Bennett Hills Rehabilitation And Care Center

- observed the door to the bathroom had been removed.

On 4/27/26 at 3:57 PM, Resident #49 (room [ROOM NUMBER]) stated the holes in the wall were there when she moved into the room and there has not been a door into the bathroom since she moved in.

On 4/28/26 at 12:05 PM, observed in the dining room: - a thick, gray substance on the vent by the television. - thick, long cobwebs on the ceiling by the dividing beam.

On 4/28/26 at 12:25 PM, observed the vents on the east hall ceiling with a gray substance.

On 4/29/26 at 11:04 AM, the Maintenance Supervisor stated the vents should have been cleaned, the toilet paper holder had been fixed but came off again, and room [ROOM NUMBER]'s bathroom should have had a door on it.

On 4/29/26 at 11:22 AM, the Administrator stated the dining room ceiling and vents should have been cleaned by housekeeping staff and had not been.

On 4/29/26 at 11:41 AM, observed the kitchen ceiling, pipes, and the vents with a thick, gray, fuzzy substance.

On 4/29/26 at 11:42 AM, the DM stated the kitchen did have a cleaning schedule, but it did not include the ceiling, vents or pipes.

She also stated it was the Maintenance Supervisor job to clean that area.

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Bennett Hills Rehabilitation and Care Center 1220 Montana Street Gooding, ID 83330

for services as needed.

record review and staff interview, it was determined the facility failed to refer residents for further

related condition.

This was true for 1 of 3 residents (Resident #7) reviewed for Level II PASARR 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.

Findings include: Resident #7 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including right femur fracture and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior).Resident #7's Level I PASRR dated 3/23/26 had not documented the schizophrenia disorder diagnosis with an onset date 3/21/22.On 4/30/26 at 8:45 AM, the DON stated the schizophrenia diagnosis for Resident #7 should have been documented on the Level I PASRR and had not been.

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Bennett Hills Rehabilitation and Care Center 1220 Montana Street Gooding, ID 83330

Based on the documented diagnoses and medications, the facility requested a Level II PASRR.The Level II PASRR dated [DATE], for Resident #38 documented under comments, participant has depression, anxiety, delusional disorder, and REM sleep behavior disorder; medications prescribed for mental health were Haldol and Valproic Acid/Depakote.Resident #38's diagnoses in her medical record had not listed depressive and anxiety disorders, delusional disorder or REM Sleep behavior disorder.Resident #38's physician orders for current and discontinued medications had not documented Haldol or Valproic Acid/Depakote as being prescribed for the resident. On [DATE] at 2:33 PM, the DON stated the documented information in Resident #38's Level I PASRR was incorrect and should have been corrected but had not been.On [DATE] at 8:43 AM, the DON stated additional information should have been submitted to mental health for Resident #7 and a Level II PASRR should have been requested for Resident #10 and had not been.

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Bennett Hills Rehabilitation and Care Center 1220 Montana Street Gooding, ID 83330

reviewed, and revised by a team of health professionals.

record review and staff interview, it was determined the facility failed to ensure residents' care plans

residents (#10 and #38) whose care plans were reviewed.

This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being developed or revised as residents' needs changed.

Findings include:Resident #10 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness) and Bipolar II disorder.On 4/27/26 at 1:56 PM, Resident #10's care plan dated 3/25/26 to 6/23/26, had the following interventions missing.- At risk for impaired cognitive function/dementia or impaired thought processes.

Date Initiated: 3/25/26- ADL Self Care Performance Deficit.

Date Initiated: 3/25/26- At risk for falls r/t (SPECIFY) Date Initiated: 3/25/26- Has nutritional problem or potential nutritional problem (SPECIFY) r/t Date Initiated: 3/25/26- Has pressure ulcer or potential for pressure ulcer development (SPECIFY location) r/t Date Initiated: 3/25/26- Has acute/chronic pain (SPECIFY) r/t Date Initiated: 3/25/26Resident #10's prior care plan dated 6/3/24 to 4/5/26, had either resolved or cancelled for every issue noted and ongoing issues were not carried forward to the newest care plan.Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and dementia.Resident #38's care plan was initially started on 2/11/26 and signed off on 2/19/26, 15 days after she was admitted on [DATE].On 4/30/26 at 8:42 AM, the DON stated Resident #10 and Resident #38's care plans should have been completed in a timely manner and had not been.

