Caldwell Care Of Cascadia

agencies.

minimal harm Based on observation and staff interview, it was determined the facility failed to ensure resident rights were honored when past survey results were not posted in an area readily accessible to

facility's prior 3 years of survey results and plans of correction.

Findings include:On 3/2/26, 3/3/26, 3/4/26, and 3/5/26, a binder labeled State Survey Results was observed in a pocket folder on the wall of a corridor leading to the courtyard.

The access to the binder was blocked by a stuffed chair with other large equipment stacked on top of it, two vitals signs towers, and an extra large padded specialized wheelchair. On 3/4/26 at 3:25 PM, during a Resident Council group discussion with surveyors, residents stated they were not aware of the facility's responsibility to make the past 3 years of survey results readily accessible or their right to review the results and plans of correction.

The residents stated they did not know where the survey results were posted in the facility. On 3/5/26 at 2:23 PM, the Administrator confirmed the survey results were not accessible because they were blocked by stored equipment.

(injury/decline/room, etc.) that affect the resident.

record review and staff interview, it was determined resident rights were not honored.

This was true

failure placed Resident #9 at risk for harm when abnormal vital signs were not reported to her physician.

Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a severe chronic mental health condition), depression, and anxiety. Resident #9's blood pressure record documented four elevated readings the past 90 days:3/1/26: 171/1042/1/26: 164/981/22/26: 171/991/20/26: 173/104Resident #9's record did not document the physician was notified of the elevated blood pressure readings. On 3/6/26 at 9:20 AM, the DON stated the nurses should have notified the physician of Resident #9's elevated blood pressures immediately.

The DON was unable to provide documentation the physician was notified.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

limited to receiving treatment and supports for daily living safely.

observation, record review, policy review, and resident and staff interview it was determined the

with visible patch work.

This was true for 2 of 16 residents (#13 and #53) whose rooms were observed.

This created the potential for psychosocial harm and embarrassment if residents did not have a homelike environment if their walls were not repaired and did not have consistent wall paint covering the white patchwork.

Findings include: The facility's Homelike Environment policy, revised 9/17/25, documented the facility supports a residents rights to a safe, clean, comfortable, and homelike environment to promote dignity, independence, and quality of life.1. Resident #13 was re-admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.On 3/2/26 at 9:52 AM it was observed in Resident #13's room there was a jagged vertical damaged line on the wall from floor to ceiling exposing broken drywall.

Other areas of the room walls were covered with white patches on top of colored paint. Resident #13 stated the white patches, and damaged wall had been there since she relocated to the room in November 2025.2. Resident #53 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and COPD.On 3/2/26 at 2:35 PM it was observed in Resident #53's room various white patches on painted walls which were both small and large throughout the room. Resident #53 stated the white patches had been on the walls since she could remember.On 3/5/26 at 11:43 AM, the Maintenance Director stated Resident #13 and #53's room walls were patched and primed, ready to be painted; however, they had not been able to paint them yet. He further stated he was unaware Resident #13's room had any damaged walls that needed to be fixed.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

establish a grievance policy and make prompt efforts to resolve grievances.

the facility failed to ensure a grievance process was available for residents.

This deficient practice

in a timely manner.

Findings include:The facility's Grievance Process policy, revised 8/29/25, documented the Grievance program addresses the concerns of residents, family members, and visitors and the facility should make prompt efforts to resolve grievances.On 3/2/26 at 8:30 AM, the SA requested a copy of the facility's grievances from September 2025 through March 2026.The facility provided grievances from January 2026 through March 2026. No additional grievances were available.On 3/3/26 at 4:02 PM, the Administrator, with the CRN present, stated there were no grievances available prior to January 2026.

The CRN confirmed the facility had identified their grievance process required a performance improvement plan.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

report which resident was the victim and aggressor in an abuse investigation submitted to the Idaho

This deficient practice created the potential for psychosocial harm as Resident #13 was identified as the victim on the report and this was reported to Resident #13 and her family member, and to the State of Idaho, contradicting witness statements which identified Resident #13 as the aggressor.

