Citations in Idaho
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Idaho.
Statistics for Idaho (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Idaho
A resident with impaired vision and multiple diagnoses was found to be self-administering antacids and Tylenol from a bedside bottle, despite documentation that she did not wish to self-administer medications and without interdisciplinary team approval, as required by facility policy.
The facility did not notify the physician of significant changes in condition for three residents, including substantial weight loss and abnormal vital signs. Two residents experienced notable weight loss without physician notification, despite care plans indicating risk for nutritional deficits. Another resident had abnormal vital signs prior to death, with no evidence that the physician or DON were informed or that appropriate monitoring was documented.
An LPN diverted multiple doses of controlled medications, including oxycodone, that were prescribed for three residents with serious medical conditions such as fractures, dementia, and post-surgical care. The LPN removed the medications, failed to administer them as ordered, provided inconsistent explanations about their whereabouts, and refused a search of personal belongings. The facility's investigation confirmed the misappropriation and exploitation of resident property.
A resident with multiple diagnoses was transferred to a hospital after experiencing severe pain and diaphoresis during a clinic visit, but the facility failed to provide discharge paperwork or document the reason for hospitalization in the medical record. The DON confirmed that documentation of the transfer and hospitalization reason was not completed as required.
A resident with a history of falls and left-sided weakness had their bed moved against the wall by staff after a fall, but this intervention was not added to the care plan. The DON and RNC confirmed the omission when reviewing the care plan and observing the resident's room.
Three residents experienced deficiencies in care, including unclarified medication orders for Parkinson's and antifungal treatment, and missed or undocumented physical and occupational therapy sessions. The facility did not ensure medication orders were clarified with providers or that therapy was delivered and documented as scheduled.
An LPN was found to have worked with residents without completing the required onboarding training, having finished only a small portion of the assigned modules. The Administrator confirmed the incomplete training, and the DON was unaware of the deficiency and had not addressed it.
A pharmacist recommended that an antipsychotic medication be administered with food for a resident, but the physician did not indicate acceptance or rejection of this recommendation on the review form. The medication was scheduled without instructions to give it with food, and nursing leadership confirmed the lack of physician acknowledgment.
A resident with multiple medical conditions was given lorazepam, an anti-anxiety medication, on two occasions without any documented symptoms or behaviors of anxiety. The DON confirmed that the medication was administered without the necessary documentation to support its use as required.
Two residents experienced significant medication errors when one received divided doses of lurasidone against physician orders, and another was given Lyrica and auvelity intended for a different resident. The DON confirmed both incidents after reviewing records and staff reports.
Failure to Ensure Interdisciplinary Team Approval for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined it was safe for a resident to self-administer medications, as required by facility policy. The policy stated that residents may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely. In this case, a resident with multiple diagnoses, including hypertension and GERD, and who was legally blind, had a care plan and a self-administration evaluation indicating she did not want to self-administer medications while in the facility. Despite this, surveyors observed a bottle labeled antacids on the resident's bedside table containing both antacids and Tylenol. The resident stated she took the antacids and Tylenol whenever she needed them. The DON confirmed the medications at the bedside and acknowledged that the resident should not be self-administering medications, as documented in the assessment.
Failure to Notify Physician of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure timely physician notification of significant changes in condition for three residents. For one resident with multiple diagnoses including a femur fracture, diabetes, and Crohn's Disease, a 14.9% weight loss occurred over 27 days, but there was no documentation that the physician was informed of this significant change. Another resident with a femur fracture, B-12 deficiency anemia, and hyperlipidemia experienced an 11.66% weight loss over 84 days, again without evidence of physician notification. Both residents were identified as being at risk for nutritional deficits and had care plans indicating that untreated weight variances should not occur. A third resident with mild cognitive impairment, sepsis, and Parkinson's disease exhibited a notable decrease in blood pressure and increases in temperature and heart rate, but there was no documentation that the physician or DON were notified of these changes. The resident was later found pulseless and passed away, with conflicting documentation regarding the frequency and nature of monitoring prior to death. Interviews with facility staff confirmed the lack of physician notification and absence of required documentation regarding these significant changes in condition.
Diversion of Controlled Substances by LPN Resulting in Misappropriation and Exploitation
Penalty
Summary
The facility failed to protect residents from misappropriation of property and exploitation, as evidenced by the diversion of controlled medications intended for three residents. The incident involved an LPN who was observed by the DON to mishandle and ultimately divert multiple pills, including oxycodone, which were prescribed for residents with significant medical needs such as fractures, dementia, post-surgical care, and congestive heart failure. The LPN removed several controlled substances into a single medicine cup, signed them out in the controlled medication logbook, and then failed to administer them to the residents as ordered. When questioned, the LPN provided inconsistent explanations regarding the disposal of the medications and refused to allow a search of her personal belongings before leaving the facility. A review of the controlled drug logbook, medication administration records, and resident interviews confirmed that five doses of oxycodone, belonging to three residents, were signed out but not administered. The facility's investigation substantiated that the LPN diverted these medications, constituting misappropriation of resident property and exploitation. The incident was documented in a Facility Reported Incident and confirmed by the Administrator, with evidence showing that the medications were not located and the LPN was responsible for their diversion.
