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
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.
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.
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.
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 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.
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.
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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