Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Vista Care Center Of Sandpoint during CMS and state inspections, most recent first.
Multiple residents with serious mental illness, dementia, or neurocognitive disorders had completed PASRR Level II evaluations, but their MDS assessments were inaccurately coded as not having such evaluations. Additionally, a resident using a wanderguard was not properly documented in the MDS. Staff interviews confirmed these errors were due to misinterpretation and oversight during assessment completion.
The facility did not consistently provide nourishing evening snacks to residents, resulting in a meal interval exceeding regulatory guidelines. Several residents reported that available snacks were insufficient, and some were unaware they could request snacks after dinner or ask for more than one. Staff interviews revealed uncertainty about whether snacks were routinely offered to all residents between dinner and breakfast, and there was no documented resident group agreement to the extended meal interval.
Surveyors found expired spices in the kitchen and unclean resident refrigerators with food residue. The CDM was unaware of the expired items and could not provide documentation that the cleaning schedule had been followed, potentially affecting all residents consuming facility-prepared food.
Staff did not offer hand hygiene to several residents before serving meals, both in the dining room and in resident rooms. One resident was observed coughing and sneezing into his hands without being provided hand hygiene before eating. LPNs confirmed that hand hygiene was not offered as required by policy.
A resident with a history of brain injury who required help with meals was fed by an LPN who stood over the resident, contrary to facility policy that requires staff to sit while assisting with feeding to ensure dignity and comfort.
Two residents with cognitive and mental health diagnoses did not have advance directives documented in their records, and there was no evidence that the facility offered resources or assistance to help them execute advance directives. Staff confirmed that discussions focused on POLST forms rather than advance directives, and there was no follow-up with residents or their legal representatives regarding these options.
A resident with significant neurological and physical impairments was found to have a room with a wall in disrepair, including peeling coving and scratched protective paneling. The issue was identified after the resident's representative raised concerns, and staff confirmed the need for repairs.
A resident with a history of stroke and left-side paralysis was transferred to the hospital without documentation that current medical information was provided to the receiving hospital. The DON confirmed that there was no record of the required transfer paperwork being sent.
Two residents with complex medical needs were transferred to the hospital without receiving written notification of the facility's bed-hold and return policy, and the Ombudsman was not informed of their transfers. Staff confirmed that bed-hold policy notifications were not provided at the time of transfer and that the Ombudsman is only contacted if assistance is needed, not for all transfers or discharges.
A resident admitted with multiple medical conditions did not receive a copy or summary of the baseline care plan within 48 hours of admission, as required by facility policy. Documentation and interviews confirmed that neither the resident nor a representative was provided with the care plan summary, and the DON could not find evidence that this requirement was met.
Two residents did not receive medications according to physician orders and professional standards: an LPN failed to instruct a resident with COPD to rinse his mouth after using an inhaler, and another resident with quadriplegia received only one tablet of Vitamin B-12 instead of the ordered three. The DON confirmed the need for mouth rinsing after inhaler use, and the LPN acknowledged the dosage error.
Three residents with complex medical histories received PRN narcotic pain medications without being offered non-pharmacological interventions as ordered by their physicians. Medication records showed repeated administration of narcotics without documentation of alternative pain management attempts, and the DON confirmed that these interventions were not documented or offered as required.
A resident with chronic bronchitis, low back pain, and dementia continued to receive guaifenesin ER for congestion over several months, despite repeated clinical documentation and observations showing no symptoms of cough, congestion, or respiratory distress. The DON could not provide a clear reason for the ongoing medication, indicating a failure to ensure the resident's drug regimen was free from unnecessary drugs.
A CNA was hired and allowed to work without verification of state-required certification. HR personnel were unable to locate or confirm the CNA's certification, resulting in the staff member providing care without proper credentials.
The facility failed to protect residents from verbal and physical abuse by staff, as evidenced by incidents involving two residents. One resident reported feeling unsafe due to an LPN's confrontational behavior, while another resident experienced physical and verbal abuse by CNAs. Despite multiple reports and a substantiated investigation, the accused staff members were not immediately removed, placing all residents at risk.