Failure to Provide Resident-Specific Discharge Documentation During Hospital Transfer
Penalty
Summary
The facility failed to provide resident-specific discharge paperwork to the hospital during the transfer of a resident. Record review showed that the resident, who had multiple diagnoses including aftercare following a surgical procedure, was transported to an infectious disease clinic but refused to get out of the vehicle due to severe pain and diaphoresis. The clinic's physician assistant assessed the resident and sent him to the emergency room. However, the nursing notes did not document the reason for the resident's hospitalization, and there was no documentation in the record explaining why the resident was at the hospital. The Director of Nursing confirmed that the best practice would have been to document the resident's transfer and the reason for hospitalization, but this was not done.
Failure to Update Care Plan After Fall Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated as needed following a significant change in the resident's condition. The resident, who had a history of repeated falls, major depressive disorder, and anxiety, was admitted with left-sided weakness and was identified as being at risk for falls. The initial care plan directed staff to encourage the use of the call light and to keep the resident's room free of clutter and tripping hazards. However, after the resident fell out of bed and staff moved the bed against the wall as a fall intervention, this change was not documented or incorporated into the resident's care plan. The Director of Nursing and Registered Nurse Coordinator confirmed that the intervention of placing the bed against the wall was not included in the care plan, despite being implemented after the fall.
Failure to Clarify Medication Orders and Provide Scheduled Therapy
Penalty
Summary
The facility failed to ensure professional standards of care were followed for three residents reviewed for quality of care. For one resident with mild cognitive impairment, dysphagia, sepsis, and Parkinson's disease, there was a lack of clarification regarding the frequency of Carbidopa/Levodopa ODT dosing after the resident's spouse brought in medication and requested a change due to swallowing difficulties. Documentation showed conflicting orders and a possible transcription error, but there was no evidence that the provider clarified the correct dosing frequency. For another resident with chronic lymphocytic leukemia, the medication order for Voriconazole was unclear and inconsistent with the hospital discharge summary, and the DON acknowledged the order should have been clarified with the physician. A third resident, admitted for aftercare following digestive surgery and heart failure, did not receive scheduled physical and occupational therapy sessions as ordered. Progress notes lacked documentation on the number of therapy attempts, whether the resident refused therapy, or reasons for missed sessions. There was also no evidence that missed therapy sessions were made up on the weekend, and a progress note explaining a missed session was entered 14 days after the fact. These deficiencies demonstrate failures in medication order clarification and therapy service delivery according to professional standards and resident care plans.
LPN Provided Care Without Completing Required Training
Penalty
Summary
The facility failed to ensure that a licensed nurse had completed the required onboarding training and demonstrated the necessary competencies before providing care to residents. Personnel record review showed that one LPN, hired on 9/26/25, had only completed 3 out of 24 assigned training modules, with no documentation of full onboarding training in her file. The Administrator confirmed that the LPN had not completed the required training and acknowledged that she should not have been working with residents. The DON stated that all newly hired staff are required to complete assigned training before working with residents but was unaware that this LPN had not fulfilled the requirement and had not addressed the issue.
Physician Failed to Address Pharmacist Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding medication administration were addressed by the physician for one resident. Specifically, a pharmacist reviewed a resident's medication regimen and recommended that lurasidone, an antipsychotic medication, be administered with food as per the manufacturer's instructions for proper absorption. This recommendation was documented on the Interim Medication Regimen Review form, which included a section for the physician to indicate acceptance or rejection of the pharmacist's recommendation. Despite the pharmacist's documented recommendation, the physician signed the form without indicating whether the recommendation was accepted or declined. Further review of the resident's Medication Administration Record (MAR) showed that the medication was scheduled for administration in the afternoon, but there was no indication that it should be given with food. Facility nursing leadership confirmed that the physician should have acknowledged the pharmacist's recommendation, but this was not done.
Psychoactive Medication Administered Without Documented Indication
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs when a psychoactive medication was administered without adequate indication for its use. A resident with multiple diagnoses, including depressive disorder, hypertension, and osteoporosis, had a physician's order for lorazepam to be given as needed for anxiety. The medication administration record showed that lorazepam was administered on two occasions, but there was no documentation of anxiety symptoms or behaviors at those times. The Director of Nursing confirmed that the medication was given without documentation of the required symptoms or behaviors, contrary to facility expectations.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by two documented incidents involving medication administration. For one resident with multiple diagnoses, including aftercare for a right femur fracture and psychiatric conditions, the physician's order specified lurasidone 100 mg daily, to be given as 20 mg and 80 mg together. However, the Medication Administration Record (MAR) showed the doses were administered separately at different times over a ten-day period, contrary to the order. The Director of Nursing (DON) reviewed the records and could not explain why the doses were divided during that period. In another case, an LPN administered Lyrica 75 mg and auvelity 45-105 mg, both controlled and antipsychotic medications, to the wrong resident. The medication was intended for a different resident in another room. The error was documented in a medication error report, and both the affected resident and her husband were upset, though no physical harm was noted. The DON confirmed the LPN reported the error and accepted responsibility.
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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