Findings include:The facility's Abuse - Reporting & Response: No Crime Suspected policy, dated 8/25/25, documented the report must include sufficient detail to describe the nature of the alleged violation, and new or revised information supplementing the initial report should be included in the follow-up submission to ensure completeness and accuracy.Resident #13 was re-admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.An abuse report, dated 11/13/25, documented Resident #13 was the victim in a resident-to-resident interaction when Resident #17 was heard banging on the restroom door while Resident #13 was using it. Resident #13 exited the bathroom on Resident #17's side, began yelling at her, and Resident #17 reacted by grabbing Resident #13's shirt, without making physical contact. Resident #13 reported she had a hurt arm, which was assessed, and no injury was found. Resident #13 was moved to a new room the same day as the facility believed Resident #13 should not share a bathroom with Resident #17 for their safety.The witness statement, dated 11/13/25, documented Resident #13 was the aggressor as she entering Resident #17's room and yelling at her. Resident #17 reacted to Resident #13 by grabbing her shirt.On 3/5/26 at 10:21 AM, the Administrator stated he filled the report out incorrectly as Resident #13 was the aggressor, not the victim as was documented on the investigation report.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

bed-hold policies.

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

communication of essential information to the receiving healthcare provider.

This was true for 1 of 2 residents (Resident #1) reviewed for discharge processes.

This failure created the potential to result in delayed or inappropriate treatment.

Findings Include:Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure, pneumonia, and chronic obstructive pulmonary disease.Resident #1's care plan initiated 6/19/23, documented he had altered respiratory status and directed staff to monitor and report to physician if signs of compromised airway occurred.Resident #1's record included the following:A progress note dated 1/16/26, documented Resident #1 was not responding to an albuterol breathing treatment and continued to have declining oxygen saturation requiring a higher level of care.A Notice of Transfer or discharge date d 1/16/26, documented Resident #1 required immediate transfer due to urgent medical needs.A bed hold agreement signed 1/16/26.Resident #1's record did not include documentation the following required information was sent to the receiving healthcare provider at the time of transfer:Contact information of the practitioner responsible for the care of the resident.Resident representative information including contact information.Advance Directive information.All special instructions or precautions for ongoing care, as appropriate.Comprehensive care plan goals.On 3/5/26 at 9:14 AM, the DON and the CRN confirmed Resident #1's record did not include the required transfer and discharge documentation.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

for services as needed.

record review, and staff interview, it was determined the facility failed to ensure Residents'

diagnosis.

This was true for 1 of 3 residents (Resident #34) reviewed for accuracy of PASRR's.

This failure resulted in incorrect PASRR Level I determination.

Findings include:Resident #34 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.A review of Resident #34's medical diagnoses showed his primary diagnosis was recurrent major depressive disorder.Resident #34's PASRR Level I, dated 9/9/25, documented, Yes in Box 12, indicating the individual had a primary diagnosis of dementia or Alzheimer's disease.On 3/5/26 at 4:45 PM, the Social Worker confirmed Resident #34's PASRR Level I was inaccurately completed.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

documented a quarterly care conference occurred on 6/24/25, attended the Social Services Manager,

Administrator and CRN stated if the care conference is not in the residents [electronic health record]

revised:a. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.Resident #5's care plan, dated 8/24/23, documented fall interventions directing staff to provide a variety of fall preventions including a low bed position at night, call light within reach, non-skid socks, and to re-evaluate quarterly and with change of condition or if a fall occurs.On 12/1/25, a fall investigation report documented Resident #5 fell while unattended in the dining room.

The IDT directed staff to supervise Resident #5 always while in the dining room.There was no record of this fall intervention being added to Resident #5's care plan until 1/27/26.On 3/4/26 at 2:10 PM, the DON confirmed the care plan related to staff supervision for Resident #5 was not added to the care plan until 1/27/26 when it should have been added in December 2025.Cross reference F-F689.b. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.A review of Resident #34's care plan, revised 4/6/22, documented the resident was independent with toileting, and staff were directed to provide oneˆperson assistance for occasional nighttime incontinence.A review of the Quarterly Minimum Data Set (MDS) dated [DATE], documented Resident #34 was dependent on staff assistance for all toileting needs, which was inconsistent with the toileting status documented in the resident's care plan.On 3/5/26 at 8:40 AM, the DON confirmed Resident #34 was dependent in toileting and stated the care plan should have been revised to reflect the resident's current care needs.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

day related to diabetes, ordered 10/23/25.

to diabetes, ordered 2/27/26.

