Monte Vista Hills Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pocatello, Idaho.
- Location
- 1071 Renee Avenue, Pocatello, Idaho 83201
- CMS Provider Number
- 135018
- Inspections on file
- 21
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 8
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.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