A resident with multiple diagnoses, including dementia and epilepsy, required two-person assistance for all ADLs. However, only one staff member assisted the resident during pericare, leading to a fall and a nondisplaced superior calcaneal fracture. The DON confirmed that the care plan was not followed and that the staff member was in-serviced after the incident.
The facility did not meet the regulation requirements for the frequency of QA meetings, as no meetings were held between April 2023 and June 2023. The Administrator could not provide sign-in sheets for this period, indicating a lapse in the required monthly meetings.
The facility failed to provide a minimum of 12 hours of in-service education per year for three CNAs, placing residents at risk of receiving care from inadequately trained staff. Training logs showed the CNAs had only completed between 2.75 and 7.75 hours of training in their respective annual periods. The Human Resources Coordinator confirmed the shortfall despite monthly reviews.
The facility failed to maintain a resident's dignity by not ensuring he was properly covered, exposing his adult diaper and PEG tube to anyone passing by his open door. The DON acknowledged the issue and covered the resident, stating that staff would be reminded to check on him regularly.
The facility failed to ensure the interdisciplinary team had determined it was appropriate for two residents to self-administer medications. One resident with COPD had a Ventolin inhaler without a completed checklist confirming proper use, and another resident with multiple diagnoses was left unattended with a cup of pills, despite not being assessed for self-administration.
A resident with multiple diagnoses, including dementia and anxiety, was taken home against medical advice (AMA) by her representative without a discharge order. The facility staff failed to document notifying the physician, placing the resident at risk due to the lack of physician input.
The facility failed to provide an Advance Beneficiary Notice (ABN) to a resident whose Medicare Part A benefits ended, resulting in potential financial liability for continued services. The resident, admitted for dementia care, continued to stay at the facility without being informed of the financial costs, as the staff assumed the resident would be going home.
The facility failed to report allegations of potential abuse to the State Survey Agency within the required 2-hour timeframe. A resident reported that an LPN was confrontational and screamed at her, making her feel very afraid. The DON and Administrator initially did not recall the incident, and the DON later confirmed that the incident was not reported as required, placing all residents at risk.
A resident reported verbal abuse by an LPN, but the facility failed to thoroughly investigate the allegation. The resident expressed fear and distress, and the accused LPN continued to work during the investigation, contrary to the facility's abuse policy.
A resident with hemiplegia and hemiparesis following a stroke did not receive the specified passive range of motion exercises as outlined in their care plan. The DON confirmed the absence of a restorative nursing program, citing the recent surgery of the staff member designated to manage the program.
A resident with multiple diagnoses, including intracranial injury and epilepsy, was observed with his head tilted to the side without any supporting device. The DON acknowledged the need for a Physical Therapist evaluation for the resident's neck positioning.
The facility failed to ensure the cleanliness of a nebulizer mouthpiece for a resident, which was not stored in a plastic bag as required by policy. The resident had multiple diagnoses, including high blood pressure, dementia, and malnutrition, and was moderately cognitively impaired. The DON confirmed the mouthpiece should have been stored properly.
The facility failed to monitor the effectiveness of a resident's Trazodone prescription for insomnia, as required. The resident's medical record lacked documentation of sleep monitoring, which was confirmed by the DON. This deficiency created the potential for adverse reactions or side effects due to inadequate monitoring.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for six residents, resulting in incorrect documentation of critical assessment information. Specifically, several residents with documented PASRR Level II evaluations indicating serious mental illness or related conditions were inaccurately coded in their MDS assessments as not having such evaluations. For example, one resident with intrahepatic bile duct cancer had a completed PASRR Level II, but the admission MDS assessment did not reflect this. Another resident with diagnoses including senile degeneration of the brain, PTSD, and personality disorder had a PASRR Level II confirming severe mental illness, yet the MDS assessment was marked as not having a PASRR Level II. Similar discrepancies were found for residents with dementia, PTSD, depression, and other neurocognitive disorders, where the MDS assessments failed to accurately document the presence of PASRR Level II evaluations. Additionally, the facility did not accurately document the use of safety devices. One resident with hypertension and chronic obstructive pulmonary disease was observed wearing a wanderguard, but the corresponding MDS assessment indicated that the device was not in use. Staff interviews confirmed that these inaccuracies were due to misinterpretation of assessment questions and oversight during the completion of the MDS. These documentation errors were identified through record reviews and staff interviews, highlighting a pattern of inaccurate assessment entries for multiple residents.
