Payette Healthcare Of Cascadia

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the State Long Term Care Reporting System, it was determined

the facility failed to ensure residents were free from abuse. This was true for 1 of 3 residents (Resident #24) reviewed for abuse, neglect, misappropriation of resident property and exploitation. The facility failed to protect Resident #24 when she experienced abuse from CNA #1 during a shower and created the potential for all residents in the facility to experience abuse. Findings include:The facility's Abuse Policy, revised 3/2024, documented the facility would prevent all types of abuse, neglect, misappropriation of residents' property and exploitation. The CMS SOM, Appendix PP, dated 4/25/25, defined:- Abuse, as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.- Willful, in the definition of abuse as the individual must have acted deliberately, not that

the individual must have intended to inflict injury or harm.Resident #24 was initially admitted to the facility

on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including diabetes, atrial fibrillation (an irregular heart rate), morbid obesity, and muscle weakness.Resident #24's Quarterly MDS Assessment, dated 4/23/25, documented this resident required total assistance to shower. On 9/9/25 at 9:59 AM, Resident #24 stated she believed CNA #1 had a look like I'm going to do something to you then sprayed her in the face with the shower hose. She also stated CNA #1 was never nice to anybody and she had informed the facility that she didn't want this person working with her anymore. A Facility Reported Incident, dated 5/6/25, included an investigation summary which documented on 4/29/25, CNA # 1 did spray water into [Resident #24's] face intentionally and didn't stop when asked to stop.The investigative summary documented, as a result of a verified finding of abuse, such as physical, sexual or mental abuse, identify counseling or other interventions planned and implemented to assist the resident: [Resident #24] accepted counseling and is being seen.The facility's investigation substantiated abuse when CNA #1 intentionally sprayed Resident #25 in the face with water and did not stop when asked to.On 9/12/25 at 11:48 AM, the Administrator stated, this was not an incident of abuse, it was an incident of poor customer service, and the CNA was terminated for that. These findings represent past non-compliance with this regulatory requirement. The facility did the following:-Resident #24 was her own representative-Resident #24 was provided counseling-CNA #1's employment was terminated-All staff were given an in-service training on abuse and customer service. Training completed on 5/2/25.There was sufficient evidence the facility corrected the non-compliance as of 5/2/25 as there was no further resident abuse after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interview, it was determined the facility failed to provide hospital transfer documents for 3 of 5 residents (#3, #5, and #59) whose records were reviewed for hospitalization. This deficient practice created the potential for the residents to experience harm if the residents were not treated in a timely manner due to lack of information. Findings include:The CMS State Operations Manual, revised 4/25/25, documented when a facility transfers or discharges a resident under any circumstances, the facility must ensure that the transfers or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.1. Resident #3 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including cancer of pyriform sinus (part of the larynx), heart failure and pneumonia.A Nursing Note dated 5/31/25 at 2:24 PM, documented a nurse received a report Resident #3 was feeling sick, nauseated and wanted to go to the hospital. The provider was notified and Resident #3 was transferred to the hospital.There was no documentation in Resident #3's record the hospital was provided of his current medical information when

he was transferred to ensure a safe and effective transition of care. 2. Resident #5 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with multiple diagnoses including end stage renal disease and diabetes. A Nursing Note dated 4/26/25 at 3:08 PM documented Resident #5 complained of belly pain, fever and was shaking. The provider and DON were notified, and Resident #5 was transferred to the hospital. There was no documentation in Resident #5's record the hospital was provided his current medical

record when he was transferred to the hospital to ensure a safe and effective transition of care. 3. Resident #59 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with multiple diagnoses including apraxia (an inability to perform purposeful movements or gestures) and aphasia (a communication disorder that makes it hard to use words) following a stroke. A Nursing Note dated 11/4/24 at 12:12 PM, documented Resident #59 was sent to the hospital for further evaluation of his elevated laboratory results.

There was no documentation in Resident #59's record the hospital was provided his current medical record when he was transferred to the hospital to ensure a safe and effective transition of care. On 9/12/25 at 1:06 PM, the DON reviewed Resident #3, Resident #5, and Resident #59's records and stated she was unable to find documentation their medical information was sent with them when they were transferred to the hospital.

Event ID:

Facility ID:

If continuation sheet

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview it was determined the facility failed to ensure residents' Minimum Data Set (MDS) assessments reflected the residents' status. This was true for 2 of 13 residents (#2 and #27) whose MDS assessments were reviewed for accuracy. This deficient practice created the potential for negative outcomes if residents' were not assessed and/or monitored due to inaccurate assessments. Findings include:1. Resident #2 was admitted to the facility on [DATE REDACTED], with multiple diagnoses including atrial fibrillation (irregular heartbeat preventing

the heart from pumping efficiently), heart failure, and diabetes.