On 3/4/26 at 6:59 AM, RN #1 was observed sanitizing Resident #56's Novolog and Toujeo insulin pens and replaced their needles. RN #1 then dialed the Novolog insulin pen to 35 units and Toujeo insulin pen to 64 units. RN #1 was not observed to prime the insulin pens. RN #1 entered Resident #56's room and administered both insulin injections.

On 3/4/26 at 7:30 AM, RN #1 stated she did not prime Resident #56's insulin pens.

On 3/4/26 at 10:06 AM, the DON stated insulin pens should be primed before dialing the prescribed amount ordered by the physician.

• The Drugs.com website accessed on 3/10/26, stated to take potassium chloride tablets with food

or just after a meal to reduce the risk of stomach irritation.

Follow with full glass of water. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, dysphagia (difficulty swallowing) and sleep apnea.

A physician's order dated 9/19/24, documented Resident #47 was to receive potassium chloride 20 meq by mouth two times a day for diuretic use.

On 3/3/26 at 3:27 PM, LPN #1 administered Resident #47's 20 meq potassium chloride which was dissolved in small amount of water and mixed it with pudding. Resident #47 answered, no when LPN #1 asked him if he would like to drink water after taking the medication. LPN #1 was not observed educating Resident #47 regarding the importance of drinking water after taking potassium chloride.

On 3/3/26 at 3:30 PM, LPN #1 stated he offered Resident #47 water for his hydration.

On 3/3/26 at 3:36 PM, the DON with the CRN present stated she would advise Resident #47 to drink a full cup of water after taking the potassium chloride.

The CRN stated LPN #1 should have educated Resident #47 regarding drinking water after taking the potassium chloride.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

for his upper extremities and the carrot splint was ordered as skin intervention for his right hand.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

prevent accidents.

record review, policy review, and staff interview, it was determined the facility failed to prevent a fall

(Resident #5) reviewed for accident prevention.

This deficient practice created the potential for harm when Resident #5 fell from her wheelchair when she was left unsupervised in the dining room.

Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.On 12/1/25, a fall investigation report documented Resident #5 fell from her wheelchair while unattended in the dining room.

The IDT investigation documented, to avoid future falls, Resident #5 was always to be supervised while in the dining room.On 1/26/26, a fall investigation report documented Resident #5 fell from her wheelchair on 1/23/26 when a staff member left her in the dining room unsupervised.A review of Resident #5's care plan, revised 1/27/26, documented Resident #5 should have constant supervision while in the dining room.There was no record of Resident #5's care plan being updated on 12/1/25 when the intervention was first identified as a fall prevention measure by the IDT.On 3/4/26 at 2:10 PM, the DON confirmed the care plan related to staff supervision for Resident #5 was not added to the care plan until 1/27/26 when it should have been added in December 2025.

When asked if the fall on 1/23/26 could have been prevented if Resident #5's care plan had been updated in December 2025, the DON declined to answer.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

following irregularity reporting guidelines in developed policies and procedures.

record review, pharmacy review, and staff interview, it was determined the facility failed to ensure

residents (Resident #38) reviewed for psychoactiveˆmedication monitoring.

This created the potential for side effects to go undetected when the facility did not complete a current AIMS (an abnormal involuntary movement scale) or DISCUS (dyskinesia identification system condensed user scale) assessment as recommended by the consulting pharmacist.

Findings include:Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses, including bipolar disorder, anxiety disorder, and traumatic brain injury.Resident #38's care plan directed staff to monitor and report side effects and adverse reactions related to psychoactive medications.A physician order dated 7/22/25 documented:Seroquel (an antipsychotic medication) 300 mg by mouth once daily for traumatic brain injury.A pharmacy review dated 1/26/26 documented antipsychotic medications have the capacity to cause tardive dyskinesia and other movement disorders, and recommended that a movementˆdisorder assessment, such as an AIMS or DISCUS test, be completed at least every six months while the resident remained on antipsychotic therapy.A review of Resident #38's medical record showed the last AIMS assessment was completed on 8/18/25, more than six months prior to the pharmacy recommendation and outside the recommended monitoring interval.On 3/4/26 at 9:55 AM, the DON confirmed the pharmacy recommendation had not been acted upon and Resident #38's record did not contain a current AIMS assessment.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

anticonvulsant medications were monitored for potential side effects as required by their

records were reviewed for unnecessary medications.