Failure to Routinely Provide Nourishing Evening Snacks
Penalty
Summary
The facility failed to ensure that residents were routinely provided with nourishing evening snacks, as required by regulatory guidelines. Observations and interviews revealed that several residents reported the snacks provided were not substantial or filling, and one resident was unaware that snacks could be requested after dinner. Additionally, residents did not know they could ask for more than one snack. A review of the facility's meal schedule showed there were 15 hours between dinner and breakfast, exceeding the recommended maximum of 14 hours unless a nourishing snack is provided at bedtime or a resident group agrees to the extended interval. Interviews with facility staff, including the CDM and DON, indicated a lack of awareness regarding whether snacks were routinely offered to all residents between dinner and breakfast. The CDM confirmed there was no documented resident group agreement to the current meal hours, and the DON was unaware if snacks were consistently offered during the extended overnight period. Nursing staff reported that snacks were offered if care planned or upon resident request, but not necessarily as a routine practice for all residents.
Expired Spices and Unclean Refrigerators Identified in Food Service Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food safety and sanitation practices in the kitchen and resident areas. Specifically, expired spices including Fajita, Chili Powder, and Onion Powder were found in the spice rack next to the cook preparation area. The Certified Dietary Manager (CDM) acknowledged being unaware of the expired spices and confirmed they should have been discarded. Additionally, the resident refrigerators located in the Lodge, the Village, and the Kitchen were found to be unclean, with food residue present on the interior shelves during multiple observations. The CDM stated that a cleaning schedule existed, documenting what was to be cleaned and when, but was unable to provide documentation that the cleaning schedule had been followed for the month of June 2025. These deficiencies had the potential to affect all 59 residents who consumed food prepared by the facility, as the lack of proper cleaning and failure to discard expired food items could lead to food contamination.
Failure to Offer Hand Hygiene to Residents Before Meals
Penalty
Summary
Surveyors determined that the facility failed to maintain proper infection prevention and control practices by not offering hand hygiene to residents before meals were served. Specifically, seven residents in the Lodge dining room and three residents eating in their rooms were not provided with hand hygiene prior to receiving their meals. One resident was observed coughing and sneezing into his hands and then rubbing his face, yet staff did not offer hand hygiene before serving his meal or after the episode. Staff interviews confirmed that hand hygiene was not offered as required by both facility policy and CMS guidelines.
Failure to Provide Dignified Mealtime Assistance
Penalty
Summary
The facility failed to uphold a resident's right to be treated with respect and dignity during mealtime assistance. According to the facility's Assistance with Meals policy, residents who cannot feed themselves are to be assisted in a manner that ensures safety, comfort, and dignity, specifically stating that staff should not stand over residents while feeding them. Observation revealed that a resident with a history of intracranial injury and loss of consciousness, who required assistance with meals, was fed by an LPN who stood over the resident during the meal. The LPN later confirmed that he was standing while assisting the resident and acknowledged that he should have been sitting, as per facility policy.
Failure to Ensure Residents' Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that residents were able to exercise their right to formulate an advance directive, as required by regulation. For two residents with multiple diagnoses including dementia, PTSD, hallucinations, and depression, there was no documentation in their records of an advance directive for healthcare. Additionally, there was no evidence that resources or assistance were offered to help these residents execute an advance directive. Staff interviews confirmed that the facility's focus during care conferences was on the POLST form, and discussions about advance directives were not conducted. In one case, a resident's sister facilitated admission and signed a financial power of attorney, but the resident did not sign a healthcare power of attorney, and there was no follow-up documented regarding advance directive options. In the other case, there was no documentation that information or assistance with advance directives was offered to the resident's legal guardian.