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Bennett Hills Rehabilitation and Care Center 1220 Montana Street Gooding, ID 83330

ensure professional standards of practice were followed for 2 of 2 Residents (#7 and #26) reviewed

care and services were not delivered according to accepted standards of clinical practices.

Findings include: Resident #7 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including right femur fracture and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior).

On 4/28/26 at 2:49 PM, observed an albuterol and fluticasone inhaler in Resident #7's room on his bedside table. Resident #7 stated the nurses gave it to him and let him keep it in the room because they sometimes cannot make it down to his room quick enough.

On 4/28/26 at 3:35 PM, Resident #7's medical record had no documentation that a physician had ordered an inhaler medication.

On 4/28/26 at 3:40 PM, Resident #7's medical record had not documented that a self-administration assessment had been completed for the inhaler medication.

On 4/29/26 at 4:30 PM, the DON stated Resident #7 should not have the inhaler in his room because there was no order for it. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including acute embolism and thrombosis of left popliteal vein (blood clot) and depression.

On 4/27/26 at 11:34 AM, observed Resident #26's Sage boots (pressure prevention) were lying in the chair next to the resident's bed.

On 4/27/26 at 11:38 AM, LPN #1 stated Resident #26 should have been wearing the Sage boots but had not been.

On 4/27/26 at 12:08 PM, Resident #26's medical record documented physician order dated 4/6/26, Sage boots to bilateral feet at all times, document refusals.

On 4/27/26 at 12:17 PM, Resident #26's medical record had not documented resident's refusal of Sage boots for 4/27/26.

On 4/29/26 at 1:47 PM, the DON stated Resident #26 should have been wearing the Sage boots but had not been.

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Bennett Hills Rehabilitation and Care Center 1220 Montana Street Gooding, ID 83330

Based on the facility's investigation:-on 12/27/25 at 8:12 AM, Resident #8 fell backwards in his wheelchair, hitting his head and back on the back door of the facility van while being transported back from his dialysis treatment. Resident #8 reported pain in his neck after the fall.- Resident #8 was sent to the hospital for evaluation.-on 12/27/25, the facility van was inspected by the Maintenance Supervisor and no issues or concerns were found.

The facility determined the incident had occurred because the straps had not been connected correctly to Resident #8's wheelchair and had come loose during the transport resulting in his wheelchair falling backwards.The facility's investigation substantiated the failure to prevent injury to a resident when the van driver did not secure the resident's wheelchair properly before transporting him. On 4/28/26 at 3:54 PM, the Administrator stated she (the Driver) did not latch the front wheels of Resident #8's wheelchair and she should have.

These findings represent past non-compliance with this regulatory requirement.

The facility did the following:The resident was immediately taken to the emergency room for evaluation.

The resident's wheelchair and the facility van continued to be inspected throughout the week. No issues noted.

Van inspections completed for the 2014 van on 9/30/25, 10/31/25, 11/30/25, 12/31/25, 1/31/26, 2/27/26, and 3/31/26. No issues noted.

Van inspection completed for the 2021 van on 9/30/25, 10/31/25, 11/30/25, 12/31/25, 1/31/26, 2/27/26, and 3/31/26.

Issue noted = cracked windshield.

Facility staff and other residents interviewed, and no issues noted. A laminated pre-departure checklist created, completed, and placed in each van on 1/2/26. A new competency completed with transportation employees on 12/30/25 - 1/2/26.

Competency audits were done weekly for 4 weeks, then monthly for 4 months starting 1/5/26.

After the completion of the monthly competency, competency tests will be done quarterly.

The facility's Transportation policy was revised 1/2/26 and updated the post incident response to policy (if injury call facility or 911, don't handle situation yourself).

