Valley Vista Care Center Of Sandpoint
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandpoint, Idaho.
- Location
- 220 South Division Ave, Sandpoint, Idaho 83864
- CMS Provider Number
- 135055
- Inspections on file
- 20
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Valley Vista Care Center Of Sandpoint during CMS and state inspections, most recent first.
Multiple residents with serious mental illness, dementia, or neurocognitive disorders had completed PASRR Level II evaluations, but their MDS assessments were inaccurately coded as not having such evaluations. Additionally, a resident using a wanderguard was not properly documented in the MDS. Staff interviews confirmed these errors were due to misinterpretation and oversight during assessment completion.
The facility did not consistently provide nourishing evening snacks to residents, resulting in a meal interval exceeding regulatory guidelines. Several residents reported that available snacks were insufficient, and some were unaware they could request snacks after dinner or ask for more than one. Staff interviews revealed uncertainty about whether snacks were routinely offered to all residents between dinner and breakfast, and there was no documented resident group agreement to the extended meal interval.
Surveyors found expired spices in the kitchen and unclean resident refrigerators with food residue. The CDM was unaware of the expired items and could not provide documentation that the cleaning schedule had been followed, potentially affecting all residents consuming facility-prepared food.
Staff did not offer hand hygiene to several residents before serving meals, both in the dining room and in resident rooms. One resident was observed coughing and sneezing into his hands without being provided hand hygiene before eating. LPNs confirmed that hand hygiene was not offered as required by policy.
A resident with a history of brain injury who required help with meals was fed by an LPN who stood over the resident, contrary to facility policy that requires staff to sit while assisting with feeding to ensure dignity and comfort.
Two residents with cognitive and mental health diagnoses did not have advance directives documented in their records, and there was no evidence that the facility offered resources or assistance to help them execute advance directives. Staff confirmed that discussions focused on POLST forms rather than advance directives, and there was no follow-up with residents or their legal representatives regarding these options.
A resident with significant neurological and physical impairments was found to have a room with a wall in disrepair, including peeling coving and scratched protective paneling. The issue was identified after the resident's representative raised concerns, and staff confirmed the need for repairs.
A resident with a history of stroke and left-side paralysis was transferred to the hospital without documentation that current medical information was provided to the receiving hospital. The DON confirmed that there was no record of the required transfer paperwork being sent.
Two residents with complex medical needs were transferred to the hospital without receiving written notification of the facility's bed-hold and return policy, and the Ombudsman was not informed of their transfers. Staff confirmed that bed-hold policy notifications were not provided at the time of transfer and that the Ombudsman is only contacted if assistance is needed, not for all transfers or discharges.
A resident admitted with multiple medical conditions did not receive a copy or summary of the baseline care plan within 48 hours of admission, as required by facility policy. Documentation and interviews confirmed that neither the resident nor a representative was provided with the care plan summary, and the DON could not find evidence that this requirement was met.
Two residents did not receive medications according to physician orders and professional standards: an LPN failed to instruct a resident with COPD to rinse his mouth after using an inhaler, and another resident with quadriplegia received only one tablet of Vitamin B-12 instead of the ordered three. The DON confirmed the need for mouth rinsing after inhaler use, and the LPN acknowledged the dosage error.
Three residents with complex medical histories received PRN narcotic pain medications without being offered non-pharmacological interventions as ordered by their physicians. Medication records showed repeated administration of narcotics without documentation of alternative pain management attempts, and the DON confirmed that these interventions were not documented or offered as required.
A resident with chronic bronchitis, low back pain, and dementia continued to receive guaifenesin ER for congestion over several months, despite repeated clinical documentation and observations showing no symptoms of cough, congestion, or respiratory distress. The DON could not provide a clear reason for the ongoing medication, indicating a failure to ensure the resident's drug regimen was free from unnecessary drugs.
A CNA was hired and allowed to work without verification of state-required certification. HR personnel were unable to locate or confirm the CNA's certification, resulting in the staff member providing care without proper credentials.
The facility failed to protect residents from verbal and physical abuse by staff, as evidenced by incidents involving two residents. One resident reported feeling unsafe due to an LPN's confrontational behavior, while another resident experienced physical and verbal abuse by CNAs. Despite multiple reports and a substantiated investigation, the accused staff members were not immediately removed, placing all residents at risk.