Failure to Maintain Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident with multiple diagnoses, including aphasia, right-sided weakness and paralysis, and dementia. The resident's representative expressed concern about exposed wood in the baseboard area of the resident's wall. Upon observation, a long section of coving was found peeling away from the wall near the headboard of the resident's bed, and there were multiple long scratches on the board panel intended to protect the wall. A CNA confirmed that the coving and board required repair, and the Maintenance Assistant stated he was unaware of the needed repairs until the previous evening.
Failure to Provide Hospital Transfer Paperwork During Resident Discharge
Penalty
Summary
The facility failed to provide hospital transfer paperwork for one resident who was discharged to the hospital. Record review showed that the resident, who had a history of stroke and left-side paralysis, was transferred to the hospital, but there was no documentation that current medical information was provided to the receiving hospital at the time of transfer. Staff interview with the DON confirmed that she could not provide documentation that the hospital received the resident's current medical documentation during the transfer. This action did not meet the requirement to ensure appropriate information is communicated to the receiving health care institution during a transfer or discharge.
Failure to Provide Bed-Hold Policy Notification and Ombudsman Notification During Resident Transfers
Penalty
Summary
The facility failed to provide required written notification of its bed-hold and return policy to residents who were transferred to the hospital, and did not notify the Ombudsman advocate of these transfers. Specifically, for two residents with significant medical histories—one with blood clots and kidney and bladder cancer, and another with a history of stroke and left-side paralysis—there was no documentation in their medical records that they received written notice regarding the facility's bed-hold policy at the time of their hospital transfers. Additionally, there was no evidence that the Ombudsman was informed of their transfers, which is necessary to ensure advocacy for residents during their absence from the facility. Staff interviews confirmed that the Director of Nursing acknowledged the lack of bed-hold policy notification, stating that residents are only informed upon admission that the facility does not hold beds for discharged residents. The CCU Coordinator also stated that the Ombudsman is only contacted if assistance is needed, not routinely notified of transfers or discharges. These actions and omissions were identified through record review and staff interviews, and were found to be true for two of four residents reviewed for discharge documentation.
Failure to Provide Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to provide a copy or summary of the baseline care plan to a resident and/or their representative within 48 hours of admission, as required by facility policy. The policy specifies that residents and/or their representatives must receive a summary of the baseline care plan, which includes initial goals, a summary of medications and dietary instructions, services and treatments to be administered, and any updated information from the comprehensive care plan. Record review and staff interviews confirmed that there was no documentation showing the baseline care plan was provided to the resident or their representative. The resident involved was admitted with multiple diagnoses, including thoracic vertebra fractures, ankylosing hyperostosis, and diabetes. The admission MDS assessment documented that the resident was cognitively intact. During an interview, the resident was unsure if he had received a copy of his care plan or had a meeting with staff about his care. The DON was unable to locate documentation that the baseline care plan had been provided to the resident or his representative.
Failure to Follow Medication Administration Orders and Standards
Penalty
Summary
The facility failed to ensure medications were administered according to physician's orders and professional standards of practice for two residents. For one resident with COPD and dementia, a physician's order required the use of an inhaled medication (fluticasone-salmeterol) with instructions to rinse the mouth after each use. During medication administration, the LPN provided the inhaler but did not instruct or offer the resident to rinse his mouth afterward, as required by the order and professional guidelines. The DON confirmed that the medication brands were equivalent and that mouth rinsing should have been performed. For another resident with a history of traumatic brain injury and quadriplegia, a physician's order specified administration of three tablets of Vitamin B-12 daily. The LPN was observed preparing and administering only one tablet instead of the ordered three. Upon review of the order, the LPN acknowledged the error and stated that the correct dosage should have been given. These actions demonstrate a failure to follow physician orders and established medication administration protocols.
