Inspection Reports for
Brookdale Chubbuck

.260.06 Housekeeping and maintenance services: the facility was not maintained in a clean, safe and orderly manner with issues including spiderwebs, dead bugs, dirty windows, weeds in entryways, damaged door jambs, missing trim pieces, yard debris, loose siding, scratched and gouged walls and door jambs, discoloration around toilets, dirty doors, separating rubber baseboards, frayed carpet strips, scratched dining furniture, uneven paint patches, and a brick placed against an exterior door creating a fire safety hazard.

.330.06.c Behavior documentation: the facility staff did not document ongoing tracking of behaviors, including interventions used and their effectiveness. Resident #1 exhibited inappropriate behaviors and Resident #3 reported delusions and suspicions interfering with care. Staff required additional training.

.330.15.a.ii. Fire and Life Safety Records: the facility failed to provide records of smoke detector sensitivity testing within the past five years.

.404. Fire and life safety standards: facility failed to maintain emergency lighting in operable condition, failed to provide documentation of smoke detector sensitivity testing, and a smoke detector initiating device was missing its smoke head.

.405.01.a. Electrical Installations and Equipment: use of multi-plug adapters was identified in room #302 powering a lamp, clock, and phone charger.

.405.02.a. Prohibited Applications: use of a relocatable power tap to power medical equipment was identified in room #102 for an oxygen concentrator.

.405.03. Medical Gases: an E-sized oxygen cylinder was found sitting directly on carpeted floor in room #102 instead of being stored in an appropriate cart or rack.

.009.06.c Use of previous criminal history and background check: one employee did not have the Idaho State Police background check completed prior to working alone with residents since November 2023.

.215.01 Administrator responsibility: the administrator did not ensure the facility's abuse, neglect, and exploitation policy was followed, failing to interview and document all relevant residents and staff during an investigation of missing money.

.215.08.d Written response to complaint within thirty days: the administrator had not consistently provided written responses to complainants within 30 days, including for a complaint about missing money reported on 4/17/24.

.215.08.e Corrective action: the facility did not ensure effective corrective actions were implemented to prevent recurrence of falls, with no new interventions after multiple incidents.

.305.02.b Current medication orders and treatment orders: residents did not consistently receive medications and specialized diets as ordered, including missed doses and conflicting medication orders.

.305.03 Resident health status: facility nurses did not consistently complete change of condition assessments for residents after falls and other health changes.

.310.01.g Medication distribution system: the facility did not ensure all ordered as-needed medications were available to residents at all times, with several medications missing from carts and records.

.320.08 Periodic review: residents' negotiated service agreements were not consistently updated to reflect significant changes in health status, including mobility and oxygen requirements (previously cited 8/10/23).

.330.13.h Personnel records: the facility failed to obtain documentation of criminal history and background check results for three employees, despite clearance to work.

.330.14 As worked schedules: the facility's schedules did not include job titles for managers and did not record working times for salaried management staff.

.600.04.b Sufficient personnel: eight sampled direct care staff lacked current first aid certifications, and seven lacked CPR certification, with staff working alone without required certifications.

.300.01 Licensed Registered Nurse (RN): the facility's RN did not perform the quarterly assessments for five of seven sampled residents who required them; quarterly assessments were not consistently completed every 90 days.

.320.01 Use of NSA: residents' Negotiated Service Agreements did not accurately reflect health status or care needs, missing instructions for teeth brushing, pain management, and delineation of hospice versus facility services.

.009.01 Criminal History and Background Check: one of ten employees did not have a Department Criminal history and background check completed.

.009.02.b Scope of a Criminal History and Background Check: three of six employees who required a state police background check did not have one completed or documented.

.215.01 Administrator Responsibility: the administrator failed to implement policies to protect residents from sexual abuse, retain residents with non-healing wounds appropriately, and provide locked storage for residents.

.215.02 Availability of Administrator: the facility did not have a licensed administrator overseeing operations for 19 days from 4/7/21 to 4/25/21.

.215.07 Notification to Adult Protection and Law Enforcement: the administrator failed to report allegations of sexual abuse of Resident #11 to Adult Protection.

.215.08.b Investigation within Thirty Days: investigations were not conducted within 30 days for sexual abuse and resident falls incidents.

.215.08.e Corrective Action: appropriate corrective actions were not implemented to prevent recurrence of sexual abuse and resident falls.

.215.08.f Notification to Licensing Agency within One Business Day: the facility did not notify Licensing and Certification within one business day of residents' falls requiring outside assessments.

.215.08.g Identify and Monitor Patterns: the administrator did not monitor incident patterns or develop interventions to prevent recurrences of sexual abuse and falls.

.250.14 Call System: the memory care unit did not have a call system in place (previously cited 8/30/19).

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe, and orderly manner with torn and stained carpets creating trip hazards.

