Citations in Idaho
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Idaho.
Statistics for Idaho (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Idaho
A resident with a history of anxiety and recent suicidal ideation exhibited escalating behaviors and ultimately physically assaulted another resident, causing facial injuries. The facility failed to protect residents from abuse, resulting in harm and placing others at risk.
The facility did not document or provide required health information to receiving hospitals during the transfer of two residents—one with epilepsy and anxiety who experienced neurological decline, and another with multiple chronic conditions who sustained injuries from a fall. In both cases, transfer paperwork was missing from the records, and staff confirmed the lack of documentation.
Two residents were involved in an incident where one physically assaulted the other, causing facial injuries. Despite documented behavioral concerns and threats from the aggressor, the facility did not implement interventions to prevent further abuse prior to the incident, relying only on the resident's arrest after the event.
A resident with cerebral palsy and major depressive disorder had documented orders for hydroxyzine for anxiety and a diagnosis of severe dementia, but the MDS assessment failed to reflect the anxiety disorder, use of anti-anxiety medication, or dementia diagnosis. Staff confirmed these omissions in the MDS despite their presence in the medical record.
A resident with chronic respiratory failure was not receiving oxygen therapy as ordered by the physician. During medication administration, the resident was observed without oxygen in place and had an oxygen saturation of 80% on room air before oxygen was applied by an RN. The RN confirmed the resident was not wearing oxygen at the time and described the weaning process as a gradual reduction with monitoring.
A resident with multiple chronic conditions was prescribed Xarelto for atrial fibrillation, with orders and a care plan directing staff to monitor and document signs and symptoms of anticoagulant complications. Review of the Treatment Administration Record revealed that staff failed to document this monitoring on several PM shifts, and the DON confirmed the documentation should have been completed.
A resident with dementia and Parkinson's disease had a pharmacy review recommending discontinuation of two medications due to lack of use. The pharmacist's recommendations were not acknowledged or acted upon by the Medical Director or DON, and there was no documentation to clarify whether the medications remained necessary.
A resident with multiple cancer diagnoses was administered the wrong nutritional supplement via PEG tube, as staff provided Glucerna 1.5 instead of the physician-ordered Jevity 1.5. Both a unit manager and an LPN confirmed the error, noting that the physician's order was not followed and the facility's policy to confirm orders prior to administration was not adhered to.
A registered nurse administered digoxin to a resident with a history of cerebral infarction, hypertension, and atrial fibrillation without first obtaining an apical pulse, as required by physician order and standard protocol. Instead, the nurse relied on an electronic machine for vital signs and did not perform the necessary assessment before giving the medication.
A resident with multiple chronic conditions was observed coughing during a meal without a beverage available, while another resident at the same table had two drinks. After the resident requested and received iced tea, her coughing stopped. The Dietary Manager indicated that CNAs are responsible for distributing beverages and that drinks are given when requested, but could not explain why some residents did not have drinks during dining.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving resident-to-resident physical abuse. One resident, who had a history of anxiety, cerebral infarction, and recent suicidal ideation, exhibited escalating behaviors including threats of self-harm and confrontational interactions with nursing staff regarding pain medication. Despite these documented behaviors and changes in mood, the resident was not effectively monitored or managed to prevent harm to others. This culminated in an incident where the resident physically assaulted another resident, resulting in facial bruising, laceration, and redness to the eye and nose area. The assaulted resident had a history of Parkinson's disease and dementia but was assessed as having no cognitive impairment at the time. The facility's failure to prevent this abuse constituted a violation of the resident's rights and placed all residents at risk for ongoing abuse and potential harm.
Failure to Document and Provide Pertinent Health Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that pertinent health information was provided to the receiving health facility during the transfer of two residents. For one resident with a history of epilepsy and anxiety, there were two separate incidents where the resident became non-responsive and exhibited neurological symptoms, prompting transfer to the hospital. In both cases, although the resident’s representative was notified and transfer forms were completed, there was no documentation in the medical record that pertinent medical information was provided to the receiving hospital at the time of transfer. A staff member later confirmed that while the required forms were sent and a report was called in, this was not documented as required. Another resident, who had multiple diagnoses including partial paralysis, dementia, cirrhosis, depression, and anxiety, was transferred to the hospital after sustaining a fall resulting in a head laceration and rib fracture. The resident’s record did not include documentation of the hospital transfer paperwork, and the Director of Nursing confirmed that there was no hospitalization paperwork from the facility to the hospital for this incident. These findings were based on policy review, record review, and staff interviews.