A resident with multiple diagnoses, including dementia and epilepsy, required two-person assistance for all ADLs. However, only one staff member assisted the resident during pericare, leading to a fall and a nondisplaced superior calcaneal fracture. The DON confirmed that the care plan was not followed and that the staff member was in-serviced after the incident.
The facility did not meet the regulation requirements for the frequency of QA meetings, as no meetings were held between April 2023 and June 2023. The Administrator could not provide sign-in sheets for this period, indicating a lapse in the required monthly meetings.
The facility failed to provide a minimum of 12 hours of in-service education per year for three CNAs, placing residents at risk of receiving care from inadequately trained staff. Training logs showed the CNAs had only completed between 2.75 and 7.75 hours of training in their respective annual periods. The Human Resources Coordinator confirmed the shortfall despite monthly reviews.
The facility failed to maintain a resident's dignity by not ensuring he was properly covered, exposing his adult diaper and PEG tube to anyone passing by his open door. The DON acknowledged the issue and covered the resident, stating that staff would be reminded to check on him regularly.
The facility failed to ensure the interdisciplinary team had determined it was appropriate for two residents to self-administer medications. One resident with COPD had a Ventolin inhaler without a completed checklist confirming proper use, and another resident with multiple diagnoses was left unattended with a cup of pills, despite not being assessed for self-administration.
A resident with multiple diagnoses, including dementia and anxiety, was taken home against medical advice (AMA) by her representative without a discharge order. The facility staff failed to document notifying the physician, placing the resident at risk due to the lack of physician input.
The facility failed to provide an Advance Beneficiary Notice (ABN) to a resident whose Medicare Part A benefits ended, resulting in potential financial liability for continued services. The resident, admitted for dementia care, continued to stay at the facility without being informed of the financial costs, as the staff assumed the resident would be going home.
The facility failed to report allegations of potential abuse to the State Survey Agency within the required 2-hour timeframe. A resident reported that an LPN was confrontational and screamed at her, making her feel very afraid. The DON and Administrator initially did not recall the incident, and the DON later confirmed that the incident was not reported as required, placing all residents at risk.
A resident reported verbal abuse by an LPN, but the facility failed to thoroughly investigate the allegation. The resident expressed fear and distress, and the accused LPN continued to work during the investigation, contrary to the facility's abuse policy.
A resident with hemiplegia and hemiparesis following a stroke did not receive the specified passive range of motion exercises as outlined in their care plan. The DON confirmed the absence of a restorative nursing program, citing the recent surgery of the staff member designated to manage the program.
A resident with multiple diagnoses, including intracranial injury and epilepsy, was observed with his head tilted to the side without any supporting device. The DON acknowledged the need for a Physical Therapist evaluation for the resident's neck positioning.
The facility failed to ensure the cleanliness of a nebulizer mouthpiece for a resident, which was not stored in a plastic bag as required by policy. The resident had multiple diagnoses, including high blood pressure, dementia, and malnutrition, and was moderately cognitively impaired. The DON confirmed the mouthpiece should have been stored properly.
The facility failed to monitor the effectiveness of a resident's Trazodone prescription for insomnia, as required. The resident's medical record lacked documentation of sleep monitoring, which was confirmed by the DON. This deficiency created the potential for adverse reactions or side effects due to inadequate monitoring.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for six residents, resulting in incorrect documentation of critical assessment information. Specifically, several residents with documented PASRR Level II evaluations indicating serious mental illness or related conditions were inaccurately coded in their MDS assessments as not having such evaluations. For example, one resident with intrahepatic bile duct cancer had a completed PASRR Level II, but the admission MDS assessment did not reflect this. Another resident with diagnoses including senile degeneration of the brain, PTSD, and personality disorder had a PASRR Level II confirming severe mental illness, yet the MDS assessment was marked as not having a PASRR Level II. Similar discrepancies were found for residents with dementia, PTSD, depression, and other neurocognitive disorders, where the MDS assessments failed to accurately document the presence of PASRR Level II evaluations. Additionally, the facility did not accurately document the use of safety devices. One resident with hypertension and chronic obstructive pulmonary disease was observed wearing a wanderguard, but the corresponding MDS assessment indicated that the device was not in use. Staff interviews confirmed that these inaccuracies were due to misinterpretation of assessment questions and oversight during the completion of the MDS. These documentation errors were identified through record reviews and staff interviews, highlighting a pattern of inaccurate assessment entries for multiple residents.