The resident continued to be monitored for psychosocial harm and latent injuries until 1/2/26. No psychosocial harm or latent injuries noted.

The incident, van inspections, and staff competencies will be reviewed by QAPI.

Staff were In-service regarding proper communication and proper action post incident occurring with transport team completed 1/2/26.

There was sufficient evidence the facility corrected the non-compliance as of 1/2/26, as there was no further resident accidents involving transportion in the facility van after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

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Bennett Hills Rehabilitation and Care Center 1220 Montana Street Gooding, ID 83330

services as ordered by the physician.

This was true for 2 of 5 residents (#7 and #9) whose records

increased fatigue and low oxygen levels.

Findings include: Resident #7 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including right femur fracture and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior).

On 4/27/26 at 11:25 AM, observed Resident #7's oxygen concentrator was set at 4 lpm, was turned on, and he was not using it during our visit. Resident #7 stated he only uses it at night or when he thinks he needs it during the day. Resident #7's physician oxygen order dated 3/23/26, documented oxygen continuously at 3 lpm via NC, every shift.

On 4/29/26 at 4:39 PM, the DON stated Resident #7 should be using his oxygen at 3 lpm as ordered and was not.

On 4/29/26 at 6:58 AM, observed during his medication pass Resident #7 sitting in his wheelchair in his room not wearing his oxygen.

On 4/29/26 at 7:03 AM, observed LPN #2 ask Resident #7 why he was not wearing his oxygen and Resident #7 stated he had not needed it.

On 4/29/26 at 7:04 AM, LPN #2 stated, Resident #7 should have been using his oxygen but had not been. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a disease process which causes decreased ability of the lungs to function) and respiratory failure.

On 4/27/26 at 10:28 AM and 4/28/26 at 2:27 PM, observed Resident #9 wearing his oxygen nasal cannula and the oxygen concentrator set at 2.5 L/min.

On 4/28/26 at 2:31 PM, Resident #9's medical record documented a physician order dated 3/25/26, Oxygen continuously at 4 L via n/c every shift.

On 4/28/26 at 2:49 PM, CNA #1stated Resident #9's oxygen had been set to 2.5 L/min and should have been set at 4 L/min via n/c.

On 4/28/26 at 3:03 PM, the RCN stated Resident #9's oxygen had not been set at 4 L/min via n/c as ordered and should have been.

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Bennett Hills Rehabilitation and Care Center 1220 Montana Street Gooding, ID 83330

services of a licensed pharmacist.

ensure controlled medications were tracked and kept secure from potential theft and/or diversion.

misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Findings include: The facility's Controlled Medications - Storage and Reconciliation policy, revision date 03.2025 documented.

Procedure 8. A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change. On 4/29/26 at 7:59 AM, observed during the East Hall medication cart audit, the Narcotic Audit Shift Count sheets, with start date 2/14/26, and start date 4/1/26, with 1 licensed nurse signature not documented on 2/15/26 for 0600 count, on 2/15/26 for 1800 count, and on 4/6/26 for 0630 count. On 4/29/26 at 8:04 AM, LPN #3 stated two nurses should have signed the Narcotic Audit Shift Count sheet and had not. On 4/29/26 at 10:16 AM, the DON stated two nurses should have signed the Narcotic Audit Count sheets when they accepted the medication cart or released the medication cart and had not.

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Bennett Hills Rehabilitation and Care Center 1220 Montana Street Gooding, ID 83330

not apply it herself, the staff apply it for her.

On 4/27/26 at 10:58 AM, a record review of Resident #18's medical record did not document an order for the Biofreeze cream.

On 4/27/26 at 11:39 AM, the ADON stated Resident #18 did not have an order or care plan for the Biofreeze cream, her family must have brought it in On 4/27/26 at 9:40 AM, observed the north hall medication cart had been left unattended, unlocked, and one medication drawer was left pulled open.

On 4/27/26 at 10:46 AM, the DON stated the medication cart should not have been left unlocked with a drawer open unattended.