Failure to Implement Interventions to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement interventions to prevent further resident-to-resident abuse incidents, as evidenced by two residents involved in an altercation. One resident with a history of anxiety, fluctuating moods, and suicidal ideation exhibited escalating behaviors, including verbal threats and expressions of self-harm, prior to the incident. Despite these documented behaviors and interactions with nursing staff regarding pain management and mental health concerns, no additional interventions were put in place to address the resident's risk of aggressive behavior toward others. The deficiency was identified when the resident physically assaulted another resident, resulting in facial injuries. Facility policies required immediate and effective measures to prevent further abuse while investigations were ongoing, but the only action taken prior to the incident was the resident's arrest after the assault. The administrator confirmed that no other interventions were implemented to prevent further potential abuse between residents.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident with multiple diagnoses, including cerebral palsy and major depressive disorder. Record review showed that the resident had physician orders and documentation for hydroxyzine, an anti-anxiety medication, as well as a diagnosis of severe, unspecified dementia. However, the resident's admission MDS did not indicate the presence of an anxiety disorder, the use of anti-anxiety medication, or a diagnosis of dementia. Staff interviews confirmed that the MDS assessments did not include these diagnoses or treatments, despite being documented in the resident's medical record.
Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
Staff failed to provide oxygen therapy as ordered by the physician for a resident with chronic respiratory failure, respiratory disorder, and cognitive impairment. The resident's care plan directed staff to provide oxygen as ordered, with an initial physician order for continuous oxygen at 5 liters per minute via nasal cannula. A subsequent order instructed staff to wean oxygen therapy for saturation levels over 94% and to administer 1-3 liters per minute as needed to maintain oxygen saturation between 88-93%. During a medication administration observation, the resident was found resting in bed without oxygen in place. An RN administered medications and then checked the resident's oxygen saturation, which was 80% on room air. The RN then applied oxygen via nasal cannula. The RN confirmed that the resident was not wearing oxygen at the time of medication administration and described the weaning process as a gradual reduction of oxygen flow with monitoring, not complete removal without monitoring.
Failure to Monitor and Document Anticoagulant Therapy
Penalty
Summary
The facility failed to follow professional standards of nursing practice for monitoring anticoagulant therapy for one resident. The resident, who had multiple diagnoses including cerebral palsy, atrial fibrillation, COPD, diabetes, schizophrenia, and hypertension, was prescribed Xarelto (Rivaroxaban) for atrial fibrillation. Physician orders and the resident's care plan required staff to monitor, document, and report signs and symptoms of anticoagulant complications. However, a review of the Treatment Administration Record (TAR) from July through September showed that staff did not document monitoring for anticoagulant signs and symptoms on several PM shifts. During an interview, the Director of Nursing confirmed that the TAR should have been marked as completed on those dates.
Failure to Act on Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the Medical Director and Director of Nursing Services acted upon pharmacist recommendations for a resident reviewed for unnecessary medications. According to the facility's policy, a medication regimen review (MRR) must include a review of the resident's medical chart, and any identified irregularities are to be documented and sent to the attending physician, Medical Director, and Director of Nursing Services for action. For one resident with multiple diagnoses, including dementia and Parkinson's disease, a pharmacy consultation report recommended discontinuing two medications due to lack of use in the past 60 days. However, there was no documentation of the provider's response to these recommendations, and the DON confirmed that the pharmacy recommendation had not been acknowledged, leaving it unclear whether the medications were still necessary.