Failure to Offer Non-Pharmacological Pain Interventions Prior to PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure that physician-ordered non-pharmacological interventions were offered to residents prior to the administration of as-needed (PRN) narcotic pain medications. This deficiency was identified through record review, policy review, and staff interviews, and was found to affect three residents with significant medical histories, including low back pain, dementia, vertebral fractures, arthritis, and a history of substance use disorder. For each resident, physician orders specifically directed staff to offer interventions such as rest, positioning, distractions, and application of cold or heat packs before administering PRN narcotic pain medications. Despite these orders, medication administration records for all three residents showed repeated administration of narcotic pain medications without any documentation that non-pharmacological interventions were offered beforehand. In one case, a resident received a narcotic pain medication 69 times in a single month with no record of non-pharmacological interventions being attempted. The Director of Nursing confirmed the absence of such documentation for all three residents, acknowledging that the interventions should have been offered prior to medication administration.
Failure to Discontinue Unnecessary Medication for Resident
Penalty
Summary
A resident with multiple diagnoses, including chronic bronchitis, low back pain, and dementia, was admitted to the facility and prescribed guaifenesin ER 600 mg every 12 hours for congestion. Despite this ongoing prescription, multiple progress notes from a Nurse Practitioner over several months documented that the resident did not exhibit symptoms such as cough, congestion, shortness of breath, nasal discharge, or abnormal lung sounds. Medication administration records confirmed that the resident continued to receive guaifenesin ER as ordered from March through late June. Direct observations of the resident on several occasions revealed no signs of cough, congestion, or difficulty breathing. When questioned about the continued administration of guaifenesin despite the absence of symptoms, the Director of Nursing was unable to provide a clear rationale and suggested the medication order needed clarification. This sequence of events demonstrates that the facility failed to ensure the resident was free from unnecessary medications, as required.
Failure to Verify CNA Certification Prior to Employment
Penalty
Summary
The facility failed to ensure that nursing staff were licensed or certified in accordance with state laws. During a review of licenses and certifications for three nursing staff members, it was found that one staff member, hired as a CNA, did not have certification to work as a CNA in the state. The HR personnel, who was recently hired, was unable to locate the certification for this staff member and confirmed that the staff member could not provide proof of certification. This deficiency had the potential to affect all 61 residents in the facility, as the staff member was providing care without the required credentials. The review and interviews with HR personnel revealed that the certification was not verified at the time of hire, and the staff member continued to work without proper documentation of state-required certification.
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 Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that Resident #16's care plan was followed, resulting in a fall and subsequent injury. Resident #16, who had multiple diagnoses including viral infection of the brain, dementia, epilepsy, and abnormal posture, required two-person assistance for all activities of daily living (ADLs) due to his cognitive and physical impairments. However, on 12/21/23, only one staff member, CNA #13, was assisting Resident #16 during pericare. While turning Resident #16, he threw his left arm to his right side and rolled off the bed, resulting in a fall. The incident report noted possible muscle spasm or seizure activity as the root cause of the fall and reiterated the need for two-person assistance for Resident #16's care. Following the fall, Resident #16 exhibited signs of injury, including a bruise and swelling on his right heel. Despite initial assessments indicating no apparent pain, a physician's progress note on 1/4/24 documented that Resident #16's right foot was painful to palpate, leading to an x-ray that confirmed a nondisplaced superior calcaneal fracture. The Director of Nursing (DON) acknowledged that the care plan was not followed and that CNA #13 should have known to provide two-person assistance by checking the Kardex. The DON also confirmed that CNA #13 was in-serviced after the incident.
Failure to Hold Required QA Meetings
Penalty
Summary
The facility failed to meet the regulation requirements for the frequency of Quality Assurance (QA) meetings. According to the facility's Quality Assurance and Performance Improvement (QAPI) Program, the committee is supposed to meet monthly to review reports, evaluate data, and monitor QAPI-related activities. However, upon review of the attendance sheets for QAPI meetings from April 2023 to April 2024, it was found that no meetings were held between April 2023 and June 2023. The Administrator was unable to provide sign-in sheets for this period, indicating a lapse in the required monthly meetings. This failure to hold regular QA meetings has the potential to negatively affect all residents in the facility if quality deficiencies are not identified and addressed in a timely manner.