Failure to Routinely Provide Nourishing Evening Snacks
Penalty
Summary
The facility failed to ensure that residents were routinely provided with nourishing evening snacks, as required by regulatory guidelines. Observations and interviews revealed that several residents reported the snacks provided were not substantial or filling, and one resident was unaware that snacks could be requested after dinner. Additionally, residents did not know they could ask for more than one snack. A review of the facility's meal schedule showed there were 15 hours between dinner and breakfast, exceeding the recommended maximum of 14 hours unless a nourishing snack is provided at bedtime or a resident group agrees to the extended interval. Interviews with facility staff, including the CDM and DON, indicated a lack of awareness regarding whether snacks were routinely offered to all residents between dinner and breakfast. The CDM confirmed there was no documented resident group agreement to the current meal hours, and the DON was unaware if snacks were consistently offered during the extended overnight period. Nursing staff reported that snacks were offered if care planned or upon resident request, but not necessarily as a routine practice for all residents.
Expired Spices and Unclean Refrigerators Identified in Food Service Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food safety and sanitation practices in the kitchen and resident areas. Specifically, expired spices including Fajita, Chili Powder, and Onion Powder were found in the spice rack next to the cook preparation area. The Certified Dietary Manager (CDM) acknowledged being unaware of the expired spices and confirmed they should have been discarded. Additionally, the resident refrigerators located in the Lodge, the Village, and the Kitchen were found to be unclean, with food residue present on the interior shelves during multiple observations. The CDM stated that a cleaning schedule existed, documenting what was to be cleaned and when, but was unable to provide documentation that the cleaning schedule had been followed for the month of June 2025. These deficiencies had the potential to affect all 59 residents who consumed food prepared by the facility, as the lack of proper cleaning and failure to discard expired food items could lead to food contamination.
Failure to Offer Hand Hygiene to Residents Before Meals
Penalty
Summary
Surveyors determined that the facility failed to maintain proper infection prevention and control practices by not offering hand hygiene to residents before meals were served. Specifically, seven residents in the Lodge dining room and three residents eating in their rooms were not provided with hand hygiene prior to receiving their meals. One resident was observed coughing and sneezing into his hands and then rubbing his face, yet staff did not offer hand hygiene before serving his meal or after the episode. Staff interviews confirmed that hand hygiene was not offered as required by both facility policy and CMS guidelines.
Failure to Provide Dignified Mealtime Assistance
Penalty
Summary
The facility failed to uphold a resident's right to be treated with respect and dignity during mealtime assistance. According to the facility's Assistance with Meals policy, residents who cannot feed themselves are to be assisted in a manner that ensures safety, comfort, and dignity, specifically stating that staff should not stand over residents while feeding them. Observation revealed that a resident with a history of intracranial injury and loss of consciousness, who required assistance with meals, was fed by an LPN who stood over the resident during the meal. The LPN later confirmed that he was standing while assisting the resident and acknowledged that he should have been sitting, as per facility policy.
Failure to Ensure Residents' Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that residents were able to exercise their right to formulate an advance directive, as required by regulation. For two residents with multiple diagnoses including dementia, PTSD, hallucinations, and depression, there was no documentation in their records of an advance directive for healthcare. Additionally, there was no evidence that resources or assistance were offered to help these residents execute an advance directive. Staff interviews confirmed that the facility's focus during care conferences was on the POLST form, and discussions about advance directives were not conducted. In one case, a resident's sister facilitated admission and signed a financial power of attorney, but the resident did not sign a healthcare power of attorney, and there was no follow-up documented regarding advance directive options. In the other case, there was no documentation that information or assistance with advance directives was offered to the resident's legal guardian.
Failure to Maintain Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident with multiple diagnoses, including aphasia, right-sided weakness and paralysis, and dementia. The resident's representative expressed concern about exposed wood in the baseboard area of the resident's wall. Upon observation, a long section of coving was found peeling away from the wall near the headboard of the resident's bed, and there were multiple long scratches on the board panel intended to protect the wall. A CNA confirmed that the coving and board required repair, and the Maintenance Assistant stated he was unaware of the needed repairs until the previous evening.