Failure to Follow Physician Orders for Tube Feeding
Penalty
Summary
The facility failed to follow physician orders for a resident who required tube feeding due to multiple cancer diagnoses, including cancer of the mouth and esophagus. The resident's care plan specified tube feeding as ordered, with a physician order directing the administration of Jevity 1.5 nutritional supplement at a specific rate and volume. However, during observation, the resident was found to be receiving Glucerna 1.5 instead of the prescribed Jevity 1.5 via PEG tube. This was confirmed by both the unit manager and an LPN, who acknowledged that the incorrect nutritional supplement was being administered and that the physician's order had not been followed. The facility's policy required staff to confirm the physician's order prior to administration, but this was not done in this instance.
Failure to Obtain Apical Pulse Prior to Digoxin Administration
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to obtain an apical pulse prior to administering digoxin to a resident. The resident, who had a history of cerebral infarction, hypertension, and atrial fibrillation, had a physician's order for digoxin with specific instructions to notify the provider if the heart rate was less than 40 beats per minute. During medication administration, the RN used an electronic machine to obtain the resident's vital signs and associated the pulse from the machine with the administration of digoxin, rather than obtaining an apical pulse as required. When questioned, the RN admitted to not obtaining an apical pulse before administering the medication. The Director of Nursing (DON) later confirmed that an apical pulse should be obtained prior to administering digoxin. The failure to follow this protocol resulted in a significant medication error for the resident observed during the medication pass.
Failure to Provide Hydration Beverages During Meals
Penalty
Summary
The facility failed to ensure that residents received hydration beverages during dining, as observed with one resident who did not have any beverages at her dining area while another resident at the same table had two. The resident, who had multiple diagnoses including atrial fibrillation, coronary artery disease, hypertension, renal insufficiency, and hyperlipidemia, was seen coughing during lunch without access to a drink. When asked by the Dietary Manager if she was okay, the resident requested iced tea, and her coughing stopped after drinking it. The Dietary Manager stated that beverages are provided upon request and that CNAs are responsible for distributing them, but could not explain why some residents, including the coughing resident, did not have drinks available during the meal.
Some of the Latest Corrective Actions taken by Facilities in Idaho
The facilities took the following corrective actions in response to the cited deficiencies:
- All residents were made safe by immediately removing the accused staff member from the building and placing them on administrative leave. Staff were re-educated on abuse policies and reporting requirements. Residents were interviewed to ensure they felt safe and knew how to report abuse allegations. (J - F0600 - ID)
- PT #1 was suspended during the investigation and later terminated. The State Licensure Board was notified of the abuse allegations. Staff were educated on abuse/neglect and identifying burnout, and counseling services were offered. NAIT #1 was suspended during the investigation, and nursing staff were retrained on abuse, neglect, and managing burnout. (G - F0600 - ID)
- The nurse assessed both residents for harm and injury. Administrators were notified, families were informed, and the state agency was alerted. Staff were interviewed, and care plans for both residents were updated. Social services interviewed other residents. Staff education was provided to redirect Resident #42, and frequent checks were initiated. Resident #42 was moved to a new room. (G - F0600 - ID)
- All facility drivers were in-serviced on proper procedures for securing passengers in wheelchairs. New seat belts were purchased, and maintenance added a monthly check of seatbelts. Training with return demonstrations was provided to drivers, and a two-person wheelchair securement check was implemented before each transport. (G - F0600 - ID)
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 Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving two residents. One resident, who was deaf and required a whiteboard for communication, reported that a physical therapist (PT) threw a soiled bed pan and urinal at her, causing urine to splash onto her arm. The incident occurred when the resident declined to attend a therapy session due to preparing to move rooms. The PT did not use the whiteboard to communicate and was reportedly yelling at the resident. A nursing assistant in training (NAIT) present during the incident confirmed the PT's actions and noted the resident was left with feces and urine on her. Another resident, who was cognitively intact and required extensive assistance with personal hygiene, experienced neglect when she used her call light multiple times to request help with incontinence care. A NAIT responded to her call light but failed to return with assistance, leaving the resident without the necessary care. Despite being informed by a registered nurse (RN) to assist the resident, the NAIT falsely claimed to have provided the care and informed another CNA that the resident had been helped. The resident reported the neglect, and the facility's investigation confirmed the NAIT's failure to provide care. These incidents highlight the facility's failure to ensure residents' rights to be free from abuse and neglect, placing all residents at risk of harm. The facility's investigations substantiated the allegations of abuse and neglect, confirming the inappropriate actions of the PT and the neglectful behavior of the NAIT.
