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 did not follow required food safety standards for storage, labeling, and dating of food items. In the walk-in freezer, an open box of frozen French bread dough and an open bag of frozen chicken breast were not sealed or dated, and a loaf of sliced bread was found on the floor between the wall and shelving. In the walk-in refrigerator, a container of heavy cream was stored past its best-by date. These practices did not comply with FDA Food Code requirements or the facility’s food safety policy for inspecting, properly storing, labeling, dating, and covering food items.
The facility failed to maintain infection prevention and control practices in both food service and insulin administration. During meal service, the kitchen supervisor and dietary staff repeatedly moved between the tray line, storage areas, and resident meal delivery without performing required hand hygiene, and some staff had uncovered ponytails hanging out from under hats instead of using hairnets as required by policy. In a separate incident, a resident with diabetes receiving ordered subcutaneous insulin had the insulin syringe placed directly on the bed surface while the LPN cleaned the injection site, after which the same syringe was used for administration.
The facility did not complete a required PASARR Level I screening before admitting a resident with multiple medical diagnoses, including kidney failure and cancer. Facility policy required all applicants to have a PASARR Level I pre-screening for serious mental disorders or intellectual disabilities prior to admission, but the screening for this resident was not obtained until several days after admission. Record review confirmed the delay, and the ADON stated she had not requested or received the PASARR Level I before admission and only requested it later from the hospital.
A resident with chronic respiratory failure using CPAP and supplemental O2 did not receive respiratory care consistent with CPAP manufacturer guidelines. Surveyors observed the CPAP device turned off while O2 at 2 L/min continued to be bled into the device, and the required in-line pressure valve to prevent O2 backflow was not present. The Administrator acknowledged that the O2 should have been shut off when the CPAP was turned off but was not.
The facility did not maintain daily nurse staffing sheets for the required 18-month period. The DON reported that only staffing records from the time she started in August 2025 were available, and the Administrator could not account for missing staffing sheets from earlier months. This resulted in a lack of accessible historical nurse staffing information for residents, their representatives, and visitors who might request to review staffing levels.
Surveyors identified that controlled medications on one medication cart were not properly tracked when narcotic accountability sheets showed only one nurse signature on a specific date instead of the required two. An LPN and the DON both acknowledged that two nurses should sign the narcotic sheet when accepting or releasing the cart, but this did not occur, affecting all residents receiving controlled medications from that cart.
A resident with diabetes and anxiety had physician orders for Basaglar (insulin glargine) 15 units SQ and insulin lispro per sliding scale. An LPN was observed preparing the glargine insulin pen by dialing it directly to 15 units and administering it without first priming the pen with 2 units, contrary to facility expectations. The LPN later acknowledged that she did not prime the pen on that occasion and only sometimes primed insulin pens before use, while the DON confirmed that insulin pens should be primed with 2 units prior to administering the ordered dose.
Surveyors found that the facility did not follow its own policy for destruction and removal of unused and expired medications. During a medication cart audit, an LPN had a bottle of Gas Relief on the cart that was past its manufacturer expiration date and acknowledged it should have been discarded. In a medication storage room audit, an LPN had two tubes of barrier cream, each bearing prescription labels for residents who had already been discharged, still kept among supplies available for resident use. The DON confirmed that expired and unused medications should have been removed from the cart and storage room but were not.
Surveyors observed spoiled strawberries with visible mold stored in a refrigerator alongside fresh produce and snacks, and the Food Service Manager acknowledged they should have been discarded. During a meal tray line, a staff member repeatedly handled ready-to-eat foods such as dinner rolls and fresh fruit without changing gloves or performing hand hygiene after touching other surfaces, including a refrigerator door. The Food Service Manager stated she was not concerned about this practice, despite acknowledging it increases the risk of cross-contamination.
Surveyors observed a medication cart left unattended in a hallway with a laptop logged into the EMR system, displaying multiple resident records, and no staff present to monitor or secure the information. In an interview, the Interim DON confirmed that the facility’s expectation is that resident records remain secured to prevent unauthorized access, indicating that this situation did not meet established standards for protecting resident information.
Improper Food Storage, Labeling, and Dating in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and dating of food items, contrary to FDA Food Code 2022 and the facility’s own Food Safety Requirements policy. The FDA Food Code requires refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours to be clearly date-marked and used or discarded within seven days at 41°F or less. The facility’s policy required staff to inspect all food upon delivery for safe transport and quality, ensure timely and proper storage, label and date refrigerated foods (including leftovers) so they are used by their use-by date or frozen/discarded, and keep foods covered or in tight containers. During an early morning kitchen tour with the Food Service Manager (FSM), surveyors observed multiple violations. In the walk-in freezer, there was an open box of frozen French bread dough that was not covered, sealed, or dated, and an open bag of frozen chicken breast that was not sealed or dated. Additionally, a loaf of sliced bread in a bag was found lying on the floor between the wall and shelving. In the walk-in refrigerator, surveyors found a container of heavy cream with a best-by date that had already passed. The FSM acknowledged that the bread must have fallen from the shelf, that the French bread and chicken breast should have been sealed and dated, and that the heavy cream had been recently ordered without noticing its expired best-by date.