Residents Affected - Few

Resident #2's Admissions MDS Assessment (a standardized assessment tool that measures health status

in nursing home residents) dated 5/11/25, documented at section M0300 Current Number of Unhealed Pressure Ulcer/Injuries at Each Stage, at item F1, F2, G1, and G2, Resident #2 had two unstageable pressure injuries (the full depth of the damage is hidden by a covering of dead tissue) and they were present when she admitted to the facility.

Resident #2's Quarterly MDS Assessment, dated 8/11/25, documented at section M0300, items F1, F2, G1, and G2, Resident #2 had two unstageable pressure injuries and those injuries had not been present when she admitted to the facility.

On 9/11/25 at 1:27 PM, the MDS Coordinator stated, when he completed Resident #2's Quarterly MDS Assessment on 8/11/25 he marked zero present on admission in error at F2 and G2 regarding her pressure injuries. He added, Resident #2's pressure injuries were not facility acquired.

1. 2. Resident #27 was admitted to the facility on [DATE REDACTED], with multiple diagnoses including post-traumatic

stress disorder (PTSD), depression, anxiety and agoraphobia (an intense anxiety that involves fearing and avoiding places of situation that might cause panic and feeling being trapped, helpless or embarrassed).

A PASRR Level 1 dated 2/11/25, documented Resident #27 had bipolar disorder, PTSD, anxiety and depression. In addition, the PASRR Level 1 also documented Resident #27 had diagnoses of agoraphobia, claustrophobia (intense fear of confined spaces that interferes with daily life), bulimia (an eating disorder, characterized by eating a large amount of food in a short amount of time), panic disorder and ADD (Attention Deficit Disorder).

Resident #27's PASRR Level II dated 2/12/25, documented Resident #27 had Multiple mental health diagnoses. Sent to MHA (Mental Health Association) to review prior SNF (Skilled Nursing Facility) admission.

Resident #27's admission MDS assessment, dated 2/24/25, documented in A1500 Preadmission Screening and Resident Review documented No for the question Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?

On 9/11/25 at 10:08 AM, the MDS Coordinator reviewed Resident #27's MDS and stated the A1500 question should have been answered Yes.

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

Event ID:

Facility ID:

If continuation sheet

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 1 of 13 residents (Resident #9) whose care plans were reviewed. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as resident needs changed. Findings include:The CMS SOM, Appendix PP, dated 4/25/25, documented a resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. Resident #9 was admitted to the facility on [DATE REDACTED], with multiple diagnoses including, sepsis (a life-threatening, extreme response to an infection that causes the immune system to damage the body's own organs and tissues), diabetes, and was dependent on hemodialysis (a treatment using a machine to replicate kidney function, removing waste from the bloodstream) for end stage renal (kidney) disease. Resident #9's medical record documented a physician order, dated 8/1/25, for a fluid restriction of 1800 ML of fluids per day. Resident #9's care plan documented the following: -Initiated 7/16/25, for bowel care, encourage fluids-Initiated 8/5/25, for bladder care, encourage fluids-Initiated 8/5/25, for nutrition care, encourage fluids Resident #9's care plan did not include the physician order for a fluid restriction. On 9/10/25 at 3:27 PM, the DON stated, Resident #9's care plan was not accurate and should have been updated when the fluid restriction was ordered on 8/1/25.

Event ID:

Facility ID:

If continuation sheet

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interview, it was determined the facility failed to ensure services provided met professional standards. This was true for 1 of 13 residents (Resident #2) whose records were reviewed.

