Versons Obsolete Event 0:4E3U Faclty 0: MOS00070 f contnuaton sheet Page 8 of / c/ 9} -f f..._ ( L r

13 Ut:-AK Mt:N Ut- Ht:AL H ANU HUMAN ;:>t:kvlt::> CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES (X) PROVDERSUPPLERCLA AND PLAN OF CORRECTON DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG OMB NO NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D SUMMARY STATEMENT OF DEFCENCES PREFX (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) B. WNG 08/2/204 STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D D PROVDERS PLAN OF CORRECTON! (X5) PREFX (EACH CORRECTVE ACTON SHOULD BE COMPLETON CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) F 323 Contnued From page 8 ncreased supervson. The surveyor asked f the faclty should have provded ncreased supervson gven the three burns n 204. The CNO stated the faclty would lke to research dfferent alternatves because the resdent nssts on smokng fve cgarettes before breakfast and t would requre a staff member to be pulled off of : the foor. The CNO then stated, "t s the facltys! responsblty to keep the resdents safe." No addtonal nformaton was provded to resolve : ths ssue.! 2. On 8/2/4 at approxmately 9:0AM, whle on : tour wth the Plant Operaton Manager (POM), the surveyor observed the Personal Groomng room, whch also housed the beauty parlor. The door to the room was open and nsde above the snk was a whte cabnet wth two doors. The door on the left was not locked and easly accessble. The cabnet contaned the followng tems:, 2 boxes of lnste- Low Tho-Ammona free Har : Perm soluton. : unmarked plastc spray bottle wth clear lqud nsde. bottle of Wave Neutralzer. Varous brands of bottles of har shampoo and har condtoners. varous bottles of har stylng gels. : The surveyor verfed wth the POM the concern : of these products beng accessble to resdent and she agreed t was a concern. On 8/24 at 0:05 AM, and 0:40 AM, the surveyor observed the cabnet door remaned unlocked. F 323 On 8/2/4 at :20 AM, the surveyor observed the cabnet. The door was locked wth a sgn on t whch stated, "Cabnet doors must be locked." FORM CMS-2567(02-99) Prevous Versons Obsolete Event t0:4e3u ~ o\ c-l~ :~ Faclty D: MDS00070 f contnuaton sheet Page 9 of (l,"c,ro/ /t j

14 sleep) DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDER/SUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG PKN cu: OB/29204 OMB NO NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) B. WNG D PREFX STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) 08/2/204 (X5) COMPLETON F 323 Contnued From page 9 On 8/2/4 at :25 AM, the surveyor asked the CNO (Chef Nurse of Operatons) f she was aware of the closet beng open and the products nsde easly accessble to resdents. She stated, "Yes, they told me. We are also gong to lock the door to the room." On 8/2/4 3:30PM, durng end of day wth the Admnstrator, the surveyor descrbed the cabnet to hm and he stated t was a problem and "thats why there s a lock on t." 3. Resdent #5 was admtted to the faclty on 6/3/3 wth dagnoses that ncluded, non-azheme~s dementa, psychotc dsorder, and schzophrena. The resdents Quarterly MDS (Mnmum Data Set), dated 8/4/4, documented: Resdents! cognton was moderately mpared and she was able to ambulate ndependently n her room. \ The resdents care plan documented: *Problem: "(Resdents name) has alteraton n self-care related to:. Dementa. 2. ; Hyponatrema 3. HX (hstory) snus headaches as. exhbted by: Mld confuson 2. Requres cueng, and Supervson 3. Short Term Memory loss 4. Unsteady on her feet 5. Poor safety awareness." *nterventons: -"Do not keep Efferdent or ts equvalent n (resdents name) room. Evenng staff to supply. one and assst her n ts use durng HS (hour of care." Dated 3/24/203. On 8/20/4 at 2:0 PM, the surveyor observed a! clear plastc contaner next to the resdents snk. [ The contaner had package wth Efferdent wrtten on t. The package was unopened. The FORM CMS-2567{02-99) Prevous Versons Obsolete Event t0:4e3u F 323 #3 - Resdent#5 - Efferdent tablets accessble to resdent wth hx of dssolvng and drnkng Efferdent Root Cause: Falure to remove Efferdent tablet from clear plastc contaner flled Nth =~~:;sd:~~s~!~kt~:~t~~p~:;e:ot safe to leave n her roomu j Acton Plan #5: All potentally( hazardous tems removed from ro~m. - All tems labeled and stored n medcaton room behnd j nurses staton f.on torng : Room check every shft to nsure no hazardous tems n room. Frequency: Every shft Responsble Party: Lcensed Nur$e 09/25/4 Faclty D: MDS00070 f contnuaton sheet Page 0 of

