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
The facility did not maintain an effective grievance process as required by its own policy, which called for addressing concerns from residents, families, and visitors and making prompt efforts to resolve them. When surveyors requested grievance records for several months, the facility could only produce grievances for a limited recent period and had no records for earlier months. The Administrator confirmed that no grievances were available for the earlier timeframe, and the CRN acknowledged that the grievance process had been identified as needing performance improvement, resulting in a lack of documented access to a functioning grievance system for residents.
Surveyors found that dietary staff prepared and served food while wearing rings and bracelets and performed hand hygiene without removing this jewelry, contrary to FDA Food Code guidance that such items can harbor soil and pathogenic organisms. In addition, kitchen cutting boards were observed to have dark stains embedded in the plastic grain, indicating they were scratched, difficult to clean, and potentially capable of harboring microorganisms. These practices affected all individuals consuming facility-prepared food and created a risk of food contamination and food-borne illness.
Staff failed to follow infection prevention and control practices during blood glucose monitoring and environmental cleaning. An RN performed a blood glucose check and handled insulin pens for a diabetic resident by placing the glucometer and insulin pens directly on the resident's bed surfaces without using a paper towel barrier, contrary to AHCA guidance and facility expectations. In a separate incident, a CNA cleaned a urine spill from a leaking urinary catheter bag in a common area by covering and wiping it with a dry towel while wearing gloves, but did not clean or disinfect the area afterward, despite CDC procedures requiring thorough cleaning and disinfection of body fluid spills.
The facility failed to hold required quarterly care conferences for multiple residents with dementia, schizoaffective disorder, bipolar disorder, heart failure, dysphagia, and other conditions, documenting only initial or single conferences and no subsequent quarterly meetings in the EHR, as confirmed by leadership. The facility also did not timely revise care plans for two residents when their needs changed: one resident’s fall-related supervision intervention, ordered after a fall, was not added to the care plan until weeks later, and another resident’s toileting status remained documented as largely independent despite an MDS showing complete dependence on staff for toileting, a discrepancy acknowledged by the DON.
Surveyors found that staff did not follow professional standards in several clinical practices. A resident with an AV fistula for hemodialysis had multiple blood pressure readings documented on the access arm despite a care plan prohibiting this. Another resident with diabetes received Novolog and Toujeo via insulin pens that an RN failed to prime before dialing to the ordered doses, contrary to manufacturer instructions. A third resident receiving oral potassium chloride had the medication mixed with pudding and was not educated by an LPN about the need to drink a full glass of water afterward, even when the resident declined water.
Multiple residents did not receive ordered or care-planned interventions, including one resident with a fall history who was left sitting on the bed edge and subsequently fell, after which ordered orthostatic BP monitoring was not documented; another resident with muscle weakness and malnutrition who had physician-ordered pressure-relieving boots was repeatedly observed in common areas without the boots on; a resident with psychiatric diagnoses had an elevated BP that was not reassessed or further evaluated; and a resident with cardiac and swallowing issues had an ordered carrot splint for the right hand that was not applied despite observations of tightly fisted hands and fingertip pressure marks on the palm.
A resident with psychiatric conditions and impaired mobility experienced repeated falls from a wheelchair in the dining room after staff left the resident unsupervised. Following an initial fall, the IDT determined the resident should always be supervised in the dining room, but this intervention was not added to the care plan until much later. During this gap, the resident sustained another fall under similar circumstances. The DON confirmed that the supervision intervention was not incorporated into the care plan when it was first identified.
A resident with bipolar disorder, anxiety disorder, and traumatic brain injury was receiving Seroquel 300 mg daily, with a care plan directing staff to monitor and report psychoactive medication side effects. A consulting pharmacist documented that antipsychotic drugs can cause tardive dyskinesia and other movement disorders and recommended completion of an AIMS or DISCUS assessment at least every six months while the resident remained on antipsychotic therapy. The resident’s record showed the last AIMS assessment had been completed more than six months earlier, outside the recommended monitoring interval, and the DON confirmed that the pharmacist’s recommendation had not been implemented and no current AIMS assessment was present in the chart.
Surveyors found that two residents receiving Depakote for conditions including alcohol dependence, borderline personality disorder, Alzheimer’s disease, and suicidal ideations were not monitored for anticonvulsant side effects as required by their person-centered care plans. Although the care plans directed staff to monitor, notify the provider, and document specific symptoms such as over-sedation, agitation, confusion, mental status changes, visual disturbances, gait changes, behavioral changes, and weight changes, the clinical records contained no documentation of such monitoring. The DON confirmed that anticonvulsant monitoring was not present in the records, and the report noted this failure created the potential for harm if side effects were undetected.