This failure placed Resident #2 at risk for harm from obstruction or over medication when her bowel medication administration was not documented in the medication administration record (MAR). Findings include: The American Nurses Association Principles for Nursing Documentation, dated 2010, accessed on 9/17/25, documented Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. It includes Documentation entries must be: Accurate, valid, and complete; Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted; Dated and time-stamped by the persons who created the entry; Legible/readable; and Made using standardized terminology, including acronyms and symbols. Resident #2 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including atrial fibrillation (irregular heartbeat preventing the heart from pumping efficiently), heart failure, and diabetes. Resident #2's medical record documented the following physician orders dated 5/5/25:-Milk of Magnesia 1200 MG/ 15 ML, give 30 ML orally as needed for no BM in 72 hours. Give 1 dose, if no results within 24 hours, see Dulcolax suppository order. -Dulcolax suppository 10 MG, insert 1 suppository rectally as needed for bowel care if no results from MOM [Milk of Magnesia]. If no results in 24 hours, see Fleet enema order. -Fleet enema 7-19 GM/ 118 ML, insert 1 unit rectally as needed for bowel care if no results from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify MD if no results. On 9/12/25 at 10:40 AM, Resident #2's medical record documented she had no BM on the following dates:-8/18, 8/19, 8/20 -8/23, 8/24, 8/25-8/28, 8/29, 8/30-9/1, 9/2, 9/3, 9/4, 9/5 Resident #2's MAR for August and September 2025 documented she received her Milk of Magnesia order on 8/25/25. Resident #2's MAR for August and September 2025 did not include documentation her bowel care medications were administered on 8/20, 8/30, 9/3, 9/4, or 9/5. On 9/12/25 at 11:38 AM, the DON provided handwritten documentation the nurses use to monitor who may need as needed bowel medications. The handwritten records document Resident #2 received MOM on 8/20, 8/30, 9/3, and 9/5, and she refused a suppository on 9/4. On 9/12/25 at 12:48 PM, the DON stated, she could not explain why the nurses who administered the bowel medications did not document the administration or refusal of doses in the MAR.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, staff interview and record review, it was determined the facility failed to ensure physician's orders were clarified for bowel medications and respiratory treatment. This was true for 2 of 13 residents (#8 and #28) whose records were reviewed for quality of care. This deficient practice had the potential for adverse effects and harm for residents whose care and services were not delivered according to accepted standards of practice. Findings include:1. Resident #28 was admitted to the facility on [DATE REDACTED], with multiple diagnoses including a complete intestinal obstruction and had a colostomy (a surgical opening from the intestine through the abdominal wall to bypass the rectum). A. Resident #28's physician orders documented

the following:-bisacodyl rectal suppository 10 MG, insert 1 suppository rectally as needed for constipation, dated 9/1/23-Dulcolax suppository 10 MG, insert 1 suppository rectally as needed for bowel care, dated 9/1/23-Fleet enema 7-19 GM/118 ML, insert 1 unit rectally as needed for bowel care, dated 9/1/23 On 9/12/25 at 10:48 AM, the DON stated, Resident #28 had a colostomy and should not have any medications administered rectally. She added, the route of administration on the orders were wrong and should have been corrected. B. Resident #28's physician orders documented the following:-magnesium hydroxide oral suspension 400 MG/5 ML, give 30 ML by mouth as needed for constipation, dated 9/1/23-Milk of Magnesia suspension 1200 MG/15 ML, give 30 ML orally as needed for no BM for 2 days, dated 9/1/23-Miralax powder 17 GM, give 17 GM by mouth as needed for bowel care in PM, give after 48-72 hours of no BM, mix with at least 4 oz fluid of choice, dated 6/5/25 On 9/12/25 at 10:50 AM, the Clinical Resource Nurse stated, Resident #28's as needed bowel medication orders were not clear and the orders should have been clarified to minimize risk for error. 2. Resident #8 was admitted to the facility on [DATE REDACTED], with multiple diagnoses including end of life care, chronic obstructive pulmonary disease (COPD- a progressive lung disease characterized by increased breathlessness), and diabetes.Resident #8's physician orders dated 3/31/25, documented, oxygen at 4 LPM (liters per minute) continually per nasal cannula via oxygen concentrator for chronic respiratory disease.Resident #8's Hospice Plan of Care dated 7/31/25, documented Oxygen at 4 LPM PRN (as needed) Resident #8's TAR (Treatment Administration Record) for September 2025 documented an order for oxygen 4 LPM continuously per nasal cannula via oxygen concentrator or tank every shift for chronic respiratory failure. On 9/8/25 at 11:56 AM, Resident #8 was observed in his room, there was no oxygen concentrator or equipment observed in his room. Resident #8 stated he refuses to wear his oxygen if his oxygen saturation is above 90% because the machine is too loud. On 9/11/25 at 2:00 PM, the DON stated resident #8's orders should have been updated to reflect his current order for oxygen as needed per the Hospice Plan of Care, and they were not.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review and staff interview, it was determined the facility failed to ensure residents' oxygen tubing were changed per physician's orders. This was true for 2 of 3 residents (#41 and #53) reviewed for oxygen therapy. This failure created the potential for harm from respiratory infections due to growth of pathogens (organisms that cause illnesses) in oxygen tubing. Findings include:1. Resident #41 was admitted to the facility on [DATE REDACTED], with multiple diagnoses including paraplegia (paralysis of the lower half of the body) and cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth). Resident #41's September 2025 MAR directed staff to change her oxygen and nebulizer tubing, humidification bottle, clean the filter every week, date and provide bag as indicated. On 9/8/25 at 11:50 AM, Resident #41 was awake in bed. An oxygen concentrator was observed at her bedside with oxygen tubing attached to it and was dated 7/23. On 9/8/25 at 11:14 AM, the DON asked LPN #1 to check the date on Resident #41's oxygen tubing. LPN #1 checked Resident #41's oxygen tubing and stated

