Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monte Vista Hills Healthcare Center during CMS and state inspections, most recent first.
The facility did not follow standing orders and physician directives for bowel care, resulting in multiple residents with complex medical conditions experiencing extended periods without a bowel movement and no documented administration of prescribed medications or interventions. Nursing staff failed to document or provide required bowel care interventions as ordered, as confirmed by record review and staff interviews.
Staff were observed providing personal care to a resident with multiple complex diagnoses while the resident's door was left open in a high-traffic area. An LPN and the DON confirmed that the door should have been closed to maintain privacy.
A resident with COPD and diabetes was found to have two unsecured portable oxygen cylinders propped in her room, along with a portable oxygen concentrator in use and a liquid oxygen tank on her wheelchair. The DON was unaware of the presence of these cylinders, which were not properly secured or stored as required.
Two residents with physician-ordered oxygen therapy were observed receiving higher oxygen flow rates than prescribed, with concentrators set at 3.5 lpm instead of the ordered 1–2 lpm or 2 lpm to maintain appropriate oxygen saturation levels. The DON confirmed the settings were incorrect.
Controlled medications were not properly tracked and secured when a narcotic accountability sheet for a medication cart was missing a required nurse signature on one date. Staff confirmed that two nurses should have signed the sheet when accepting or releasing the cart, but this was not done as required.
Surveyors found that medications and biologicals were not properly stored or monitored for expiration. A resident had Nystatin cream left at bedside, and expired items, including a fiber supplement, muscle rub, and glucose test solutions, were found on a medication cart. Staff confirmed these expired items should have been removed but were not.
Surveyors found that food items in the kitchen and storage areas were not properly labeled, dated, or stored according to facility policy and the Idaho Food Code. Items such as ranch dressing, milk, diced tomatoes, cucumbers, sliced cheese, and barbeque sauce lacked required date markings, and a case of food was stored directly on the floor. The CDM confirmed these practices did not meet required standards.
Two garbage cans in the kitchen food prep area were observed uncovered and not in use, in violation of FDA Food Code requirements. The CDM confirmed the cans should have been covered when not in use, creating a potential for pest attraction affecting all residents and staff.
The facility failed to employ a qualified director of food and nutrition services, affecting nearly all residents receiving meals. The Dietary Supervisor, with no healthcare experience, had only completed 34% of a certification program and lacked necessary credentials. This was confirmed by the Administrator and RD.
The facility failed to comply with food storage, labeling, and hygiene standards, as observed in the walk-in refrigerator and mini freezer containing improperly labeled and stored food items. The ovens and grease trays were not cleaned daily, and clean kitchen items were covered in residue due to hard water. Staff did not follow proper hand hygiene practices during meal preparation, as confirmed by the RD.
The facility failed to provide necessary health information during hospital transfers for four residents, as required by policy. This included missing documentation of advance directives and care plans. The DON and SSD confirmed the lack of documentation and awareness of requirements.
The facility failed to secure and label unidentified loose pills in a medication cart, as observed during an audit. Several loose pills of various colors and sizes were found in the cart, indicating non-compliance with the facility's medication storage policy. An LPN was unaware of the reason for the loose pills, and the DON acknowledged a lack of documentation for medication cart audits.
A facility failed to assist a resident in exercising their right to formulate an advanced directive, as required by policy. Despite having an advanced directive documented in a Medical Treatment Decisions form, it was not included in the resident's care plan. The DON confirmed the oversight, noting the resident had a POST and a DPOA but lacked documentation of the advanced directive in the care plan.
Two residents in the facility did not receive care according to their care plans, leading to potential health risks. One resident, with a history of surgical amputation, did not have her wound care documented as completed on several occasions. Another resident, with multiple diagnoses including diabetes and respiratory failure, had his urinary catheter tubing unsecured during observations. The DON confirmed these deficiencies.
A resident with severe cognitive impairment and contractures did not have positioning devices in place as ordered by a physician. Despite documentation indicating their use, observations and staff interviews confirmed the devices were not used, and there was no record of the resident refusing them. This oversight could lead to further contractures and pain.