Failure to Provide Hospital Transfer Paperwork During Resident Discharge
Penalty
Summary
The facility failed to provide hospital transfer paperwork for one resident who was discharged to the hospital. Record review showed that the resident, who had a history of stroke and left-side paralysis, was transferred to the hospital, but there was no documentation that current medical information was provided to the receiving hospital at the time of transfer. Staff interview with the DON confirmed that she could not provide documentation that the hospital received the resident's current medical documentation during the transfer. This action did not meet the requirement to ensure appropriate information is communicated to the receiving health care institution during a transfer or discharge.
Failure to Provide Bed-Hold Policy Notification and Ombudsman Notification During Resident Transfers
Penalty
Summary
The facility failed to provide required written notification of its bed-hold and return policy to residents who were transferred to the hospital, and did not notify the Ombudsman advocate of these transfers. Specifically, for two residents with significant medical histories—one with blood clots and kidney and bladder cancer, and another with a history of stroke and left-side paralysis—there was no documentation in their medical records that they received written notice regarding the facility's bed-hold policy at the time of their hospital transfers. Additionally, there was no evidence that the Ombudsman was informed of their transfers, which is necessary to ensure advocacy for residents during their absence from the facility. Staff interviews confirmed that the Director of Nursing acknowledged the lack of bed-hold policy notification, stating that residents are only informed upon admission that the facility does not hold beds for discharged residents. The CCU Coordinator also stated that the Ombudsman is only contacted if assistance is needed, not routinely notified of transfers or discharges. These actions and omissions were identified through record review and staff interviews, and were found to be true for two of four residents reviewed for discharge documentation.
Failure to Provide Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to provide a copy or summary of the baseline care plan to a resident and/or their representative within 48 hours of admission, as required by facility policy. The policy specifies that residents and/or their representatives must receive a summary of the baseline care plan, which includes initial goals, a summary of medications and dietary instructions, services and treatments to be administered, and any updated information from the comprehensive care plan. Record review and staff interviews confirmed that there was no documentation showing the baseline care plan was provided to the resident or their representative. The resident involved was admitted with multiple diagnoses, including thoracic vertebra fractures, ankylosing hyperostosis, and diabetes. The admission MDS assessment documented that the resident was cognitively intact. During an interview, the resident was unsure if he had received a copy of his care plan or had a meeting with staff about his care. The DON was unable to locate documentation that the baseline care plan had been provided to the resident or his representative.
Failure to Follow Medication Administration Orders and Standards
Penalty
Summary
The facility failed to ensure medications were administered according to physician's orders and professional standards of practice for two residents. For one resident with COPD and dementia, a physician's order required the use of an inhaled medication (fluticasone-salmeterol) with instructions to rinse the mouth after each use. During medication administration, the LPN provided the inhaler but did not instruct or offer the resident to rinse his mouth afterward, as required by the order and professional guidelines. The DON confirmed that the medication brands were equivalent and that mouth rinsing should have been performed. For another resident with a history of traumatic brain injury and quadriplegia, a physician's order specified administration of three tablets of Vitamin B-12 daily. The LPN was observed preparing and administering only one tablet instead of the ordered three. Upon review of the order, the LPN acknowledged the error and stated that the correct dosage should have been given. These actions demonstrate a failure to follow physician orders and established medication administration protocols.
Failure to Offer Non-Pharmacological Pain Interventions Prior to PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure that physician-ordered non-pharmacological interventions were offered to residents prior to the administration of as-needed (PRN) narcotic pain medications. This deficiency was identified through record review, policy review, and staff interviews, and was found to affect three residents with significant medical histories, including low back pain, dementia, vertebral fractures, arthritis, and a history of substance use disorder. For each resident, physician orders specifically directed staff to offer interventions such as rest, positioning, distractions, and application of cold or heat packs before administering PRN narcotic pain medications. Despite these orders, medication administration records for all three residents showed repeated administration of narcotic pain medications without any documentation that non-pharmacological interventions were offered beforehand. In one case, a resident received a narcotic pain medication 69 times in a single month with no record of non-pharmacological interventions being attempted. The Director of Nursing confirmed the absence of such documentation for all three residents, acknowledging that the interventions should have been offered prior to medication administration.