Infection Control Failures in Dietary Services and Insulin Administration
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices in both the dietary department and during insulin administration. Facility policies required dietary employees to perform hand hygiene before food preparation, when changing tasks, after contact with unsanitary items or body parts, and as often as necessary to prevent cross contamination, as well as to wear hairnets when cooking, preparing, or assembling food. During a meal service observation, the Kitchen Supervisor left the tray line to enter the walk-in refrigerator and dry storage areas and then returned to continue prepping plates without performing hand hygiene. A dietary aide pureed resident food items without performing hand hygiene, and another dietary aide prepped plates, left the kitchen to deliver trays, and returned to prep more plates without washing hands. The Food Service Manager and a dietary aide had their hair pulled back in ponytails under baseball-type hats, with the ponytails hanging out and not restrained by hairnets. The Kitchen Supervisor later stated he was probably not seen washing his hands as much as he should have because one of the handwashing sinks was out of order, and the Food Service Manager stated she believed hairnets were not required if staff wore hats and that handwashing was only needed when hands were visibly dirty and when changing tasks. The deficiency also includes improper infection control practices during insulin administration to a resident with diabetes and anxiety. The resident had physician orders for subcutaneous insulin glargine and insulin lispro per sliding scale. During an observation, an LPN placed a syringe containing insulin glargine on the resident’s bed next to the resident while cleaning the injection site, then picked up the syringe from the bed and administered the insulin. The LPN later acknowledged she should not have placed the insulin syringe on the resident’s bed. The Infection Preventionist stated that the LPN should have placed resident medications on a protective cover on top of the bedside table rather than in the bed.
Failure to Obtain PASARR Level I Screening Prior to Admission
Penalty
Summary
The facility failed to ensure completion of a Pre-admission Screening and Resident Review (PASARR) Level I prior to admitting a resident, as required by its policy and state Medicaid rules. The facility’s policy dated 12/24/25 stated that all applicants would be screened for serious mental disorders or intellectual disabilities through a PASARR Level I pre-screening completed before admission. One resident, identified as Resident #32, was admitted with multiple diagnoses including kidney failure and cancer, but the PASARR Level I, dated 12/16/25, was not received by the facility until four days after the resident’s admission. Record review on 1/28/26 confirmed the PASARR I was not on file at the time of admission, and during an interview, the ADON acknowledged she had not requested or received the PASARR I prior to admission and only realized it was missing on 12/16/25, at which time she requested it from the hospital. This failure created the potential for harm if residents required but did not receive specialized services for mental health while residing in the facility.
Failure to Follow CPAP Manufacturer Guidelines for Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with CPAP manufacturer warning guidelines and professional standards of practice for one resident whose respiratory equipment was observed. The CPAP manufacturer’s warnings specified that oxygen supports combustion and should not be used while smoking or near open flame, that when using supplemental oxygen with the CPAP the device must be turned on before the oxygen is turned on and the oxygen must be turned off before the device is turned off to prevent oxygen accumulation in the device, and that a specific pressure valve must be placed in-line between the device and the oxygen source to prevent backflow of oxygen into the device when it is off. The manufacturer’s explanation stated that if oxygen flow is left on while the device is not operating, oxygen may accumulate within the device enclosure, creating a risk of fire, and that failure to use the pressure valve could result in a fire hazard. The resident involved had multiple diagnoses, including a left femur fracture and chronic respiratory failure with hypoxia. On observation in the resident’s room, the CPAP machine was turned off while supplemental oxygen at 2 L/min was still turned on and being bled into the CPAP device, contrary to the manufacturer’s instructions. A subsequent observation with the Administrator confirmed that the resident’s supplemental oxygen continued to be bled into the CPAP while the CPAP was not turned on, and that the required Respironics pressure valve was not installed in the circuit between the device and the oxygen source. The Administrator stated that the oxygen in the resident’s room should have been shut off when the CPAP was turned off and was not.
Failure to Maintain Required Daily Nurse Staffing Records
Penalty
Summary
The facility failed to maintain daily nurse staffing sheets for the required minimum of 18 months. During the survey, the DON reported that she only had access to daily staffing sheets dating back to when she began employment in August 2025. The Administrator stated he was unsure what happened to the daily staffing sheets covering the period from January 2025 through July 2025. This failure affected the facility’s ability to provide historical nurse staffing information for that seven-month period to residents, their representatives, visitors, or others who wished to review the facility’s staffing levels.