A resident with multiple diagnoses, including a status-post hip fracture, required substantial assistance for transfers. During a transfer from a wheelchair to a recliner, the resident lost balance and was assisted to the floor by a COTA, resulting in a femoral fracture. The COTA did not use a gait belt or a second person, contrary to the care plan and facility policy.
The facility failed to adhere to infection control practices, impacting several residents. Staff did not perform proper hand hygiene, clean equipment like the Hoyer lift and glucometer, or follow insulin administration protocols. Additionally, an oxygen concentrator filter was not maintained as required, placing residents at risk for infection.
Failure to Administer and Document Bowel Care Interventions per Physician Orders
Penalty
Summary
The facility failed to follow its bowel care standing orders and physician directives for administering specific medications when residents did not have a bowel movement within 72 hours. For five residents with various complex medical conditions, including respiratory failure, morbid obesity, schizoaffective disorder, cancer, osteolysis, malnutrition, femur fracture, diabetes, multiple sclerosis, and quadriplegia, there were multiple documented instances where no bowel movement occurred for periods exceeding 72 hours—sometimes up to 240 hours—without any documented nursing intervention or administration of prescribed bowel care medications. The facility's standing orders required timely administration of medications such as Peri Colace, MiraLAX, Milk of Magnesia, Bisacodyl, and Lactulose, and mandated provider notification if symptoms persisted, but these protocols were not followed as documented in the residents' records. Record reviews and staff interviews confirmed that nurses did not document the administration of bowel care medications or interventions as ordered for the affected residents during the periods of constipation. In some cases, physician orders specifically outlined a stepwise approach to bowel management, including escalation to suppositories or enemas if initial interventions were ineffective, but there was no evidence these steps were taken or recorded. The DON acknowledged that the required interventions and documentation were not completed by the nursing staff for the residents identified.
Resident Privacy Not Maintained During Personal Care
Penalty
Summary
Staff failed to maintain a resident's privacy during personal care activities. On the morning of 12/16/25, two staff members were observed assisting a resident with personal cares in the resident's room while the door was left open. The resident's room was located across from the nurse station in a high-traffic area, making the resident visible to passersby. The surveyor observed this from the hallway and confirmed with an LPN at the nurse station that the door should have been closed during such care. The Director of Nursing later confirmed that staff should not have left the door open during personal care. The resident involved had multiple diagnoses, including Ataxic Cerebral Palsy, schizoaffective disorder, and PTSD. The failure to close the door during personal care was directly observed and acknowledged by staff as not following proper privacy protocols.
Unsecured Portable Oxygen Cylinders in Resident Room
Penalty
Summary
The facility failed to ensure that a resident's room was free from accident hazards, as evidenced by the presence of two unsecured portable oxygen cylinders propped up in the corner of the room. The resident, who had multiple diagnoses including COPD and diabetes, stated that she brought the portable oxygen cylinders from home but was not using them at the time. During observation, it was also noted that the resident was using a portable oxygen concentrator and had a portable liquid oxygen tank hanging on her wheelchair. The Director of Nursing was unaware that the resident had portable oxygen cylinders in her room, and acknowledged that they were not properly secured or stored in the designated oxygen room as required.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents. One resident with diagnoses including respiratory failure and morbid obesity was observed on two occasions with their oxygen concentrator set at 3.5 liters per minute (lpm), despite a physician order for oxygen via nasal cannula at 1 to 2 lpm to maintain oxygen saturation at or above 88%. Another resident with osteolysis and malnutrition was observed with their oxygen concentrator set at 3.5 lpm, while the physician order specified 2 lpm via nasal cannula to keep oxygen saturation above 90%. The Director of Nursing confirmed that both residents' oxygen concentrators were set higher than ordered.
Failure to Properly Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by a missing licensed nurse signature on the narcotic accountability sheet for one of two medication carts reviewed. Specifically, during an audit of the 200 Hall medication cart, it was observed that the narcotic accountability sheets covering a two-week period had only one nurse's signature documented on a particular date, instead of the required two. Staff interviews confirmed that two nurses were expected to sign the narcotic accountability sheet when accepting or releasing the medication cart, but this procedure was not followed on the identified date.