Failure to Discontinue Unnecessary Medication for Resident
Penalty
Summary
A resident with multiple diagnoses, including chronic bronchitis, low back pain, and dementia, was admitted to the facility and prescribed guaifenesin ER 600 mg every 12 hours for congestion. Despite this ongoing prescription, multiple progress notes from a Nurse Practitioner over several months documented that the resident did not exhibit symptoms such as cough, congestion, shortness of breath, nasal discharge, or abnormal lung sounds. Medication administration records confirmed that the resident continued to receive guaifenesin ER as ordered from March through late June. Direct observations of the resident on several occasions revealed no signs of cough, congestion, or difficulty breathing. When questioned about the continued administration of guaifenesin despite the absence of symptoms, the Director of Nursing was unable to provide a clear rationale and suggested the medication order needed clarification. This sequence of events demonstrates that the facility failed to ensure the resident was free from unnecessary medications, as required.
Failure to Verify CNA Certification Prior to Employment
Penalty
Summary
The facility failed to ensure that nursing staff were licensed or certified in accordance with state laws. During a review of licenses and certifications for three nursing staff members, it was found that one staff member, hired as a CNA, did not have certification to work as a CNA in the state. The HR personnel, who was recently hired, was unable to locate the certification for this staff member and confirmed that the staff member could not provide proof of certification. This deficiency had the potential to affect all 61 residents in the facility, as the staff member was providing care without the required credentials. The review and interviews with HR personnel revealed that the certification was not verified at the time of hire, and the staff member continued to work without proper documentation of state-required certification.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by staff, as evidenced by incidents involving two residents. Resident #37 reported that an LPN on the night shift was confrontational, yelled at her, and made her feel unsafe. Despite the resident's immediate report to the Administrator and the presence of another LPN who witnessed the distress, the accused LPN continued to work in the facility without immediate removal, contrary to the facility's abuse policy. The DON and Administrator initially denied any recent allegations of verbal abuse, but later confirmed the incident occurred and was investigated as unsubstantiated, although the accused LPN was not removed from duty until much later. Resident #3 experienced multiple instances of physical and verbal abuse by CNAs, including ear flicking, hair pulling, and mocking, which were reported by other staff members. The abuse caused Resident #3 to become agitated and use profanity, which further escalated the situation. Despite multiple witness reports and a substantiated abuse investigation, the involved CNAs and an LPN who failed to intervene were only terminated after the incidents were reported to Human Resources. The facility's failure to immediately remove the accused staff members and protect the residents from further abuse placed the health and safety of all residents at risk. The incidents were not promptly addressed according to the facility's abuse policy, leading to a determination of immediate jeopardy for the residents' well-being.
Removal Plan
- All residents were safe by having the accused leave the building immediately and placed on administrative leave.
- The facility will re-educate all staff members to Valley Vista Care Corporation Abuse Policy and Procedures and the Federal and State requirements for reporting prior to their next shift following Train the Trainer in-service.
- The CEO, Director of Corporate Compliance, and/or Director of Administrative Services will be alerted of any allegation(s) of abuse immediately to ensure Federal and State law has been followed.
- Residents were interviewed to ensure they felt safe in the building, if they were abused (verbal, physical, and/or neglect), and if they knew who they could report abuse allegations.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that Resident #16's care plan was followed, resulting in a fall and subsequent injury. Resident #16, who had multiple diagnoses including viral infection of the brain, dementia, epilepsy, and abnormal posture, required two-person assistance for all activities of daily living (ADLs) due to his cognitive and physical impairments. However, on 12/21/23, only one staff member, CNA #13, was assisting Resident #16 during pericare. While turning Resident #16, he threw his left arm to his right side and rolled off the bed, resulting in a fall. The incident report noted possible muscle spasm or seizure activity as the root cause of the fall and reiterated the need for two-person assistance for Resident #16's care. Following the fall, Resident #16 exhibited signs of injury, including a bruise and swelling on his right heel. Despite initial assessments indicating no apparent pain, a physician's progress note on 1/4/24 documented that Resident #16's right foot was painful to palpate, leading to an x-ray that confirmed a nondisplaced superior calcaneal fracture. The Director of Nursing (DON) acknowledged that the care plan was not followed and that CNA #13 should have known to provide two-person assistance by checking the Kardex. The DON also confirmed that CNA #13 was in-serviced after the incident.