Failure to Provide Required CNA In-Service Education
Penalty
Summary
The facility failed to provide a minimum of 12 hours of in-service education per year for three CNAs, which placed residents at risk of receiving care from inadequately trained staff. The facility's policy required 24 hours of in-service training annually, and non-compliance could impact pay raises and result in termination. However, the training logs for three CNAs showed they had only completed between 2.75 and 7.75 hours of training in their respective annual periods. During interviews, the Human Resources Coordinator (HRC) confirmed that the facility used the employee anniversary date to track training hours and reviewed them monthly. Despite this, the HRC acknowledged that the CNAs were short on their required training hours. The deficiency was identified through record reviews, policy reviews, and staff interviews, highlighting a failure in ensuring adequate training for CNAs to meet residents' needs.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure respect and maintain a resident's dignity for Resident #12, who was admitted with multiple diagnoses including intracranial injury, epilepsy, and aphasia. An annual MDS assessment documented that Resident #12 was rarely/never understood. On two separate occasions, Resident #12 was observed from outside his room with no sheet covering his lower body, exposing his adult diaper and PEG tube. His door was fully open, making him visible to anyone passing by. The DON acknowledged the situation and stated that Resident #12 would always uncover himself, then proceeded to cover him and mentioned reminding the staff to check on him regularly.
Failure to Ensure Appropriate Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the interdisciplinary team had determined it was appropriate for two residents to self-administer medications. Resident #39, who was cognitively intact and diagnosed with chronic obstructive pulmonary disease (COPD), had a physician order to keep a Ventolin inhaler in her room. However, there was no checklist completed to confirm that Resident #39 knew and understood how to use the inhaler. Additionally, the Resident Care Specialist (RCS) was unaware of the order and confirmed that the interdisciplinary team had not determined Resident #39 was appropriate for self-administering medications. Resident #52, who was moderately cognitively impaired and diagnosed with type 2 diabetes mellitus, heart disease, and dementia, was observed with a cup of pills placed on the dining room table by an LPN. The LPN left the dining room to obtain a glucometer strip, leaving the medication cup unattended. The LPN later confirmed that Resident #52 was not assessed or determined by the interdisciplinary team to be appropriate to self-administer medications. The Director of Nursing (DON) also confirmed that Resident #52 had not been assessed for self-administration of medications.
Failure to Notify Physician of Resident's AMA Discharge
Penalty
Summary
The facility failed to ensure the physician was notified of a resident's decision to leave the facility against medical advice (AMA). Resident #62, who had multiple diagnoses including dementia, weakness, and anxiety, was taken home by her representative without a discharge order. The nurse documented the representative's intention to take the resident home and attempted to explain the need for a discharge order. Despite this, the representative insisted on taking the resident home, and an AMA form was signed. The Social Services progress note also documented the representative's decision and the resident's inability to urinate without assistance. The Director of Nursing (DON) confirmed that staff are expected to notify the physician of any resident wanting to go home AMA. However, upon reviewing Resident #62's record, the DON found no documentation that the physician was notified. The DON then contacted the Resident Services Coordinator (RSC), who stated that the physician was verbally notified but failed to document it in the resident's record. This lack of documentation and communication placed Resident #62 at risk of harm due to the absence of physician input or involvement in the discharge process.