Failure to Properly Store and Remove Expired Medications and Biologicals
Penalty
Summary
Surveyors identified that medications and biologicals were not properly stored or monitored for expiration in the facility. During observation, two medication cups containing Nystatin cream were found on a resident's nightstand, and the resident was unaware of why they were there or how long they had been present. The Nystatin cream had been left at the bedside, contrary to storage requirements. Additionally, an audit of a medication cart revealed a bottle of fiber supplement with an expiration date of 7/24 and a tube of muscle rub with an unclear expiration date of 12/12, both of which were expired and had not been discarded. Further review of the medication cart uncovered expired biologicals, specifically glucose test solutions with expiration dates of 10/10/25 and 10/12/25, which remained in use. Staff interviews confirmed that these expired medications and biologicals should have been removed but were not. The resident involved had multiple diagnoses, including COPD and diabetes, and was admitted to the facility prior to the observations.
Deficient Food Storage, Labeling, and Distribution Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, labeling, and distribution practices. During observations in the dining room, a squeeze bottle containing a white liquid, identified by the Certified Dietary Manager (CDM) as ranch dressing, was found without a contents label or any dates. Additionally, a container labeled as milk lacked both a date poured and an expiration date, with the CDM stating that milk and ranch dressing are poured out after each meal. In the walk-in refrigerator, surveyors observed a small zip lock bag with diced tomatoes, another with diced cucumbers, a plastic container with sliced cheese, and a plastic container with barbeque sauce, none of which were labeled with dates. Furthermore, a case of food was found stored directly on the ground in the dry food storage room, contrary to facility policy and food code requirements. The facility's Food Storage policy requires that food items be stored on shelves, dated when placed on shelves, stored at least six inches above the floor, and that leftover food be stored in covered containers or wrapped securely, clearly labeled, and dated before refrigeration. The Idaho Food Code also mandates date marking for refrigerated, ready-to-eat, time/temperature control for safety foods held for more than 24 hours. The CDM acknowledged that food in the dry storage area should not be stored on the floor and that all food items should be labeled and dated, which was not being done at the time of the survey.
Uncovered Garbage Cans in Kitchen Area
Penalty
Summary
Surveyors observed that two garbage cans in the kitchen food preparation area were left uncovered and not in continuous use, contrary to the requirements outlined in the U.S. Food and Drug Administration 2022 Food Code, section 5-501.113. The code specifies that receptacles containing food residue must be kept covered when not in continuous use or after being filled. During an interview, the Certified Dietary Manager (CDM) acknowledged that the garbage cans were not in use at the time and should have had their lids on, indicating a failure to ensure proper closure of garbage cans to minimize the attraction of pests and rodents into the kitchen. This practice had the potential to affect all residents and staff in the facility.
Unqualified Dietary Supervisor in Facility
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, which had the potential to affect 61 of 62 residents who received meals prepared in the facility's kitchen. The Dietary Supervisor (DS) had been working as the Dietary Manager since April 2023 but was not certified as a Dietary Manager. The DS had ten years of food service experience in restaurants but none in healthcare. She had completed only 34% of a Dietary Manager certification training program and held only a food handler's certification, without completing other courses in food safety and management. This deficiency was confirmed during interviews with the Administrator and Registered Dietitian (RD), who acknowledged that the DS was currently enrolled in a qualifying course to obtain the necessary credentials.
Deficiencies in Food Storage, Labeling, and Hygiene Practices
Penalty
Summary
The facility failed to comply with food storage, labeling, and hygiene standards as outlined in the Idaho and FDA Food Codes. Observations revealed that the walk-in refrigerator contained open containers of salad dressings with expired use-by dates and exposed spouts. Additionally, the mini freezer housed various food items that were loosely wrapped and lacked proper labeling and dating. The Dietary Supervisor (DS) acknowledged these issues but was under the misconception that USDA rules allowed for extended storage times. The Registered Dietitian (RD) confirmed that the items should have been protected from freezer burn and properly labeled. The facility also failed to maintain cleanliness in food-contact surfaces and equipment. The ovens and grease trays were observed to have white dried residue and food drainage, which were not cleaned daily as required. Clean trays, tubs, and silverware were covered in a white residue due to hard water, and the water softener had been down for a week. The DS admitted that the dishes had not been de-limed for over a month. Additionally, the refrigerator in the nutrition room contained undated and expired food items, which the DS confirmed should have been disposed of. Hand hygiene practices were not followed by the staff, as observed during meal preparation. Staff members, including the DS and Dietary Aide, failed to wash their hands between glove changes and after handling potentially contaminated surfaces. The RD stated that the facility should adhere to state food codes, which require secure sealing and labeling of foods and proper handwashing when indicated.