Failure to Maintain Dual-Nurse Narcotic Accountability on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications on one of two medication carts reviewed. During an audit of the North Hall medication cart, narcotic accountability sheets dated from 1/1/26 to 1/27/26 were observed with only one licensed nurse signature documented for 1/21/26, instead of the required two signatures. An LPN stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart, and the DON confirmed that two nurses were expected to sign the narcotic accountability sheet at those times. This deficiency involved the process for documenting controlled medication accountability rather than a specific resident, and it affected all residents who received controlled medications in the facility, as the lack of dual signatures meant controlled medications on that cart were not properly tracked for that date.
Failure to Properly Prime Insulin Pen Before Administration
Penalty
Summary
Surveyors identified a deficiency in medication preparation and administration involving insulin for Resident #2. The resident, who had multiple diagnoses including diabetes and anxiety, had physician orders for Basaglar (insulin glargine) 15 units subcutaneously and insulin lispro per sliding scale. On 1/27/26 at 8:27 AM, an LPN was observed removing the glargine insulin pen from the medication cart and dialing it directly to 15 units without first priming the pen with 2 units, as required. At 8:32 AM, the LPN administered the unprimed glargine insulin dose to the resident. At 8:37 AM, the LPN acknowledged she had not primed the insulin pen on that occasion and stated she only sometimes primed the pen before administration. On 1/28/26 at 4:18 PM, the DON confirmed that insulin pens should be primed with 2 units prior to administering the ordered insulin dosage. This failure to consistently prime the insulin pen before dialing and administering the ordered dose resulted in the resident not being ensured freedom from significant medication preparation and administration errors and placed the resident at risk for not receiving the prescribed medication dosage and other adverse outcomes, as stated in the report.
Failure to Remove Expired and Unused Medications From Storage and Use Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of medications, including failure to ensure medications were properly stored, not expired, and appropriately disposed of when unused. The facility’s policy titled “Destruction of Unused Drugs” dated 12/29/25 stated that unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. During a medication cart audit on 1/28/26 at 8:52 AM on the South Hall with an LPN present, surveyors observed one bottle of Gas Relief on the cart with a manufacturer expiration date of 7/25 printed on the bottle, and the LPN acknowledged the bottle should have been discarded and had not been. Later that day at 2:01 PM, during an audit of the North Hall medication storage room with another LPN present, surveyors observed one tube of barrier cream labeled for a resident discharged on 10/3/25 and another tube of barrier cream labeled for a resident discharged on 11/18/25 among available supplies for resident use. At 4:38 PM, the DON stated that expired and unused medications should have been removed from the medication cart and storage room and had not been, confirming the failure to follow the facility’s medication storage and disposal policy. No specific medical histories or current clinical conditions of the residents for whom the labeled barrier creams were prescribed are provided in the report.
Improper Food Storage and Unsanitary Handling of Ready-to-Eat Items
Penalty
Summary
Surveyors identified deficiencies in the facility’s food storage and handling practices based on observations and staff interviews. During a kitchen tour, a container of soft strawberries with fuzzy white substances was found in the front kitchen refrigerator where fresh produce and snacks were stored. The Food Service Manager stated that staff relied on visual inspection to determine spoilage and acknowledged that the strawberries should have been discarded, indicating that spoiled produce had not been removed from an area used for resident food items. During a tray line observation, a staff member preparing resident meal trays was seen handling ready-to-eat foods without maintaining proper hand hygiene or glove use. The staff member left the workstation to obtain sorbet, then returned and immediately picked up a dinner roll with the same gloved hand without performing hand hygiene or changing gloves. Later, the same staff member opened a refrigerator door with a gloved hand, retrieved a bowl of fresh fruit, and then handled another dinner roll with that same glove. The Food Service Manager stated she was not concerned about the staff member touching other surfaces while handling ready-to-eat food, though she acknowledged that touching additional surfaces increases the risk for cross-contamination.
Unattended Medication Cart with Open EMR Exposes Resident Records
Penalty
Summary
Surveyors identified a deficiency in safeguarding resident-identifiable information when a medication cart was observed unattended in the hallway in front of a resident room. The cart contained a laptop that was logged into the electronic medical record system, with the screen displaying access to multiple resident records. At the time of the observation, no staff member was present at the cart to monitor or secure the device or the information displayed. During an interview shortly after the observation, the Interim Director of Nursing stated that the facility’s expectation is that resident records are to remain secured to prevent unauthorized access, confirming that the observed practice did not align with facility expectations for protecting resident medical records.
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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