Failure to Provide Advance Beneficiary Notice
Penalty
Summary
The facility failed to ensure that residents were provided with an Advance Beneficiary Notice (ABN) when their Medicare Part A benefits ended. This deficiency was identified for one resident who was admitted for care related to dementia. The resident's representative was given the Notice of Medicare Non-Coverage (NOMNC) form, indicating that skilled nursing service coverage would end on 4/5/24. However, the resident continued to stay at the facility after this date without being provided an ABN to inform them of the financial costs they would be liable to pay. The Resident Services Coordinator (RSC) stated that the ABN was not provided because they thought the resident would be going home.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of potential abuse to the State Survey Agency within the required 2-hour timeframe. This deficiency affected a resident who was cognitively intact and had multiple diagnoses, including heart disease, high blood pressure, arthritis, and depression. The resident reported that an LPN on the night shift was confrontational, screamed at her, and made her feel very afraid. The resident immediately called the Administrator, who planned to send another LPN to sit with her, but the confrontational LPN returned alone and had another verbal encounter with the resident. When interviewed, the Director of Nursing (DON) and the Administrator initially did not recall any recent allegations of verbal abuse. The DON later confirmed that the incident occurred on the evening shift and should have been reported to the State Agency. However, the DON could not find the investigation report and admitted that the incident was not reported as required. This failure to report and investigate the allegation in a timely manner placed all residents in the facility at risk of abuse.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was thoroughly investigated for Resident #37, who was admitted with multiple diagnoses including heart disease, high blood pressure, arthritis, and depression. Resident #37, who was cognitively intact, reported that an LPN on the night shift was confrontational, hollered, and screamed at her, stating she never liked Resident #37 and wanted her out of the facility. The resident immediately called the Administrator, who planned to send another LPN to sit with her. However, the confrontational LPN returned to the room alone, leading to another verbal encounter. The resident expressed fear and distress over the incident and stated she had not seen the LPN since but knew she was still in the building. The Director of Nursing (DON) and the Administrator were unaware of any recent allegations of verbal abuse when initially asked. The DON later provided a phone interview statement dated the day after the incident but could not provide documentation of interviews with the involved LPNs or other CNAs on duty. The DON confirmed that the accused LPN continued to work during the investigation period, contrary to the facility's abuse policy, which mandates the immediate removal of the accused from resident care areas pending investigation results. This lack of thorough investigation and failure to follow protocol subjected Resident #37 and other residents to potential ongoing abuse without detection.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to implement a restorative nursing program for a resident with hemiplegia and hemiparesis following a stroke. The resident's care plan, revised on 5/19/22, specified that the resident was to receive passive range of motion exercises for the left upper extremity. However, the resident reported that he had not been receiving the restorative program recently and did not know why. The Director of Nursing (DON) confirmed that the facility currently did not have a restorative nursing program and mentioned that the staff member who was supposed to manage the program had recently undergone surgery.
Failure to Follow Professional Standards of Practice
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for a resident with multiple diagnoses, including intracranial injury, epilepsy, and aphasia. The resident was observed on multiple occasions with his head tilted to the left side, almost touching his shoulder, without any supporting device for his head or posture. The Director of Nursing (DON) acknowledged that it had been a while since the resident was evaluated by a Physical Therapist and confirmed that the resident should be assessed for his neck positioning.
Failure to Maintain Cleanliness of Nebulizer Mouthpiece
Penalty
Summary
The facility failed to ensure the cleanliness of a nebulizer mouthpiece for a resident, which was not stored in a plastic bag as required by the facility's policy. This was observed on two separate occasions, where the mouthpiece was found lying directly on the overbed table. The resident involved had multiple diagnoses, including high blood pressure, dementia, and malnutrition, and was moderately cognitively impaired. The Director of Nursing confirmed that the nebulizer mouthpiece should have been stored in a plastic bag.
Failure to Monitor Medication Effectiveness
Penalty
Summary
The facility failed to ensure professional standards of practice were met for monitoring the effectiveness of a resident's medication. This was identified for one resident who was prescribed Trazodone for insomnia. The resident's medical record did not include documentation of sleep monitoring, which is necessary to evaluate the effectiveness of the medication. The Director of Nursing (DON) confirmed that the resident's hours of sleep were not being recorded, despite the requirement for such monitoring. This deficiency created the potential for the resident to experience adverse reactions or side effects due to the lack of appropriate monitoring.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sandpoint
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Sandpoint | 0.8 mi | — | 0 | 0 |
| Boundary County Nursing Home | 31.9 mi | — | 14 | 0 |
| Life Care Center Of Coeur D'alene | 38 mi | — | 25 | 0 |
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