.300.01 Licensed Registered Nurse (RN): required nursing assessments were not completed for all residents, including overdue quarterly assessments and missing initial assessments.

.310.01.c Medication Distribution System: medication refrigerator temperatures were not monitored or maintained within required ranges, and temperature logs were incomplete.

.310.04.e Psychotropic or Behavior Modifying Medication: psychotropic medication reviews were not completed within the previous six months for residents taking such medications.

.319.04 Maladaptive Behaviors: behaviors of residents exhibiting sexual abuse and wound picking were not evaluated after exhibited behaviors.

.320 Negotiated Service Agreement (NSA) Requirements: NSAs were not updated or developed timely to reflect residents' current needs and behaviors.

.330.04.c.vii Resident Care Records: assessments for changes in residents' conditions were not consistently documented.

.330.06.a Behavior Documentation: behaviors of residents exhibiting sexual abuse and wound picking were not evaluated after exhibited behaviors.

.330.06.b Behavior Documentation: behavior plans with interventions were not developed for residents exhibiting sexual abuse and wound picking behaviors.

.450 Requirements for Food and Nutritional Care Services: the facility did not have a Certified Food Protection Manager.

.600.04.a Sufficient Personnel: medication administration was delayed due to insufficient staffing and medication technicians covering multiple hallways.

.630 Training Requirements for Facilities Admitting Residents with a Diagnosis of Dementia, Mental Illness, Developmental Disability, or Traumatic Brain Injury: staff files lacked evidence of specialized training required for caring for residents with these diagnoses.

.510 Requirements to Protect Residents from Abuse: the facility failed to protect Resident #11 from sexual abuse by Resident #8, including failure to investigate, implement behavior plans, and monitor incidents.

.520 Requirements to Protect Residents from Inadequate Care: the facility retained Resident #6 with a non-healing wound requiring skilled nursing care without appropriate care plans or discharge notice.

.550.04.d Personal Possessions: the facility failed to provide all residents with locked storage for personal property, violating residents' rights.

.217.04 Resident's Appeal of Involuntary Discharge: the facility discharged Resident #1 without providing a written notice of discharge; Resident #1's family was informed their loved one had to leave due to the need for a higher level of care.

.415.03 Portable Fire Extinguisher Service and Testing: fire extinguishers throughout the facility measure 67 inches to the top, exceeding the maximum height of 60 inches, and the Class K fire extinguisher in the kitchen lacks the required placard.

.405.01.b Electrical Installations and Equipment: extension cord in use at front entry table going through the wall and plugged into a relocatable power tap (RPT), resident room #318 had a microwave and refrigerator plugged into a dangling RPT, furnace room power cord mounted over door and through wall to power lighting fixture, storage/office in Memory Care had RPT plugged into extension cord and microwave plugged into RPT, resident room #103 had microwave and refrigerator plugged into RPT with frayed cord, and GFI outlet at kitchen near main entrance is broken.

.405.05 Structure, Maintenance, Equipment to Assure Safety: main door to kitchen has a kick down door stop being used to hold the door open; only magnetic hold open devices interconnected to the fire alarm system are permitted.

.405.07 Exit Door Locks: exit door from kitchen has a deadbolt and is non-single operational.

.250.01 Building Character: approximately 2 inch circular hole in the wall at the nurse's station, multiple penetrations at conduits in mechanical and electrical rooms where wires and cables run through to the attic, and penetrations at red pex pipe going through the ceiling in the #2 boiler room.

.250.15 Call system: the facility's memory care unit did not have a call system in place; staff and the administrator confirmed it had never been installed.

.405.05 Structure, Maintenance, Equipment to Assure Safety: southwest side of building missing soffit allowing rodents and insects to penetrate inside facility; exterior of building needs to be in good repair to prevent infestation of pests.

.415.05 Automatic Fire Extinguishing System Service and Testing: dry system gauges were not inspected weekly and wet system gauges and control valves were not inspected monthly in accordance with NFPA 25.

.405.01 Medical Gases: relocatable power taps were used without proper listing as designed in accordance with NFPA 70 and UL 1363; kitchen used RPT for supplying power to blender, Nutribullet, and coffee maker.

.405.03 Medical Gases: medical gas cylinders were not secured properly; Room 106 had one oxygen cylinder out of rack and laying on top of two cylinders (corrected on site 1/28/19); Room 206 was not signed for oxygen in use and had one oxygen cylinder unsecured by rack or chained.

.415.02 Fuel-Fired Heating: last annual fuel-fired heating inspection for furnaces was performed on 10/19/17 and is overdue.

.260.06 Housekeeping Services and Equipment: the facility did not maintain the interior in a clean, safe and orderly manner; carpets were worn and stained, bathroom sink laminate was coming off, furniture was stained and worn, and urine odors were noted in some rooms.