This failure created the potential for harm if side effects were undetected.

Findings include:1. Resident #34 was admitted on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.Resident #34's record included a physician order for Depakote (an anticonvulsant) sprinkles delayed release capsule 250 mg by mouth three times a day for alcohol dependence.Resident #34's care plan revised 8/6/25, directed staff to monitor, notify the provider and document side effects for anticonvulsants such as:Over-sedation or lethargyRestless agitationIncreased confusion or poor concentrationMental status changeVisual disturbanceChange in gaitBehavioral changesWeight changeResident #34's record did not include documentation the facility staff were monitoring for side effects of anticonvulsants.2. Resident #41 was admitted to the facility on [DATE] with multiple diagnosis including borderline personality disorder, Alzheimer's disease, and suicidal ideations.Resident #41's record included a physician order for Depakote sprinkles delayed release capsule 750 mg by mouth two times a day for borderline personality disorder.Resident #41's care plan revised 10/14/24, directed staff to monitor, notify the provider and document side effects for anticonvulsant such as:Over-sedation or lethargyRestless agitationIncreased confusion/poor concentrationMental status changeVisual disturbanceChange in gaitBehavioral changesWeight changeResident #41's record did not include documentation that facility staff were monitoring for side effects of anticonvulsants.On 3/5/26 at 8:32 AM, The DON confirmed Resident #34 and #41's record did not include monitors for anticonvulsants.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

Based on observation and interview, it was determined the facility failed to ensure expired

residents.

This was true for 1 of 1 medication room observed.

This failed practice created the potential for adverse effects if residents received expired medications with decreased efficacy.

Findings include:On 3/4/26 at 1:14 PM, during the inspection of the Medication Storage Room with the ADON, five acetaminophen suppositories which expired on 10/2025 were found inside the refrigerator.

The ADON stated the acetaminophen suppositories were expired and should not be kept in the refrigerator.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

serve food in accordance with professional standards.

failed to ensure employees were not wearing jewelry during food preparation and service, and cutting

consumed food prepared by the facility.

This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Findings include:1.

The FDA Food Code Section 2-303.11 documented items of jewelry such as rings, bracelets, and watches may collect soil, and the construction of the jewelry may hinder routine cleaning. As a result, jewelry may act as a reservoir of pathogenic (disease causing) organisms transmissible through food.On 3/4/26 from 6:30 AM to 7:35 AM, [NAME] #1 and [NAME] Trainee #1 were observed preparing and serving food while wearing rings on their fingers, [NAME] Trainee #1 had additional bracelets on her right and left wrist.

Hand hygiene was performed with the jewelry on.On 3/4/26 at 7:40 AM, the Dietary Manager stated jewelry should not be worn while preparing or serving food, and if the jewelry was permanent gloves should be worn to cover.2.

The FDA Food Code Section 4-501.12 Cutting Surfaces documented cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate.

These microorganisms may be transferred to foods that are prepared on such surfaces.On 3/5/26 at 2:35 PM, it was observed the cutting boards in the kitchen had dark colored stains within the grains of the plastic.On 3/5/26 at 2:37 PM, the Culinary Manager stated the cutting boards should be replaced when they are not able to get clean or have the stains removed.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

Living (NCAL) and CDC guidance, the facility failed to ensure an infection control prevention and

deficient practices created the potential for the spread of infectious diseases which could harm the residents in the facility.

Findings include:1.

The American Health Care Association website accessed on 3/10/26, stated to place a clean and dry paper towel under blood glucose meter before placing on resident's table or on top of medication cart. Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and asthma.

On 3/4/26 at 6:59 AM, RN #1 entered Resident #56's room with the glucometer with the test strip inserted into it, two insulin pens, lancet and alcohol wipes. RN #1 placed the glucometer and insulin pens on the foot of Resident #56's bed, performed hand hygiene and donned gloves. RN #1 then took the glucometer and placed it above the pillow where Resident #56's arm was resting and checked her blood glucose. RN #1 was not observed to place a barrier when she placed the glucometer and insulin pens on two different surfaces on Resident #56's bed.