Failure to Provide Pertinent Health Information During Resident Transfers
Penalty
Summary
The facility failed to ensure continuity of care by not providing pertinent health information to the receiving hospital for four residents during their transfers. The facility's policy required specific information to be sent, including contact information for the resident's practitioner, advance directives, comprehensive care plans, and other necessary health information. However, the records for these residents did not include documentation that such information was sent. This lack of documentation was confirmed by the Director of Nursing (DON) and other staff members during interviews. Resident #19 was transferred to the hospital due to lab results indicating hyponatremia and abnormal renal function, but there was no documentation of the advance directive or care plan being sent. Resident #34 was transferred for gastrointestinal bleeding, yet her care plan and advanced directives were not sent. Resident #55 was transferred with a new onset of foul drainage from a foot ulcer, but there was no documentation of the information sent or a physician's order for the transfer. Resident #33 was transferred twice for pneumonia and respiratory failure, with no documentation of the information provided to the hospital. The Social Services Director (SSD) responsible for transfer documentation was unaware of the necessary documentation requirements.
Failure to Secure and Label Medications
Penalty
Summary
The facility failed to secure and label unidentified loose pills in the North side medication cart, as observed during an audit. The audit revealed several loose pills of various colors and sizes in the second drawer of the medication cart. These included four unidentified pink pills, three unidentified blue pills, one unidentified half of a brown tablet, and ten unidentified white pills of different sizes. The presence of these loose pills indicates a failure to adhere to the facility's Medication Access and Storage policy, which requires medications to be stored in containers that meet legal requirements and to be removed if they are outdated, contaminated, or deteriorated. During the audit, an LPN present was unaware of the reason for the loose pills and uncertain about whose responsibility it was to check the medication cart for such issues. The Director of Nursing (DON) later stated that nurses should check the medication cart throughout their shift and destroy loose medication, with narcotics requiring destruction by two nurses. However, the DON also mentioned uncertainty about whether the pharmacy checks the carts and acknowledged that while medication cart audits are conducted, there is no documentation of these audits, including what is being checked or the findings.
Failure to Document Advanced Directive in Care Plan
Penalty
Summary
The facility failed to ensure that a resident and their representative received assistance to exercise their right to formulate an advanced directive. This deficiency was identified for one resident whose records were reviewed for advanced directives. The facility's policy, revised in December 2023, mandates that residents' choices about advance directives be recognized and respected, and that written information be provided to all adult residents regarding their rights to accept or refuse medical treatment and formulate an advanced directive. Despite this policy, the resident in question, who was admitted with multiple diagnoses including stroke and dementia, had an advanced directive documented in a Medical Treatment Decisions form. However, this advanced directive was not included in the resident's care plan. The Director of Nursing confirmed that the resident did not have an advanced directive documented in the care plan, although they had a POST and a DPOA, indicating a failure to adhere to the facility's policy.
Failure to Follow Care Plans for Wound and Catheter Management
Penalty
Summary
The facility failed to adhere to professional standards of practice and comprehensive care plans for two residents, leading to potential health risks. Resident #17, who had multiple diagnoses including orthopedic aftercare following a surgical amputation and morbid obesity, did not receive wound care as directed by her care plan. The wound care interventions, such as monitoring the wound vac and changing dressings, were not documented as completed on several specified dates. The Director of Nursing (DON) confirmed that the wound care was not performed as ordered, and there was no documentation explaining the omissions. Resident #41, with diagnoses including traumatic subdural hemorrhage, diabetes, malnutrition, and respiratory failure, was also not provided care according to his care plan. His physician's order required that his urinary catheter tubing be secured every shift to prevent kinking and accidental removal. However, observations on two separate occasions revealed that the catheter tubing was not secured. The DON acknowledged that the catheter should have been secured to prevent it from being pulled out.
