Owyhee Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Owyhee Health & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Aug 21, 2025

  Based on observation and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents and ensure medication were prepared following standards of practice. This was true for 3 of 3 medications carts observed. This failed practice created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include: 1. On 8/19/25 at 11:44 AM, the middle medication cart was observed outside the dining room left unlocked. The CMA assigned to the medication cart was not present. On 8/19/25 at 11:46 AM, the DON stated the medication cart should not have been left unlocked. 2. […]

• No harm, potential for more than minimal, patternF812Aug 21, 2025

  Based on observation, staff interview, and record review, and the FDA Food Code, the facility failed to ensure food was maintained at appropriate temperatures, sanitation practices were followed, and expired food was discarded from the dry storage unit. This deficient practice had the potential to affect 55 of 56 residents who consumed food prepared by the facility, creating the potential for adverse outcomes including foodborne illness. Findings include:1.The FDA Food Code Section 3-501.16(A)(2) states that Except during preparation, cooking, or cooling, potentially hazardous food (time/temperature control for safety food) shall be maintained at a temperature of 41 degrees Fahrenheit or below. a. […]

• No harm, potential for more than minimal, patternF880Aug 21, 2025

  Based on observation, glucometer manual review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The following was observed for hand hygiene:a) On [DATE] at 1:30 PM, Resident #62's meal tray was served to her in her room by CNA #1. Resident #62 was not offered or encouraged to perform hand hygiene before eating.On [DATE] at 1:34 PM, CNA #1 stated she did not offer Resident #62 hand hygiene and had not thought about it.b) On [DATE] at 10:10 AM, CMA #1 entered Resident #10's room with oxygen tubing and humidification bottle. […]

• No harm, potential for more than minimal, isolatedF641Aug 21, 2025

  Based on record review and staff interview, it was determined the facility failed to ensure the Minimum Data Set assessment accurately reflected resident's status.This was true for 3 of 3 residents (Resident #6, #10, and #33) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments. Findings include:1.Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including COPD (a group of lung diseases that block airflow and make it difficult to breathe), psychotic disorder, generalized anxiety disorder, and major depressive disorder. Resident #33's Annual MDS dated [DATE], documented in Section A - A1500 PASRR. […]

• No harm, potential for more than minimal, isolatedF657Aug 21, 2025

  Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 14 residents (Resident #10) 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's needs changed. Findings include:The CMS SOM, Appendix PP, dated 8/8/24, 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 #10 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses… […]