Promontory Point Rehabilitation

facility failed to assess whether residents had the ability to self-administer their medications for 1 of

potential for adverse effects if medications were self-administered inappropriately by the resident.

Findings include: The facility's Self-Administration of Medication policy revised 10/22/22, documented residents may self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . 3.

The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the patient's medical record . 10.

The care plan must reflect patient self-administration and storage arrangements for such medications. Resident #66 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute embolism and thrombosis (blood clots) and anemia. On 5/26/26 at 9:12 AM, observed in Resident #66's room one Albuterol inhaler lying on the bed linen next to the resident. On 5/26/26 at 9:39 AM, review of Resident #66's medical record included physician orders dated 5/15/26, for Albuterol Sulfate HFA Inhalation Aerosol Solution. On 5/27/26 at 2:10 PM, Resident #66's medical record had not documented an interdisciplinary team assessment, care plan update for self-administration of medication for Albuterol inhaler to be self-administered. On 5/28/26 at 2:28 PM, the DON stated Resident #66 had not been assessed by the interdisciplinary team for self-administration of medications and should not have had the albuterol inhaler at his bedside.

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Promontory Point Rehabilitation 3909 South 25th East Ammon, ID 83406

ensure a resident's call light was within reach for 1 of 37 residents (Resident #9) reviewed for

for assistance when needed or experienced an adverse medical event that required attention.

Findings include: The facility's Call Lights Accessibility and Timely Response policy, no version date, documented. 5.

Staff will ensure the call light is within reach of resident and secured, as needed. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including displaced trimalleolar fracture (ankle fracture), major depressive disorder, and diabetes. On 5/26/26 at 11:17 AM, observed Resident #9 sitting in her recliner with her legs propped up.

The recliner was positioned with the back against the bed and the call light plugged into the wall and the cord hanging down the wall and under the foot of her bed and not within her reach. Resident #9 unable to independently reach call light. On 5/28/26 at 2:32 PM, the DON stated resident's call light should be within reach and had not been.

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Promontory Point Rehabilitation 3909 South 25th East Ammon, ID 83406

not have documentation of her advance directive.

medical record.

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Promontory Point Rehabilitation 3909 South 25th East Ammon, ID 83406

bed-hold policies.

policy review, record review, and staff interviews it was determined the facility failed to ensure

Long-Term Care Ombudsman for 2 of 12 residents (#37 and #47) and the facility reviewed for transfers.

This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner, allowed to return to the facility, or protected from inappropriate transfers and discharges.

Findings include: The facility's Bed Hold Notice Before/Upon Transfers revision date 12/1/22, documented, 1.

When a patient is transferred to the hospital or goes on therapeutic leave, facility will provide to the patient and/or representative written or verbal information that specifies: a.

The duration of the state bed-hold policy, if any, during which the patient is permitted to return and resume residence in the nursing facility. 2. In the event of an emergency transfer of a patient, the facility will provide within 24 hours written or verbal notice of the facility's bed-hold policies.5.

Facility will keep a signed and dated copy of bed-hold notice information given to the patient and/or representative in the patient's file.1. Resident #37 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including displaced intertrochanteric fracture (thigh bone) and delirium (disorientation to time and place, usually with hallucinations).On 5/26/26 at 1:53 PM, review of Resident #37's medical record had documented on 5/13/26 at 2237, resident had been transferred to the local emergency department due to low blood pressure and low oxygen saturation. On 5/26/26 at 1:56 PM, Resident #37's medical record had not documented a bed-hold policy had been reviewed with the resident or her representative. On 5/28/26 at 11:09 AM, the Administrator stated Resident #37 had not been presented with a bed-hold policy and should have been.2. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including weakness and recent sepsis (a serious condition in which the body's response to an infection causes injury to its own tissues). On 5/27/26 at 10:24 AM, review of Resident #47's medical record documented Resident #47 had been transferred to the local emergency department on 4/7/26 at 17:57, for increased cough, shortness of breath, and low oxygen saturations. On 5/27/26 at 11:32 AM, Resident #47's medical record had not documented required pertinent medical information including care plan goals, medication list, and advance directive was provided to the receiving hospital. On 5/27/26 at 11:34 AM, Resident #47's medical record had not documented a bed-hold policy had been presented to the resident or resident's representative.On 5/28/26 at 1:11 PM, the Administrator stated Resident #47's medical record had not documented the required transfer information and should have. 3. On 5/28/26 at 12:07 PM, the surveyor requested six months of the facility's Ombudsman notifications of transfers and discharges.On 5/28/26 at 12:33 PM, the Administrator stated the facility did not have documentation of notifications to the Ombudsman as requested.

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Promontory Point Rehabilitation 3909 South 25th East Ammon, ID 83406

scheduled and actual hours.

This failed practice had the potential to affect the 37 residents residing

staffing levels.

Findings include:State Operations Manual, Appendix PP -.the facility posts the following information on a daily basis: facility name, current date, total number and actual hours worked by licensed and unlicensed nursing staff, and resident census. On 5/27/26 at 11:14 AM, the daily posted staffing sheets were reviewed for the months of December 2025 - May 2026, the following was observed:No actual licensed and unlicensed staff hours documented on the sheets for the 6 months reviewedOn 5/27/26 at 1:41 PM, the Administrator stated the facility had not documented the actual licensed and unlicensed staff hours on the daily posted staffing sheets and the facility daily staff schedules are not kept as time adjustments are only made on the staff time sheets.

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Promontory Point Rehabilitation 3909 South 25th East Ammon, ID 83406

serve food in accordance with professional standards.

appropriately stored, distributed, and labeled.

This deficient practice had the potential to affect all

staff at risk for potential contamination of food and adverse health outcomes including food-borne illnesses.

Findings include:The FDA Food Code Section 3-305.11 Food Storage documented, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.The FDA Food Code Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding documented bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 degree C to 57 degree C (41 degree F to 135 degree F) too long. On 5/26/26 at 5:52 AM, observed in the kitchen with the Administrator present three uncovered plates of food on the serving counter (tray line area): - one plate filled with cooked peas and carrots - one plate filled with cooked mashed sweet potato-looking orange substance - one plate filled with meat and gravy-like off white thick substanceOn 5/28/26 at 2:28 PM, the Dietary Manager stated the three plates of food had been left out from the prior dinner meal for the night shift staff and should have been discarded but had not been.On 5/27/26 at 3:43 PM, the following was observed in the 100 Hall resident unit refrigerator with RN #2 present:Multiple Ensure bottles - not dated or labeled with resident nameMultiple soda bottles - labeled with resident room number and residents' initials onlyThree cans of drinks - labeled with staff initials On 5/27/26 at 3:45 PM, RN #2 stated the refrigerator contents should be labeled with the resident name and the date and staff drinks should not have been in the refrigerator.On 5/27/26 at 4:13 PM, the following was observed in the 200 & 300 Hall resident unit refrigerator with staff present:One large bottle of Gatorade - not dated or labeled with resident name On 5/28/26 at 11:22 AM, the DON stated the unit refrigerators are for resident items only and items should have been dated with the resident's room number, first name and last name initial and had not been.

obstruction-Dryer lint vacuum-Dryer running properly-Laundry room floor clean and room

cleaning schedule for the personal size washing machines or dryers.

135137 05/28/2026

Promontory Point Rehabilitation 3909 South 25th East Ammon, ID 83406