it was dated 7/23. The DON stated the oxygen tubing should be changed weekly. 2. Resident #53 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease characterized by increasing breathlessness). A physician's order dated 8/22/24, documented Resident #53 was to receive oxygen at 2 liters per minute via nasal cannula intermittently for shortness of breath. Resident #53's September 2025 MAR directed staff to change her oxygen and nebulizer tubing, humidification bottle, clean the filter every week, date and provide bag as indicated. On 9/8/25 at 10:08 AM, Resident #53 was observed receiving oxygen at 2 liters per minute via nasal cannula. Resident #53's oxygen tubing was dated 8/20. On 9/8/25 at 11:11 AM, the DON checked Resident #53's oxygen tubing and stated it was 8/20. The DON stated the oxygen tubing should be changed weekly.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0757

medications in error.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation and staff interview, it was determined the facility failed to ensure medications carts were secured and house stock medications were labeled when opened. This deficient practice created the potential for harm if the medications were left unsecured and if the medications administered were expired.

Findings include: 1. On [DATE REDACTED] at 3:25 PM, the [NAME] Hall Medication Cart was observed to be unlocked and unobserved by the assigned nurse. On [DATE REDACTED] at 3:30 PM, RN #2 returned to the medication cart and stated, I was in there (pointing to the therapy office) eating a muffin and should not have left my cart unlocked and unattended. On [DATE REDACTED] at 3:30 PM, the DON stated the medication carts are to always be locked when the nurse is not there with it. 2.) On [DATE REDACTED] at 9:00 AM, during observation of RN #3's medication pass. A bottle of liquid Prosource (a protein supplement) was observed to be previously opened and had no open by or use by date written on it. On [DATE REDACTED] at 9:03 AM, RN #3 stated the bottle should have had a date written on it when it was opened, and it did not. On [DATE REDACTED] at 2:15 PM, the ADON confirmed all house stock medications should be dated when opened to ensure quality.

Event ID:

Facility ID:

If continuation sheet

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Payette Healthcare of Cascadia

1019 Third Avenue South Payette, ID 83661

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, CDC recommendation review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and transmission of infection.

Findings include:The Centers for Disease Control and Prevention (CDC) web page titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24, accessed on 9/16/25, documented hand hygiene should be performed:-Immediately before touching a patient.-Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices.-Before moving from work on a soiled body site to a clean body site on the same patient.-After touching a patient or patient's surroundings.-After contact with blood, body fluids, or contaminated surfaces.-Immediately after glove removal.The following was observed for hand hygiene and Personal Protective Equipment (PPE):On 9/12/25 at 9:20 AM, observed RN # 3 enter Resident #63's room to administer an injection. RN #3 placed the injection on the bedside table then sanitized his hands and donned gloves. Resident #63 asked to be repositioned in bed prior to the injection and RN #3 then pressed the call light button, then the bed positioning control to adjust bed height. CNA #2 then entered the room, sanitized her hands then reached into her pocket and retrieved

a pair of gloves before donning them. RN #3 and CNA #2 then assisted Resident #63 to his requested position. RN #3 then retrieved the injection from the bedside table, cleansed the injection site in Resident #63's abdomen then administered the medication. After removing the needle from Resident #63's abdomen, RN #3 then placed a gloved finger over the injection site and held it there for several seconds.

RN #3 then removed his gloves, sanitized his hands and left the room. CNA #2 was observed emptying Resident #63's bedside urinal in the resident's bathroom and placed it back by his bed. She did not rinse

the urinal out and a small amount of urine was noted to be in the bottom of the urinal, and an odor of urine was present.On 9/12/25 at 9:40 AM, RN #3 stated, I should have changed gloves after providing patient care and before giving the injection. When asked about pressing his finger against the injection site, RN #3 stated since COVID there hasn't been a lot of quality control training. On 09/12/25 at 11:15 AM, the DON stated, nurses should always perform hand hygiene and change gloves when alternating between patient care to giving an injection. The DON also stated, when giving an injection the nurse should always place a barrier on the table prior to setting items down, perform hand hygiene, don gloves, clean site, administer

the injection, and if bleeding occurs, use gauze or a Band-Aid to stop leakage. When asked about rinsing urinals after emptying them, the DON stated, our facility doesn't have a way to rinse urinals in any resident bathrooms, so we don't do it.

Residents Affected - Few

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

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