.305.02.b Current Medication Orders and Treatment Orders: the facility did not implement Resident #6's therapeutic diet order and Resident #5 did not receive Celexa as ordered.

.711.01 Ongoing Resident Care Records: the facility did not consistently document times and dates of behaviors, interventions used, or their effectiveness for Residents #4, #5, and #10.

.405.01 Medical Gases: three electrical breaker panels were not completely labeled, and an outlet cover was missing with exposed wiring at the disposable briefs storage closet.

.350.04 Written response to complaint within thirty days: the administrator did not respond to all complainants in writing within 30 days (previously cited on 10/20/2016).

.451.02 Snacks: the facility did not offer snacks between meals and at bedtime (previously cited on 10/20/2016).

.550.23.a Fee changes: the facility did not provide a written notice to residents, legal guardians, or conservators of fee changes within 5 days of the fee change.

.550.23.b Fee changes: the facility increased residents' fees prior to the five day notification period.

.600.06.b Sufficient personnel: five out of eight caregivers did not have evidence of CPR/First Aid certification, and the facility could not ensure all shifts were covered in both the main building and the memory care unit with at least one properly certified staff member.

.215.09 Identify and monitor patterns of incidents and accidents: the administrator did not develop interventions based on tracking and trending of incidents and accidents to prevent them from reoccurring.

.225.01 Evaluation for behavior management: Resident #1 and Resident #2 exhibited verbal and physically aggressive behaviors and the facility did not develop behavior management plans (previously cited 9/25/2014 and 2/25/2015).

.250.09 Ventilation: from 10/17 through 10/19/16, strong urine odor was noted in the 100 hallway and room 329; residents also complained of air freshener smell being too strong throughout the facility during this time period.

.300.01 Licensed professional nurse (RN): the facility nurse did not delegate five out of 10 sampled caregivers prior to the caregivers assisting residents with their medications and cares.

.330.02 Resident record retention: residents' records were not retained in the facility for 3 years.

.350.02 Administrator or designee investigation within thirty days: the administrator did not complete an investigation or written report within 30 days of complaints, incidents, and accidents, including failure to investigate Resident #14's report of Resident #2 wandering into her room and three unwitnessed falls in September 2016 (previously cited 9/25/2014 and 2/25/2015).

.350.04 Written response to complaint within thirty days: the administrator did not respond in writing to all complaints within 30 days.

.350.05 Facility notification to appropriate agencies: the administrator did not notify Adult Protection and law enforcement when allegations of verbal and physical abuse were reported and/or documented.

.350.07 Notification of licensing and survey agency within twenty-four hours: the facility did not notify Licensing and Certification within 24 hours when Resident #7 fell and received multiple staples to the back of her head.

.405.03 Medical gases: multiple oxygen tanks were found unsecured in rooms 217, 308, and 323.

.451.02 Snacks: the facility did not offer snacks between meals and at bedtime.

.711.08.c Care notes: caregivers did not document unusual events such as unwitnessed falls, resident behaviors, resident refusal of cares, or resident change of condition.

.510 Requirements to protect residents from abuse: the facility failed to protect residents from verbal and physical abuse by not conducting investigations of reported resident-to-resident abuse or reporting serious injuries of unknown origin to Adult Protection, leaving 100% of residents at risk. Resident #2 exhibited aggressive and intrusive behaviors that were not adequately addressed or investigated, and Resident #12 sustained severe injuries of unknown origin with no proper investigation or reporting.

.250.01 Building Character: two 3/4 inch circular penetrations were found in the room labeled Mechanical Room.

.250.10 Plumbing: water temperatures throughout the facility were found to be above the maximum temperature of 120 degrees Fahrenheit, ranging from 129 to 139 degrees.

.400 Requirements For Fire And Life Safety Standards: the required self-closing door leading to/from the kitchen was held open by a rubber wedge.

.405.01 Medical Gases: refrigerators and microwaves were plugged into relocatable power taps utilized as permanent wiring in rooms 301, 304, 219, 118, and the kitchen area.

.405.01.b Electrical Installations and Equipment: multiple electrical adapters were found in use in rooms 220 and 313.

.405.03 Medical Gases: five oxygen tanks were found unsecured in room 126.

.405.05.a Structure, Maintenance, Equipment to Assure Safety: in the 100 hallway of pod 4, four wheelchairs and a bench were stored in the means of egress.

.415.01 Maintenance of Equipment and Systems: three pieces of cardboard boxes were found in the kitchen hood system venting area; a sprinkler head in the walk-in freezer was blocked; and the nurses office closet had storage within 18 inches of a sprinkler head.

.415.03 Portable Fire Extinguisher Service and Testing: there was no class K fire extinguisher located in the kitchen and multiple fire extinguishers throughout the facility were installed above 60 inches.