Removal Plan
- PT #1 was suspended during the investigation, then terminated from employment at the facility.
- The State Licensure Board was notified of the abuse allegations and investigative findings related to PT #1's involvement in the incident.
- All staff were educated on abuse/neglect and identifying burnout.
- Staff were offered counseling services for burnout.
- NAIT #1 was suspended immediately during the investigation.
- The facility provided retraining to all nursing staff regarding abuse, neglect, and how to manage burnout.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. Resident #63, who was severely cognitively impaired, was inappropriately touched by Resident #42, who was moderately cognitively impaired. The incident occurred while both residents were near the nurses' station, and staff members initially did not notice the inappropriate behavior. When a staff member observed Resident #42 massaging Resident #63's breasts, the residents were separated, and the nurse was alerted. Despite the inappropriate contact, Resident #63 did not show signs of distress or injury, and both residents were assessed as unable to make decisions due to their cognitive impairments. A second incident occurred when Resident #42 managed to access the dining room where Resident #63 was seated. Although staff did not witness the event, Resident #63's disheveled blouse and her verbal response suggested possible inappropriate contact. The nurse's assessment again found no physical injury, but Resident #63 confirmed that Resident #42 had touched her breast. The facility's investigation concluded that Resident #42 mistakenly believed Resident #63 was his deceased wife, which led to the inappropriate behavior. The facility's initial response to the first incident included separating the residents and moving Resident #42 to a different floor. However, the second incident highlighted a lapse in staff awareness and communication, as some staff members were unaware of Resident #42's relocation and inadvertently directed him back to the area where Resident #63 was present. This oversight allowed Resident #42 to have further contact with Resident #63, leading to the second reported incident.
Removal Plan
- The nurse assessed both residents for harm and evidence of injury.
- Administrator, Regional Director of Operations notified.
- Families of both residents notified.
- The State Agency Long Term Care Program was notified via the portal.
- Staff members were interviewed.
- Care plans for both residents were reviewed and updated.
- Social Services interviewed other residents and no further concerns were found.
- Staff education was provided to remind and redirect Resident #42 to stay downstairs.
- Frequent checks were initiated for both residents.
- Resident #42 was fully moved downstairs to a new room with all of his belongings set up to his preferences.
Failure to Protect Residents from Neglect During Transport
Penalty
Summary
The facility failed to ensure residents' rights were protected from neglect, resulting in physical harm to two residents. Resident #191, who had spinal stenosis, suffered a significant cut to her lower left leg when the van she was riding in stopped suddenly, causing her to fall forward out of her chair. The seat belt and wheelchair restraints were inspected and found to be functioning properly, indicating that the issue was related to the proper securing of the resident in the van. The incident was not known to the current Administrator as it occurred before her tenure. Resident #192, who had multiple diagnoses including kidney disease and stroke, tipped backwards in his wheelchair while in the van, resulting in an open contusion to his right elbow and a non-displaced fracture of his right femur. The Maintenance Supervisor confirmed that the van's equipment was functioning correctly and attributed the incident to staff not properly securing the wheelchair. The Administrator confirmed that the metal hooks used to fasten the wheelchair were not tight enough, leading to the accident. These findings represent past noncompliance with the regulatory requirement to protect residents from neglect.
Removal Plan
- All facility drivers were in-serviced on the proper procedure for securing and un-securing passengers in wheelchairs.
- New seat belts were purchased, and maintenance added a monthly check of all seatbelts to routine van maintenance.
- All facility drivers were educated on ensuring all van straps were in place and tightened on the wheelchair before transport and the lap seatbelt was in place before the van moved.
- The van was inspected to ensure the seat belts were properly functioning.
- Training with return demonstration was provided to the van drivers.
- A 2-person wheelchair securement check before each resident transport was put into place.
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