Surveyors found that the facility failed to remove expired medications from the medication storage room. During an inspection of the medication room refrigerator with the ADON, five acetaminophen suppositories with a past expiration date were discovered still stored and available for use. The ADON confirmed the suppositories were expired and should not have remained in the refrigerator, creating the potential for adverse effects if administered.
Failure to Maintain and Implement an Effective Grievance Process
Penalty
Summary
The facility failed to ensure a grievance process was available for residents as required by its own Grievance Process policy, which stated that the grievance program addresses concerns of residents, family members, and visitors and that the facility should make prompt efforts to resolve grievances. During the survey, when the SA requested copies of grievances covering the period from September 2025 through March 2026, the facility was only able to provide grievances from January 2026 through March 2026 and had no additional grievances available for the earlier months. In an interview, the Administrator, with the CRN present, confirmed there were no grievances available prior to January 2026 and the CRN acknowledged that the facility had identified its grievance process as needing a performance improvement plan. This lack of an available and functioning grievance process created the potential for psychosocial harm if residents’ concerns were not identified and addressed in a timely manner. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency centered on the facility-wide failure to maintain and implement an effective grievance process over the specified time period.
Improper Jewelry Use and Unsanitary Cutting Boards During Food Preparation
Penalty
Summary
Surveyors identified a deficiency in food service practices related to staff wearing jewelry during food preparation and service. On the morning of 3/4/26, one dietary staff member and one dietary trainee were observed preparing and serving food while wearing rings, and the trainee was also wearing bracelets on both wrists. Hand hygiene was performed while the jewelry remained in place. According to the FDA Food Code, items of jewelry such as rings, bracelets, and watches may collect soil, be difficult to clean, and act as reservoirs for pathogenic organisms transmissible through food. The Dietary Manager stated that jewelry should not be worn while preparing or serving food and that if jewelry was permanent, gloves should be worn to cover it. A second deficiency involved the condition and cleanliness of cutting boards used in the kitchen. On the afternoon of 3/5/26, surveyors observed that the plastic cutting boards in the kitchen had dark-colored stains within the grains of the plastic. The FDA Food Code states that cutting surfaces that become scratched and scored may be difficult to clean and sanitize, allowing pathogenic microorganisms transmissible through food to accumulate and be transferred to foods prepared on those surfaces. The Culinary Manager stated that cutting boards should be replaced when they are not able to get clean or have stains removed. These deficiencies had the potential to affect the 59 residents who consumed food prepared by the facility and placed them at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.
Failure to Follow Infection Control Practices During Glucose Monitoring and Urine Spill Cleanup
Penalty
Summary
The deficiency involves failure to implement proper infection prevention and control practices during medication administration. A resident with multiple diagnoses including diabetes and asthma was observed during a blood glucose check and insulin administration. An RN entered the resident's room with a glucometer (with test strip inserted), two insulin pens, a lancet, and alcohol wipes, and placed the glucometer and insulin pens directly on the foot of the resident's bed. After performing hand hygiene and donning gloves, the RN then moved the glucometer to a position above the pillow where the resident's arm was resting to check the blood glucose level, again without using any barrier. The RN did not place a clean, dry paper towel or other barrier under the glucometer or insulin pens on either surface, despite guidance from the American Health Care Association that such equipment should be placed on a paper towel before being set on a resident's table or medication cart. The DON later stated that insulin pens and glucometers should be placed on top of a paper towel before placing them on any surface in residents' rooms. The deficiency also includes improper cleaning of a urine spill in a common area. A CNA was observed assisting another CNA with a urine spill from a leaking urinary catheter collection bag in a wing common area. The CNA placed a dry white towel over a small puddle of urine, donned gloves, wiped up the urine with the towel, and then left the area without further cleaning or disinfection. CDC environmental cleaning procedures for spills of blood or body fluids specify wearing appropriate PPE, confining and wiping up the spill with absorbent material to be disposed of as infectious waste, then thoroughly cleaning with neutral detergent and warm water, disinfecting with a facility-approved intermediate-level disinfectant, and sending reusable supplies for reprocessing. When later asked about the process for cleaning soiled areas, the CNA stated the process was to wear gloves, wipe up the soiled area, and use alcohol or disinfectant wipes, and acknowledged that no disinfectant was used on the urine spill and that the area should have been sanitized and housekeeping notified.