Failure to Hold Required QA Meetings
Penalty
Summary
The facility failed to meet the regulation requirements for the frequency of Quality Assurance (QA) meetings. According to the facility's Quality Assurance and Performance Improvement (QAPI) Program, the committee is supposed to meet monthly to review reports, evaluate data, and monitor QAPI-related activities. However, upon review of the attendance sheets for QAPI meetings from April 2023 to April 2024, it was found that no meetings were held between April 2023 and June 2023. The Administrator was unable to provide sign-in sheets for this period, indicating a lapse in the required monthly meetings. This failure to hold regular QA meetings has the potential to negatively affect all residents in the facility if quality deficiencies are not identified and addressed in a timely manner.
Failure to Provide Required CNA In-Service Education
Penalty
Summary
The facility failed to provide a minimum of 12 hours of in-service education per year for three CNAs, which placed residents at risk of receiving care from inadequately trained staff. The facility's policy required 24 hours of in-service training annually, and non-compliance could impact pay raises and result in termination. However, the training logs for three CNAs showed they had only completed between 2.75 and 7.75 hours of training in their respective annual periods. During interviews, the Human Resources Coordinator (HRC) confirmed that the facility used the employee anniversary date to track training hours and reviewed them monthly. Despite this, the HRC acknowledged that the CNAs were short on their required training hours. The deficiency was identified through record reviews, policy reviews, and staff interviews, highlighting a failure in ensuring adequate training for CNAs to meet residents' needs.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure respect and maintain a resident's dignity for Resident #12, who was admitted with multiple diagnoses including intracranial injury, epilepsy, and aphasia. An annual MDS assessment documented that Resident #12 was rarely/never understood. On two separate occasions, Resident #12 was observed from outside his room with no sheet covering his lower body, exposing his adult diaper and PEG tube. His door was fully open, making him visible to anyone passing by. The DON acknowledged the situation and stated that Resident #12 would always uncover himself, then proceeded to cover him and mentioned reminding the staff to check on him regularly.
Failure to Ensure Appropriate Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the interdisciplinary team had determined it was appropriate for two residents to self-administer medications. Resident #39, who was cognitively intact and diagnosed with chronic obstructive pulmonary disease (COPD), had a physician order to keep a Ventolin inhaler in her room. However, there was no checklist completed to confirm that Resident #39 knew and understood how to use the inhaler. Additionally, the Resident Care Specialist (RCS) was unaware of the order and confirmed that the interdisciplinary team had not determined Resident #39 was appropriate for self-administering medications. Resident #52, who was moderately cognitively impaired and diagnosed with type 2 diabetes mellitus, heart disease, and dementia, was observed with a cup of pills placed on the dining room table by an LPN. The LPN left the dining room to obtain a glucometer strip, leaving the medication cup unattended. The LPN later confirmed that Resident #52 was not assessed or determined by the interdisciplinary team to be appropriate to self-administer medications. The Director of Nursing (DON) also confirmed that Resident #52 had not been assessed for self-administration of medications.
Failure to Notify Physician of Resident's AMA Discharge
Penalty
Summary
The facility failed to ensure the physician was notified of a resident's decision to leave the facility against medical advice (AMA). Resident #62, who had multiple diagnoses including dementia, weakness, and anxiety, was taken home by her representative without a discharge order. The nurse documented the representative's intention to take the resident home and attempted to explain the need for a discharge order. Despite this, the representative insisted on taking the resident home, and an AMA form was signed. The Social Services progress note also documented the representative's decision and the resident's inability to urinate without assistance. The Director of Nursing (DON) confirmed that staff are expected to notify the physician of any resident wanting to go home AMA. However, upon reviewing Resident #62's record, the DON found no documentation that the physician was notified. The DON then contacted the Resident Services Coordinator (RSC), who stated that the physician was verbally notified but failed to document it in the resident's record. This lack of documentation and communication placed Resident #62 at risk of harm due to the absence of physician input or involvement in the discharge process.
