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)
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.
Latest Citations in Idaho
Several residents with complex medical, behavioral, and safety needs did not have individualized care plans that reflected their current conditions, physician orders, or observed behaviors. For example, residents on psychotropic medications were not monitored for side effects as required, and behaviors such as aggression, sadness, and fall risks were not documented in care plans despite being tracked elsewhere. Staff acknowledged these omissions during interviews.
The QAA committee did not effectively identify or resolve systemic issues, as it lacked a method to measure or track improvements in performance improvement plans. The DON was unable to provide evidence of improved outcomes, relying only on incident counts, which led to failures in reporting resident assessments and comprehensive care planning for all residents.
The facility did not complete and transmit required MDS assessments within the mandated timeframe for several residents with complex medical conditions, resulting in overdue assessments and delayed reporting to CMS. The DON acknowledged the backlog and lack of timely reporting.
The facility did not have a certified dietary manager overseeing food and nutrition services. The current dietary manager was not yet certified and was supervised by a Registered Dietitian who visited weekly, not full-time. This affected all residents receiving meals from the kitchen.
Kitchen staff did not consistently wear hair restraints as required, with one aide observed having hair exposed while working. Inspections also revealed several expired or undated food items, including syrups, tortillas, and seasonings, which remained in storage despite being past their best by or expiration dates. The dietary manager confirmed these practices did not meet food safety standards.
Surveyors found that kitchen equipment, including a baking sheet and two skillets, had black, encrusted residue that was not properly cleaned, as confirmed by the Food Services Manager. This failure to maintain clean food-contact surfaces did not meet FDA Food Code standards and had the potential to affect all residents consuming food prepared in the facility.
Four residents were inaccurately assessed as using bedrails as restraints in their MDS documentation, despite care plans and assessments indicating the bedrails were used for mobility or independence. Staff interviews confirmed that the MDS coding did not match the actual use of bedrails, leading to inaccurate resident assessments.
A resident with Huntington's disease was exposed during wound care when an LPN left the window blinds open, resulting in a failure to maintain privacy as required. The LPN later acknowledged the oversight.
Surveyors found that the main shower in the south wing was unsanitary, with mold-like spots on the floor and drain, red residue on shower chairs, and a missing end cap on the wall bar exposing a sharp metal edge. Facility leadership confirmed the shower was in disrepair, should have been closed, and had not been properly cleaned.
Two residents with serious mental illness diagnoses had inaccurate MDS assessments, where section A1500 was incorrectly marked 'no' despite PASRR level II screenings confirming their conditions. These errors were identified through record review and staff interviews.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed all identified needs for several residents. For multiple residents with complex medical and behavioral histories, care plans did not reflect current physician orders, observed behaviors, or required monitoring. For example, one resident with dementia and behavioral issues was being monitored for paranoia, hallucinations, delusions, and verbal aggression, but these behaviors were not included in her care plan. Another resident with depression and chronic pain was monitored for increased sadness, excessive sleeping, and overeating, yet these behaviors and specific side effects to monitor for her antidepressant were not documented in her care plan. Additional deficiencies were noted for residents with psychiatric and neurological conditions. One resident with aphasia and on psychotropic medication was monitored for behaviors such as being snappy, short-tempered, and experiencing air hunger, but these were not included in her care plan, nor was there documentation to monitor for adverse side effects of her medication. Another resident with bipolar disorder, anxiety, and depression did not have these diagnoses or related interventions and triggers documented in her care plan, despite being a trauma survivor. The facility also failed to address physical safety and equipment use in care plans. A resident with a history of falls and a recent fall incident did not have fall prevention interventions documented or updated in the care plan following the event. Another resident who used bed rails daily did not have this use reflected in her care plan. Staff interviews confirmed that these omissions were recognized and acknowledged as deficiencies in the care planning process.
Failure of QAA Committee to Identify and Resolve Systemic Problems
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee effectively identified and resolved systemic problems, impacting all 20 residents in the facility. Document review and staff interviews revealed that while the QAPI plan required comprehensive monitoring, evaluation, and cross-departmental involvement, the committee did not have a method to measure or track improvements in performance improvement plans (PIPs). The Director of Nursing (DON) was unable to provide evidence of improved outcomes or measurements for the PIPs, instead relying on incident counts from the prior month without a system to track progress. This deficiency resulted in failures to report resident assessments and comprehensive care planning, as required, with the potential for adverse outcomes when residents' needs were not identified.
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and transmitted to the State within the required 7-day timeframe for 7 out of 9 residents reviewed. Record review, staff interviews, and reference to the RAI manual revealed that multiple MDS assessments, including Admission, Quarterly, and Annual assessments, were either not completed or not transmitted on time. The Director of Nursing (DON) confirmed that the facility was behind in reporting assessments to CMS and offered no explanation for the delays. Specific examples included residents with diagnoses such as malnutrition, seizures, dementia, bipolar disorder, and diabetes mellitus, whose MDS assessments were overdue by periods ranging from 11 to 52 days. The failure to complete and transmit these assessments as required resulted in the potential for harm and inaccuracy in identifying and addressing residents' needs, as timely assessments are necessary for proper care planning and regulatory compliance.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified dietary manager with the required certification and competencies to oversee the food and nutrition service. The current dietary manager had been working in the role for about five weeks but had not yet obtained certification, although she was enrolled in classes to become a certified dietary manager. The dietary manager reported being supervised by a Registered Dietitian, who was not employed full-time at the facility but visited at least once a week. This deficiency had the potential to affect all 20 residents who received food from the facility's kitchen.