Failure to Hold Quarterly Care Conferences and Timely Revise Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to conduct required quarterly care conferences and to timely revise care plans based on residents’ changing needs. Facility policy dated 9/3/25 required that care plans be created, reviewed, and revised by an interdisciplinary team (IDT) with resident and/or representative involvement, and that updates occur as needed based on residents’ response to interventions and changes in condition. Record review showed that multiple residents with complex medical and psychiatric diagnoses had only an initial or single quarterly care conference documented, with no evidence of subsequent quarterly conferences in the electronic health record. The Administrator and Clinical Resource Nurse confirmed that if a care conference was not documented in the electronic health record, it was not completed. For one resident with dementia, depression, anxiety, muscle weakness, and difficulty walking, a quarterly care conference was documented in July 2025, but there was no documentation of additional quarterly conferences around October 2025 or January 2026. Another resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia had a care conference in August 2025, with no further quarterly conferences documented for November 2025 or March 2026. A resident with paranoid schizophrenia, depression, anxiety, and difficulty walking had a care conference in June 2025, but there were no records of required quarterly conferences for September and December 2025, nor documentation that a March 2026 conference was scheduled. Additional residents with schizoaffective disorder, depression, anxiety, dementia, bipolar disorder, heart failure, dysphagia, and sleep apnea similarly lacked documentation of required quarterly care conferences after an initial or single documented meeting. The facility also failed to revise care plans in a timely manner for two residents when their care needs changed. One resident with paranoid schizophrenia, depression, anxiety, and difficulty walking had a fall care plan dated August 2023 that included various fall-prevention interventions and directed quarterly re-evaluation and revision with changes in condition or after a fall. A fall investigation on December 1, 2025 documented that the resident fell while unattended in the dining room, and the IDT directed that the resident be supervised at all times while in the dining room; however, this new supervision intervention was not added to the care plan until January 27, 2026. Another resident with major depressive disorder, anxiety disorder, and alcohol dependence had a care plan revised in April 2022 indicating independence with toileting and one-person assistance for occasional nighttime incontinence, but a later quarterly MDS documented that the resident was dependent on staff for all toileting needs. The DON confirmed the resident was dependent in toileting and that the care plan should have been revised to reflect the current care needs.
Failure to Follow Professional Standards in BP Monitoring and Medication Administration
Penalty
Summary
The deficiency involves failures to follow accepted professional standards of clinical practice during care and medication administration for multiple residents. For a resident with end stage renal disease and an AV fistula in the left forearm for hemodialysis, the care plan specified that blood pressures should not be taken on the left arm. Despite this, the resident’s vital sign records showed 18 blood pressure readings documented as taken on the left arm over a 90‑day period. The DON later confirmed the record showed blood pressures taken on the left arm and suggested the person measuring the blood pressure may have documented incorrectly, while also stating there had been no adverse outcomes and that the resident was aware blood pressures should not be taken on that arm. Additional deficiencies were identified in insulin administration and oral medication administration. For a resident with diabetes, physician orders required Novolog (insulin aspart) three times daily and Toujeo (insulin glargine) twice daily. During observation, an RN sanitized and re‑needled both insulin pens, dialed each pen directly to the ordered dose, and administered the injections without priming either pen, contrary to the manufacturers’ Instructions for Use that require priming to ensure proper dosing. For another resident with heart failure, dysphagia, and sleep apnea who was ordered potassium chloride 20 mEq twice daily, an LPN dissolved the potassium chloride in a small amount of water, mixed it with pudding, and administered it. When the resident declined water afterward, the LPN did not provide education about the importance of drinking a full glass of water after taking potassium chloride, despite reference material indicating it should be taken with food or just after a meal and followed with a full glass of water to reduce stomach irritation.
Failure to Implement Care Plan Interventions and Physician Orders for Multiple Residents
Penalty
Summary
The deficiency involves failures to implement resident-centered care plan interventions and physician-ordered treatments for multiple residents. One resident with a history of falls and a need for assistance with personal care was care planned for one-person assistance with ambulation and transfers and for staff to monitor her position in bed and in her wheelchair for safety. While a CNA was assisting with dressing, the resident was left sitting on the edge of the bed while the CNA stepped away to the closet, during which time the resident stood and fell forward, striking her face on the floor. Following this fall, the interdisciplinary team determined that orthostatic blood pressures should be monitored, but the facility was unable to provide any documentation that orthostatic blood pressures were obtained. Another resident with muscle weakness, dementia, and protein-calorie malnutrition had a care plan and physician order directing that pressure-relieving boots be applied bilaterally when in bed and in a wheelchair, but he was repeatedly observed in common areas without the boots, which were seen on his bedside nightstand. An LPN stated the resident only wore the boots in bed, and the DON confirmed the resident should have had the boots on at all times. Additional deficiencies included failure to reassess an elevated blood pressure and to implement a physician-ordered splint. A resident with schizoaffective disorder, depression, and anxiety had a documented blood pressure of 171/104, with no record of a reassessment of the blood pressure or assessment for related symptoms on that date. The DON stated that nurses should have notified the provider and reassessed the resident but could not provide documentation that this occurred. Another resident with heart failure, dysphagia, and sleep apnea had a physician’s order for a carrot splint to the right hand with monitoring for skin alteration twice daily. Despite this order, the resident was observed multiple times with both hands closed in fists and no carrot splint applied. When staff assisted in opening the right hand, pressure marks from the fingertips were noted on the palm, and the DON confirmed that the carrot splint should have been in use as ordered.