Failure to Provide Advance Beneficiary Notice
Penalty
Summary
The facility failed to ensure that residents were provided with an Advance Beneficiary Notice (ABN) when their Medicare Part A benefits ended. This deficiency was identified for one resident who was admitted for care related to dementia. The resident's representative was given the Notice of Medicare Non-Coverage (NOMNC) form, indicating that skilled nursing service coverage would end on 4/5/24. However, the resident continued to stay at the facility after this date without being provided an ABN to inform them of the financial costs they would be liable to pay. The Resident Services Coordinator (RSC) stated that the ABN was not provided because they thought the resident would be going home.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of potential abuse to the State Survey Agency within the required 2-hour timeframe. This deficiency affected a resident who was cognitively intact and had multiple diagnoses, including heart disease, high blood pressure, arthritis, and depression. The resident reported that an LPN on the night shift was confrontational, screamed at her, and made her feel very afraid. The resident immediately called the Administrator, who planned to send another LPN to sit with her, but the confrontational LPN returned alone and had another verbal encounter with the resident. When interviewed, the Director of Nursing (DON) and the Administrator initially did not recall any recent allegations of verbal abuse. The DON later confirmed that the incident occurred on the evening shift and should have been reported to the State Agency. However, the DON could not find the investigation report and admitted that the incident was not reported as required. This failure to report and investigate the allegation in a timely manner placed all residents in the facility at risk of abuse.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was thoroughly investigated for Resident #37, who was admitted with multiple diagnoses including heart disease, high blood pressure, arthritis, and depression. Resident #37, who was cognitively intact, reported that an LPN on the night shift was confrontational, hollered, and screamed at her, stating she never liked Resident #37 and wanted her out of the facility. The resident immediately called the Administrator, who planned to send another LPN to sit with her. However, the confrontational LPN returned to the room alone, leading to another verbal encounter. The resident expressed fear and distress over the incident and stated she had not seen the LPN since but knew she was still in the building. The Director of Nursing (DON) and the Administrator were unaware of any recent allegations of verbal abuse when initially asked. The DON later provided a phone interview statement dated the day after the incident but could not provide documentation of interviews with the involved LPNs or other CNAs on duty. The DON confirmed that the accused LPN continued to work during the investigation period, contrary to the facility's abuse policy, which mandates the immediate removal of the accused from resident care areas pending investigation results. This lack of thorough investigation and failure to follow protocol subjected Resident #37 and other residents to potential ongoing abuse without detection.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to implement a restorative nursing program for a resident with hemiplegia and hemiparesis following a stroke. The resident's care plan, revised on 5/19/22, specified that the resident was to receive passive range of motion exercises for the left upper extremity. However, the resident reported that he had not been receiving the restorative program recently and did not know why. The Director of Nursing (DON) confirmed that the facility currently did not have a restorative nursing program and mentioned that the staff member who was supposed to manage the program had recently undergone surgery.
Failure to Follow Professional Standards of Practice
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for a resident with multiple diagnoses, including intracranial injury, epilepsy, and aphasia. The resident was observed on multiple occasions with his head tilted to the left side, almost touching his shoulder, without any supporting device for his head or posture. The Director of Nursing (DON) acknowledged that it had been a while since the resident was evaluated by a Physical Therapist and confirmed that the resident should be assessed for his neck positioning.
Failure to Maintain Cleanliness of Nebulizer Mouthpiece
Penalty
Summary
The facility failed to ensure the cleanliness of a nebulizer mouthpiece for a resident, which was not stored in a plastic bag as required by the facility's policy. This was observed on two separate occasions, where the mouthpiece was found lying directly on the overbed table. The resident involved had multiple diagnoses, including high blood pressure, dementia, and malnutrition, and was moderately cognitively impaired. The Director of Nursing confirmed that the nebulizer mouthpiece should have been stored in a plastic bag.
Failure to Monitor Medication Effectiveness
Penalty
Summary
The facility failed to ensure professional standards of practice were met for monitoring the effectiveness of a resident's medication. This was identified for one resident who was prescribed Trazodone for insomnia. The resident's medical record did not include documentation of sleep monitoring, which is necessary to evaluate the effectiveness of the medication. The Director of Nursing (DON) confirmed that the resident's hours of sleep were not being recorded, despite the requirement for such monitoring. This deficiency created the potential for the resident to experience adverse reactions or side effects due to the lack of appropriate monitoring.
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.
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