Karcher Post Acute

F 0600 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

shot up crooked towards the ceiling and she began to start blinking rapidly and trying to respond. I said that I was getting the nurse and that something was not right. I ran to get the nurse.The incident report included

the records from Resident #50's hospitalization. The emergency department physician documented patient with history of advanced dementia, comes from skilled nursing facility with possible convulsions.The hospital records documented a diagnosis of displaced left femoral neck fracture (break in the bone that connects the hip to the thigh where the fractured segment is moved out of position).The hospital records documented a reported episode of possible convulsion and no corroborating evidence of seizure event following computed tomography (CT) scan (a medical imaging procedure that uses X-rays and computer technology to create detailed, cross-sectional images of the inside of the body) of her head with no acute findings.On 11/7/25 at 1:13 PM, CNA #8 stated he provided a written statement to the facility of his

observation during the incident on 7/12/25 with Resident #50. CNA #8 stated the DON said his statement was unacceptable and shredded his original statement. CNA #8 reported, the DON typed up a second statement minimizing the severity of the situation and made him sign it, and the second statement is the one in the investigation report. CNA #8 provided a copy of his original statement dated 7/12/25. The original statement documented Numerous times for the morning of my work shift I was asked what the staff were supposed to do if [Resident #50] refused care. I stated we are to leave her alone and reapproach at another time. While the day went on, this resident had refused about 5-6 different times, when lunch was approaching around noonish- [LPN #10] stated it was neglect and abuse to leave her [soiled] so [RNA #1] and I were going to try to reapproach her. When we got to her room, the resident was already requesting to be left alone when [RNA #1] pulled her up from a laying position to sitting. When [RNA #1] did that, [Resident #50] started to fight against [RNA #1] and was swinging at her. I asked if I could help and maybe change her just in bed and [RNA #1] said she was wet and had to get up. [RNA #1] was focused on getting her out of bed and she did not put shoes on [Resident #50]. When she sat her in the wheelchair, her head shot up, crooked toward the ceiling and she began to stutter and blink rapidly, still trying to respond. I said, I'm going to get the nurse, something isn't right.On 11/7/25, at 1:25 PM, CNA #8 stated, Resident #50 had been approached multiple times that morning and continuously refused to get out of bed and LPN #20 had directed him to let her rest. CNA #8 stated RNA #1 was trying to get her out of bed for restorative activities and he reminded her of their training the month prior, that Resident #50 should not be transferred if she is refusing or combative to avoid injury. CNA #8 stated he observed RNA #1 picking up Resident #50 under her arms, without footwear on, while she was yelling and striking RNA #1. CNA #8 reported he was shocked RNA #1 was picking up the resident, and brought the wheelchair closer to try to keep her safe.

CNA #8 stated, RNA #1 firmly placed Resident #50 into her wheelchair and he heard two snapping or cracking sounds. He stated, Resident #50 immediately threw her head back and began making full body jerking movements and yelling ow, 911 repeatedly through a garbled voice.On 11/7/25 at 1:48 PM, LPN #20 stated, I instructed the CNAs to leave [Resident #50] in bed if she wanted to rest, and [RNA #1] did not listen.On 11/7/25 at 3:14 PM, the DON stated the 2 CNAs involved did not report Resident #50 was transferred unsafely. The DON was asked, did the CNA's follow the care plan for transferring?, she responded, yes, because [Resident #50] would always refuse and become combative no matter what you were approaching her with.On 11/7/25 at 3:44 PM, the Administrator stated he was not employed at the facility at the time of the incident. He added, it seemed like they were in a tough spot and there is a fine line between neglecting someone by leaving them soiled or abusing them by transferring them when they're refusing.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Karcher Post Acute

1127 Caldwell Boulevard Nampa, ID 83651

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility's Medication Error Report, dated 10/27/25, documented a medication error occurred on 10/27/25 when the day nurse failed to administer the morning dose of Lyrica 150 mg to Resident #6.On 11/7/25 at 12:47 AM, the DON confirmed on 10/20, 10/24, and 10/27, medication errors occurred involving Resident #6's Lyrica.4. Resident #7 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including osteomyelitis (a bacterial infection of the bone), diabetes, and kidney failure.Resident #7's physician's orders, dated 10/9/25, documented, daptomycin (an antibiotic) intravenous solution reconstituted, 1250 mg intravenously in the morning every other day for infection related to osteomyelitis.The facility's Medication Error Report documented a medication error occurred on 10/19/25 when nurse administered ceftriaxone (an antibiotic) 1 gm intravenously instead of the ordered daptomycin.On 11/7/25 at 12:54 PM, the DON confirmed the nurse administered Resident #7 the wrong IV antibiotic on 10/19/25. 5. Resident #8 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including cerebral palsy (CP is caused by abnormal brain development or damage to the developing brain that affects

a person's ability to control their muscles) and dysphasia (inability to use or understand language).Resident #8's physician's orders, dated 8/21/25, documented to give an enteral feed four times a day for nutritional needs, Vital AF 1.2 calorie nutrition formula - 250 ml, bolus feeds (a method of delivering nutrition directly into the stomach through a gastrostomy (G-tube) feeding tube using a large syringe and gravity. The bolus method involves infusing a set amount of formula, similar to a single meal, over a short period of time).The facility's Medication Error Report documented a medication error occurred on 10/13/25 when Resident #8 was not administered his enteral feeding as ordered.On 11/7/25 at 12:56 PM, the DON confirmed Resident #8 was not administered his ordered tube feeding on the evening of 10/13/25 in error. 6. Resident #9 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including chronic obstructive pulmonary disease (COPD is a disease that causes airflow blockage and breathing related problems), diabetes, and opioid dependence.Resident #9's physician's order, dated 7/9/25, documented fentanyl transdermal patch 25 mcg/hour, apply one patch every 3 days for pain. The facility's Medication Error Report documented a medication error occurred on 9/10/25 when Resident #9 was administered Fentanyl 37.5 mcg/hour transdermal patch. The mistake was reported on the evening of 9/11/25 when it was noted the narcotic count was not correct.On 11/7/25 at 1:00 PM the DON confirmed Resident #9 was administered the wrong dose of Fentanyl on 9/10/25 and it was not discovered until 9/11/25. 7. Resident #10 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including stroke and insomnia (a sleep disorder characterized by persistent difficulty falling or staying asleep).Resident #10's physician's order dated 7/18/25, was for zolpidem tartrate (Ambien) 10 mg, give 1 tablet by mouth at bedtime for insomnia.The facility's Medication Error Report documented a medication error occurred on 8/7/25 when Resident #10 was administered 20 mg of Ambien rather than the 10 mg ordered.On 11/7/25 at 1:02 PM the DON confirmed Resident #10 was administered double the ordered dose of Ambien on 8/7/25. 8. Resident #11 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including respiratory failure, heart failure, and end of life care.Resident #11's physician's order, dated 7/18/25, documented an order for alprazolam (Xanax) 1 mg tablet, give 1 mg by mouth at bedtime for anxiety.Resident #11's physicians orders did not include an order for tramadol 50mg.The facility's Medication Error Report documented a medication error occurred on 7/22/25 when Resident #11 was administered another resident's tramadol 50 mg instead of the ordered Xanax.On 11/7/25 at 1:05 PM, the DON confirmed Resident #11 was administered another resident's tramadol by mistake.

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