Failure to Update Care Plan With Required Dining Room Supervision After Fall
Penalty
Summary
The facility failed to ensure a resident’s fall-prevention intervention was timely incorporated into the care plan, resulting in the resident being left unsupervised in the dining room and experiencing repeat falls. The resident was admitted with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking. On 12/1/25, an IDT fall investigation documented that the resident had fallen from her wheelchair while unattended in the dining room and concluded that she was to be always supervised while in the dining room to avoid future falls. However, this supervision intervention was not added to the resident’s care plan at that time. On 1/23/26, the resident again fell from her wheelchair when a staff member left her unsupervised in the dining room, as documented in a 1/26/26 fall investigation report. The care plan was not revised to include constant supervision in the dining room until 1/27/26, and the DON confirmed that the supervision intervention should have been added in December 2025 but was not. The deficiency centers on the facility’s failure to update the resident’s care plan after the first documented fall and identified intervention, leaving staff without a formalized directive to provide constant supervision in the dining room between early December 2025 and late January 2026. During an interview on 3/4/26, the DON acknowledged that the care plan related to staff supervision for this resident was not added until 1/27/26, despite the IDT’s earlier determination on 12/1/25. When asked if the fall on 1/23/26 could have been prevented had the care plan been updated in December 2025, the DON declined to answer.
Failure to Complete Recommended Antipsychotic Movement-Disorder Monitoring
Penalty
Summary
The facility failed to ensure recommended monitoring for adverse effects of antipsychotic medication was completed for one resident receiving psychoactive medication. The resident was readmitted with multiple diagnoses, including bipolar disorder, anxiety disorder, and traumatic brain injury, and had a care plan directing staff to monitor and report side effects and adverse reactions related to psychoactive medications. A physician’s order documented that the resident was to receive Seroquel 300 mg by mouth once daily for traumatic brain injury. A pharmacy review noted that antipsychotic medications can cause tardive dyskinesia and other movement disorders and recommended that a movement-disorder assessment, such as an AIMS or DISCUS test, be completed at least every six months while the resident remained on antipsychotic therapy. Record review showed the last AIMS assessment was completed more than six months before the pharmacy recommendation and outside the recommended monitoring interval, and the DON confirmed that the pharmacy recommendation had not been acted upon and the record did not contain a current AIMS assessment.
Failure to Monitor and Document Anticonvulsant Side Effects
Penalty
Summary
Surveyors identified a failure to ensure residents’ drug regimens were free from unnecessary drugs by not monitoring for side effects of anticonvulsant medications as required by the residents’ care plans. One resident with major depressive disorder, anxiety disorder, and alcohol dependence had a physician order for Depakote 250 mg by mouth three times a day for alcohol dependence. The resident’s comprehensive person-centered care plan, revised 8/6/25, directed staff to monitor, notify the provider, and document specific anticonvulsant side effects, including over-sedation or lethargy, restless agitation, increased confusion or poor concentration, mental status change, visual disturbance, change in gait, behavioral changes, and weight change. Record review showed no documentation that staff were monitoring for these anticonvulsant side effects. Another resident with borderline personality disorder, Alzheimer’s disease, and suicidal ideations had a physician order for Depakote sprinkles 750 mg by mouth two times a day for borderline personality disorder. This resident’s care plan, revised 10/14/24, contained the same directives for staff to monitor, notify the provider, and document anticonvulsant side effects, listing the same potential symptoms. Record review similarly showed no documentation that staff were monitoring for these side effects. On 3/5/26 at 8:32 AM, the DON confirmed that the records for both residents did not include anticonvulsant monitoring, and the report stated this failure created the potential for harm if side effects were undetected.
Expired Acetaminophen Suppositories Found in Medication Storage Room
Penalty
Summary
Surveyors identified a failure to ensure drugs and biologicals were properly managed and stored when expired medications were found in the facility’s medication storage room. During an inspection of the medication room refrigerator with the ADON, five acetaminophen suppositories with an expiration date of 10/2025 were observed still stored inside. The ADON acknowledged that the acetaminophen suppositories were expired and confirmed they should not have been kept in the refrigerator. This deficiency involved the medication storage area only; no specific residents or administrations of the expired medications were described in the report. The report stated that this failed practice created the potential for adverse effects if residents received expired medications with decreased efficacy.
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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