Failure to Use Positioning Devices for Contracture Prevention
Penalty
Summary
The facility failed to ensure that positioning devices were in place for a resident with severe cognitive impairment and multiple diagnoses, including traumatic brain dysfunction, quadriplegia, and contractures. The resident had a physician's order to use positioning devices, such as carrots or rolled-up washcloths, to prevent further contractures. However, observations over several days revealed that the resident did not have these devices in her hands, despite documentation in the Treatment Administration Record (TAR) indicating otherwise. Interviews with staff, including an LPN, RNA, and CNA, confirmed that the positioning devices were not in use, and there was no documentation of the resident refusing the devices. The Director of Nursing (DON) was unaware of the discrepancy between the TAR and the actual use of positioning devices. The Physical Therapy Assistant (PTA) mentioned that the devices had been provided to the resident about two months prior and should have been in use. The lack of positioning devices could lead to further contractures and pain for the resident, as the facility did not adhere to the care plan and physician's orders, and failed to document any refusals by the resident.
Failure to Use Gait Belt and Two-Person Assist During Transfer
Penalty
Summary
The facility failed to ensure staff used a gait belt during a transfer, as per policy, which resulted in a potential for more than minimal harm for a resident. The resident, who was admitted with multiple diagnoses including a status-post left hip fracture, osteoporosis, Parkinson's disease, and arthritis, required substantial assistance with transfers. The care plan indicated the need for a two-person mechanical lift for transfers. However, during a transfer from a wheelchair to a recliner, the resident lost balance and was assisted to the floor by a COTA, resulting in a complaint of pain and a skin tear. The resident was subsequently transferred to the hospital, where a left femoral fracture was diagnosed, requiring surgical repair. The investigation revealed that the COTA did not use a gait belt during the transfer and did not utilize a second person, despite the resident being a two-person transfer for CNAs. The COTA stated she normally used a gait belt but could not recall if it was used during the incident. The PTA confirmed that the policy required a gait belt and a two-person transfer, which was not followed. The facility's administrator stated that all staff, including therapy staff, are expected to follow the care plan and use a gait belt for transfers.
Infection Control and Equipment Cleaning Deficiencies
Penalty
Summary
The facility failed to adhere to infection control and prevention practices, impacting several residents. Staff did not perform proper hand hygiene, as observed when CNAs failed to offer handwashing to residents before meals. Additionally, a CNA did not change gloves or perform hand hygiene after providing catheter care and before handling a clean brief for a resident. These actions were contrary to the facility's hand hygiene policy and CDC guidelines, which require hand cleaning when moving from a contaminated to a clean body site. The facility also did not ensure the cleanliness of resident equipment. A Hoyer lift used for transferring a resident was not cleaned after use, and staff were unsure of the cleaning protocol. Furthermore, the glucometer used for checking blood sugar levels was not disinfected according to the manufacturer's instructions, as staff did not allow the disinfectant to remain wet for the required time. Insulin administration procedures were also not followed correctly, as staff did not clean the rubber cap of the insulin pen before use. Additional deficiencies were noted in the maintenance of medical equipment. The oxygen concentrator filter for a resident was observed to have a thick layer of dust, indicating it had not been cleaned as per the facility's policy. These lapses in protocol and hygiene practices placed residents at risk for cross-contamination and infection, as the facility did not adhere to its own policies and CDC guidelines.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Pocatello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gateway Transitional Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Idaho State Veterans Home - Pocatello | 2 mi | ★★★★★ | 0 | 0 |
| Quinn Meadows Rehabilitation And Care Center | 2.2 mi | ★★★★★ | 6 | 0 |
| Syringa Chalet Nursing Facility | 20.8 mi | ★★★★★ | 8 | 0 |
| Bingham Memorial Skilled Nursing & Rehabilitation | 21.1 mi | ★★★★★ | 9 | 0 |
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