On 3/4/26 at 10:06 AM, the DON stated insulin pens and glucometer should be placed on top of a paper towel before placing them on any surface in residents' room.

• The CDC web page titled Environmental Cleaning Procedures accessed on 3/12/26, under This is

the general processes for cleaning of spills of blood or body fluids: Wear appropriate PPE.

Confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or absorbent granules (if available) that are spread over the spill to solidify the blood or body fluid (all should then be disposed as infectious waste).

Clean thoroughly, using neutral detergent and warm water solution.

Disinfect by using a facility-approved intermediate-level disinfectant.

Immediately send all reusable supplies and equipment (e.g., cleaning cloths, mops) for reprocessing (i.e., cleaning and disinfection) after the spill is cleaned up.

On 3/4/26 at 9:57 AM, CNA #2 was observed assisting CNA #3 with a urine spill from a leaking urinary catheter collection bag in the [NAME] Wing common area. CNA #2 was observed placing a dry white towel over top of a small puddle of urine. CNA #2 donned gloves and wiped the urine spill with the dry white towel and left the [NAME] Wing common area.

On 3/4/26 at 2:25 PM, when asked what the process was for cleaning soiled areas, CNA #2 stated the process was to wear gloves, wipe up the soiled area, and to use alcohol wipes or disinfectant wipes on the soiled area.

When asked if CNA #2 used any alcohol wipes or disinfectants on the urine spill she cleaned that morning, CNA #2 stated she did not use any disinfectant and stated she should have sanitized the area and notified housekeeping of the spill.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605

Antibiotic Stewardship practices were followed by initiating antibiotic therapy without obtaining

(Resident #64) reviewed for antibiotic stewardship.

This failure created the potential for inappropriate antibiotic use and development of antibioticˆresistant organisms.

Findings include:The facility's Antibiotic Stewardship Policy, revised 8/10/25, documented the facility focuses on improving antibiotic use through an Antibiotic Stewardship Program to ensure appropriate antibiotic usage, promote therapeutic and costˆeffective care, and reduce the likelihood of developing multiˆdrugˆresistant organisms.

The policy also documented the facility utilizes McGeer's Criteria to validate infections and routinely reviews culture and sensitivity reports as part of infection surveillance.The Revised McGeer's Criteria for urinary tract infection (UTI) without an indwelling catheter requires both of the following be present:1. At least one clinical sign or symptom, such as:Fever, rigors, or newˆonset hypotension (low blood pressure) with no alternate site of infectionAcute change in mental status or functional decline with leukocytosis (extremely high white blood cell counts)Newˆonset suprapubic pain or costovertebral angle tenderness (pain at the angle formed by the 12th rib and spine)Purulent discharge or acute pain/swelling of the testes, epididymis (inflammation of the coiled tube at the back of the testicle that stores and carries sperm) or prostate.AND:2. At least one microbiologic criteria, such as:ˆ 10ˆ cfu/mL of no more than two organisms in a voided urine sampleˆ 10^2 cfu/mL of any organism in a catheterized specimenResident #64 was readmitted to the facility on [DATE] with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care.Resident #64's care plan revised 3/27/25, directed staff to encourage fluids and monitor for the following symptoms:[urinary] frequency malaisefoul smelling urinedysuria (pain when urinating)fevernauseavomitingflank painsupra-pubic painhematuriacloudy urinealtered mental statusloss of appetitebehavioral changesA progress note dated 3/27/25 at 4:43 PM, documented Resident #64 was observed to be increasingly lethargic with decreased muscle function. As a result, the provider was notified, and the following new orders were given:CBC (complete blood count lab test)CMP (comprehensive metabolic panel blood test)Urine analysis with culture and sensitivityCefdinir (an antibiotic) 300mg by mouth twice daily for 5 days for a diagnosis of urinary tract infection.A review of Resident #64's lab results documented the urine specimen was collected on 3/27/25 at 1:45 PM and the culture and sensitivity were completed on 3/29/25 at 7:54 AM, 3 days after antibiotics were started.On 3/5/26 at 4:12 PM, the DON confirmed Resident #64 did not meet McGeer's criteria for antibiotics for a urinary tract infection.

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Caldwell Care of Cascadia 210 Cleveland Boulevard Caldwell, ID 83605