Improper Hair Restraint Use and Storage of Expired Food Items in Kitchen
Penalty
Summary
Kitchen staff failed to wear hair restraints appropriately, as observed when a dietary aide was seen in the kitchen with her hair not completely restrained, leaving her bangs and hair around her face exposed. The dietary manager confirmed that the aide should have worn her hair restraint to fully cover her hair, in accordance with FDA Food Code requirements for food safety. Additionally, multiple outdated and undated food items were found during two separate kitchen inspections. These included expired Hershey syrup, taco mix, flour and corn tortillas, and undated soup base and seasoning. The dietary manager acknowledged that these items should not have been present in the kitchen and should have been discarded.
Failure to Clean Kitchen Equipment According to FDA Food Code
Penalty
Summary
Surveyors observed that kitchen equipment, specifically a baking sheet and two skillets, were not properly cleaned. The baking sheet used for preparing honey buns had a black residue along its edge that flaked off easily, while the two skillets had a ring of dark, encrusted residue on both their interior and exterior surfaces that could not be scraped off. The Food Services Manager confirmed that the pans should not have this black, encrusted coating and acknowledged that they should be replaced. These findings indicate that the facility failed to clean food-contact surfaces of cooking equipment in accordance with professional standards and the FDA Food Code, which requires such surfaces to be free of encrustations that could impede proper cooking or attract insects. The deficiency had the potential to affect all 56 residents who consumed food prepared by the facility, as they were exposed to food prepared with inadequately cleaned equipment.
Inaccurate Resident Assessments Related to Bedrail Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status regarding the use of bedrails. For four residents, the Minimum Data Set (MDS) assessments were coded to indicate daily use of bedrails as restraints, despite documentation in care plans and side rail assessments that the bedrails were used for mobility, independence, or at the resident's discretion. In several cases, care plans and assessments noted that the bedrails were not used as restraints, and residents or their representatives were informed of the risks and had provided consent for their use. However, the MDS continued to be coded as if the bedrails were restraints. Staff interviews, including statements from the Director of Nursing (DON) and Licensed Social Worker (LSW), confirmed that the MDS coding did not accurately reflect the actual use of bedrails for these residents. The DON stated that the coding was based on daily use of the side rails, not on whether they functioned as restraints, and expressed concern about falsifying records. This inconsistency between the MDS coding and the documented purpose and use of bedrails resulted in inaccurate assessments for the affected residents.
Resident Privacy Not Maintained During Wound Care
Penalty
Summary
A deficiency occurred when a resident with Huntington's disease, who was admitted with multiple diagnoses, received wound care from an LPN while her privacy was not maintained. During the care, the resident was in bed with her shorts pulled down to her knees, exposing her periarea as she moved from her back to her side. The window blind in the room was left open throughout the procedure, allowing potential exposure. The LPN acknowledged that the blinds should have been closed before performing the wound care. This incident was observed directly by surveyors and confirmed through staff interview, demonstrating a failure to ensure the resident's right to privacy during personal care, as required by regulatory guidelines.
Unsanitary and Unsafe Shower Room Conditions
Penalty
Summary
Surveyors observed that the main shower in the south wing was not maintained in a sanitary or safe condition. Specifically, brown and black spots resembling mold were present on the shower floor and near the drain, and the shower chairs had a ring of red residue built up on the underside of the seat. Additionally, the edge of the shower wall bar was missing an end cap cover, exposing a sharp metal ridge. Facility leadership, including the CRN, DON, and Administrator, acknowledged that the shower was in disrepair, should have been closed, and that proper cleaning between uses and daily deep cleaning had not occurred. These conditions resulted in the shower room not being clean or in good repair, as required.
Inaccurate MDS Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents with serious mental illness diagnoses. For one resident admitted after a fracture with diagnoses including bipolar disorder and generalized anxiety disorder, the medical record contained both a PASRR level I and an abbreviated PASRR level II screening, both identifying serious mental illness. However, the resident's Admission MDS Assessment incorrectly documented 'no' in section A1500, indicating the resident was not considered to have a serious mental illness or intellectual disability, despite the PASRR level II findings. Similarly, another resident with a diagnosis of bipolar disorder had a PASRR level I and an abbreviated PASRR level II screening, both confirming serious mental illness. While the MDS assessment initially reflected this, subsequent annual MDS assessments incorrectly marked 'no' in section A1500, failing to indicate the presence of a serious mental illness as determined by the PASRR level II screening. These inaccuracies were confirmed by the Regional MDS Nurse during staff interviews.