15 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDERSUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG r r\ L..L, VlN.0/L.V l"t OMB NO NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) B. WNG D PREFX STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) 08/2204 (XS) COMPLET!ON F 323 Contnued From page 0 contaner also contaned straws and pnk mouth sponges. On 8/2/4 at :30 AM, the surveyor observed the clear plastc contaner next to the resdents snk. The contaner had package wth Efferdent wrtten on t. The package was unopened. The contaner also contaned straws and pnk mouth ~ sponges.! On 824 at :35 AM, the surveyor wth LN# observed the Efferdent packet n the plastc contaner by the resdenfs snk. LN# removed the packet and stated, "Thats not a good thng." The surveyor asked LN # why the resdent was not allowed to have Efferdent n her room. LN # stated, "She put t n a cup and drank t. She thought t was Alka Seltzer so we decded that t would not be safe. The famly brngs t n to her." F 323 F323- Ensure resdents do not 09/25/4 have access to hazardous phemcals. Acton Plan: All resdent rooms audted for hazardous chemcals completed. No hazardous chemcals found. Montorng: Monthly checks of, each room to nsure no hazardouk materals present. Frequency: Monthly durng "unt \/eek Responsble Party: Lcensed Nurse/ Desgnee On 8/2/4 at 3:30PM the Admnstrator and the CNO were nformed of the fndngs. No addtonal nformaton was provded. FORM CMS-2567(02-99) PreVOUS Versons Obsolete Faclty D: MDS00070 f contnuaton sheet Page of C LC 2- / Ll f) {

16 Bureau of Facltv Standards STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDERJSUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG: MDS00070 B. WNG 08/2/204 NAME OF PROVJDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THEAPPRDPRATE DEFCENCY) (XS Cm\PLETE C ood NTAL COMMENTS c 000 The Admnstratve Rules of the daho Department of Health and Welfare, Sklled Nursng and ntermedate Care j Facltes are found n DAPA 6, Ttle 03, Chapter 2.! The followng defcences were cted durng the : State lcensure survey of your faclty.! The surveyors conductng the survey were: ~ Amy Barkley, RN, BSN, Team Coordnator Susan Gollobt, RN The team entered the faclty on 8/8/4 and exted on 8/2/4.. :::! C ,03,c, nformed of Medcal Condton by Physcan. s fully nformed, by a, physcan, of hs medcal condton unless medcally contrandcated (as documented, by a physcan, n hs medcal record), and s afforded the opportunty to partcpate n the plannng of hs medcal treatment and to refuse to partcpate n expermental research; Ths Rule s not met as evdenced by: Refer to F 54 related to nformed consent. C ,04,b, Taxes Stored Under Lock and Key. All toxc chemcals shall be properly labeled and stored under lock and key. Ths Rule s not met as evdenced by: Refer to F323 related to mproprly stored chemcals. c 9 c 342 Refer to F-54 for Plan of Correcton Refer to F-323 for Plan of Correcton Bureau of Facllty Standards LABORATORY DRECTORS OR PROVDERJSUPPLER REPRESENTATVES SGNATURE 3~~ TTLE (X6) D/f)d.uy STATE FORM "" 4E3U f contnuaton sheet t of 3

17 Bureau of Faclty Standards STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVlDER/SUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG: MDS00070 B. WNG 08/2/204 NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D PREFX! SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) STREET ADDRESS, CTY, STATE. ZP CODE 6640 KANKSU STREET BONNERS FERRY, D D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (XS) COMPLETE C ,02,a Requred Members of Commttee : a. nclude the faclty medcal drector, admnstrator, pharmacst,. detary servces supervsor, drector of nursng servces, housekeepng servces representatve, and! mantenance servces representatve. Ths Rule s not met as evdenced by: Based on staff ntervew and revew of the nfecton Control Commttee (CC) meetng attendance records, t was determned the faclty dd not ensure the Admnstrator and the Pharmacst attended/partcpated n quarterly CC meetngs. Ths falure created the potental for a negatve effect for all resdents, staff and vstors n the faclty when CC members were not nvolved n the CC meetngs. Fndngs ncluded: On 8/2/4 at :5 AM, the surveyor asked the CNO (Chef Nurse Offcer) whether the Admnstrator attended the CC meetngs, and she stated, "He does not." The surveyor asked f the Pharmacst attended the meetngs and the CNO stated, "He doesnt." On 8/2/4 at approxmately :20 AM, the surveyor was provded the sgn-n sheets for the quarterly CC meetng whch were dated, /28/4, 4/22/4, and 7/22/4; nether the Admnstrator nor the Pharmacst were n attendance. \ On 8/2/4 at 3:30PM, the Admnstrator and CNO were nformed of the fndngs. No addtonal nformaton was provded. C ,03,b,v Protecton from njury/accdents v. Protecton from accdent or njury; c 664 c 790 dmnstrator and Pharmacst wll attend, uarterly nfecton Control meetngs ext meetng scheduled: Tuesday, October, 204 at :00 a.m., ualty Montorng: evew of Attendance sgn-n sheets uarterly/one year esponsble Party: nfecton Preventon ~anager Refer to F-323 for Plan of Correcton Bureau of Fachty Standards STATE FORM (_ (_f::o 4E3U f contnuaton sheet 2 of 3

18 Bureau of Faclty Standards STATEMENT OF DEFCENCES AND PlAN OF CORRECTON (X) PROVDERSUPPLERCLA DENTFCATON NUMBER (X2) MULTPLE CONSTRUCTON A BULDNG: MDS00070 B. WNG 08/2/204 NAME OF PROVDER OR SUPPLER BOUNDARY COUNTY NURSNG HOME (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) C 790 Contnued From page 2 Ths Rule s not met as evdenced by: Please refer to F323 as t relates to accdents. STREET ADDRESS, CTY, STATE, ZP CODE 6640 KANKSU STREET BONNERS FERRY, D PREFX c 790 PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) [X5 COWPLETE Bureau of Faclhty Standards STATE FORM 4E3U f cootnuauofl sheet 3 of 3 Cc,_, / c/ 7 / l