Inspection Reports for
Aspen Creek Senior Living – Caldwell
4119 Lenity Living Ave, Caldwell, ID 83605, United States, ID, 83605
Back to Facility Profile3 Reports
Inspection Report — Jul 19, 2024
Routine
Date: Jul 19, 2024
Visit Reason
A health care licensure and follow-up survey with complaint investigation was conducted to assess compliance with regulations and investigate complaints.
Complaint Details
The complaint investigation involved three documented complaints between 10/1/23 and 7/17/24 regarding resident care concerns; two complaints lacked written responses within 30 days.
Findings
Three deficiencies were found related to failure to provide written responses to complaints, missing as-needed medications for residents, and incomplete documentation of resident care records.
Deficiencies (3)
.215.08.d. Written Response to Complaint within Thirty Days: the administrator did not consistently provide written responses to complaints, with two of three documented complaints lacking timely written responses regarding resident care concerns.
.310.01.g. Medication Distribution System: the facility did not ensure all ordered as-needed medications were available to five sampled residents, including missing PRNs such as calmoseptine, insulin needles, and melatonin.
.330.04.c.iii. Resident Care Records: residents' care records were not maintained with all entries current and accurate, including missing documentation of sliding scale insulin units for Resident #8 on 113 of 118 opportunities.
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Inspection Report — May 3, 2024
Life Safety
Date: May 3, 2024
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety codes and regulations.
Findings
The facility failed to maintain compliance with multiple fire and life safety standards including missing documentation for smoke detector sensitivity tests, emergency lighting tests, and fire door inspections. Additional deficiencies included incomplete relocation agreements, lack of emergency generator maintenance records, insufficient fire drill frequency, unsecured oxygen cylinders, and prohibited electrical installations.
Deficiencies (6)
.404 Fire and life safety standards for existing buildings: the facility lacked documentation for a 5-year smoke detector sensitivity test, periodic staff emergency plan training, monthly and annual emergency lighting tests, had a 30" x 30" hole in a 1-hour rated smoke partition wall, and missing annual inspection documentation for a vertical rolling fire door.
.155.01 Relocation agreements: the facility had only one relocation agreement instead of the required two.
.155.03 Emergency generators: the facility could not produce documentation for weekly inspections, monthly load tests, or annual maintenance of the emergency generator.
.410 Requirements for emergency actions and fire drills: the facility did not conduct bi-monthly drills with at least two at night; only one drill was conducted at night during the past year.
.405.03 Medical gases: three unsecured oxygen cylinders were observed and the facility lacked documentation of periodic staff training on oxygen safety despite having five residents on oxygen therapy.
.405.01.a Electrical installations and equipment: extension cords and multi-plug adapters were in use in resident rooms, including a non-grounded extension cord, an extension cord with a microwave, and two multi-plug adapters.
Report Facts
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Inspection Report — Feb 3, 2023
Original Licensing
Date: Feb 3, 2023
Visit Reason
A health care initial licensure survey combined with a complaint investigation was conducted to assess compliance with Idaho regulations for Residential Assisted Living Facilities.
Complaint Details
The complaint investigation was combined with the initial licensure survey. The complaint concerned inadequate care related to wound management and resident safety, which was substantiated by findings of residents admitted and retained with unstageable and non-healing wounds requiring skilled nursing care.
Findings
The survey found multiple deficiencies in resident care, including inadequate admissions and retention of residents requiring skilled nursing care, failure to follow medication orders, lack of adherence to negotiated service agreements, insufficient staffing especially in the memory care unit, and failure to update care plans to reflect residents' changing needs. Core deficiencies involved admitting and retaining residents with unstageable and non-healing wounds requiring skilled nursing care without proper care plans.
Deficiencies (7)
.215.05. Responsibility for Acceptable Admissions: the administrator knowingly admitted or retained residents requiring skilled nursing care, including residents with unstageable and non-healing wounds, without proper knowledge or care plans.
.305.02.b. Current Medication Orders and Treatment Orders: residents did not consistently receive medications as ordered, including insulin, tramadol, amoxicillin, donepezil, sertraline, and thickened liquids.
.320.01. Use of NSA: residents were not provided care according to their Negotiated Service Agreements, including failure to assist with toileting every two hours and lack of staff monitoring in the common area.
.320.08. Periodic Review: Negotiated Service Agreements were not updated to reflect significant changes in residents' care needs, such as mobility, diet, and wound care instructions.
.460.02.d. Frequency of Meals: residents in the memory care unit were not consistently offered snacks and fluids during the day, and requests for snacks were repeatedly denied.
.600.04. Personnel Management: insufficient staffing was observed, especially in the memory care unit, with periods of no staff present while residents were unattended; staff lacked current first aid and CPR certifications.
.520. REQUIREMENTS TO PROTECT RESIDENTS FROM INADEQUATE CARE: the facility admitted and retained residents with unstageable and full-thickness pressure injuries requiring skilled nursing care without appropriate care plans, resulting in inadequate care and failure to protect residents.
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