Inspection Reports for
Brookdale Coeur d’Alene

.009.06.c Use of Previous Criminal History and Background Check: two employees did not have the Idaho State Police background check completed prior to working alone with residents.

.310.01.c Medication Distribution System: the facility did not maintain medication refrigerator temperatures between 38 and 45 degrees F daily, with temperatures below 38 degrees on multiple occasions in March and April 2025; staff were unaware of the required temperature range.

.161.04 Designated smoking areas: the facility smoking policy allowed smoking in designated areas, but no smoking area was clearly marked or identified (previously cited 9/27/2022).

.250 Requirements for building construction and physical standards: the facility failed to ensure 1-hour construction and compartment containment per NFPA 101, Chapter 33, Section 33.3.3.7; a fire suppression system impairment caused damage removing fire resistive properties, and the facility failed to notify the Authority Having Jurisdiction of the impairment requiring Fire Watch.

.405.02.c Prohibited applications: Room 223 used a relocatable power tap to power a microwave and coffee maker, which is prohibited.

.405.04 Fuel-fired heating: the facility could not provide documentation of annual inspections for fuel-fired heating systems (previously cited 4/1/2021 and 9/27/2022).

.410 Requirements for emergency actions and fire drills: the facility did not hold emergency egress and relocation drills on a bi-monthly basis; drills were not conducted between January 2023 and June 2023 (previously cited 9/27/2022).

.152.03.a.ii. Policies of Acceptable Admissions: two private-duty caregivers provided care without facility arrangement or coordination, and the administrator was unaware of these services.

.260.06. Housekeeping and Maintenance Services: the facility was not maintained in a safe, clean, and orderly manner with stained carpets, dirty floors, urine odors, overflowing trash, and multiple complaints about unclean rooms (previously cited 1/27/2023, 10/22/2021, and 2/26/2021).

.305.02.b. Current Medication Orders and Treatment Orders: residents did not consistently receive medications and treatments as ordered, including missed doses and insufficient weighing frequency; the nurse was unaware of these issues (previously cited 1/27/2023, 10/22/2021, and 2/26/2021).

.305.02.c. Current Medication Orders and Treatment Orders: not all residents' written, signed orders were obtained and retained, including missing orders for Resident #4 and Resident #3 (previously cited 1/27/2023).

.305.03. Resident Health Status: nursing assessments were not conducted when residents experienced changes in health status, and some assessments were done by nurses without valid Idaho licenses (previously cited 1/27/2023).

.330.09. Resident Admission and Discharge Register: the register was not up-to-date and did not accurately document residents, with discrepancies among records and inclusion of a deceased resident (previously cited 1/27/2023).

.600.04.a. Sufficient Personnel: insufficient staff were available to meet residents' needs and maintain cleanliness, resulting in missed showers and housekeeping; some residents relied on private caregivers or family for care, and the administrator cited staff loss due to a hostile work environment.

.645.02. Delegation: ten of eleven medication-passing staff were not delegated by a nurse with a valid license until after the lapse was identified during survey (previously cited 1/27/2023).

.009.01 Criminal History and Background Check: one of ten employees did not have a Department Criminal History and Background Check completed (previously cited on 8/25/2017).

.009.06.a Use of Previous Criminal History and Background Check: the facility administrator did not have a Department Criminal History and Background Check completed within three years of her hire date.

.009.06.c Use of Previous Criminal History and Background Check: eight employees did not have required State Police background checks completed (previously cited on 8/25/2017 and 2/26/2021).

.215 REQUIREMENTS FOR A FACILITY ADMINISTRATOR: the facility did not have a licensed administrator overseeing day-to-day operations between 10/20/22 and 11/18/22 (previously cited on 2/11/2019).

.215.08.d Written Response to Complaint within Thirty Days: the administrator did not provide written responses to resident complaints about housekeeping, stained carpets, medication issues, and food complaints (previously cited on 8/25/2017 at rule 350.04).

.215.12 Notification to Licensing Agency: Licensing and Certification was not notified of administrator changes and license reinstatement delays.

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a safe, clean, and orderly manner with stained carpets, stored fencing, and exposed rusty metal brackets (previously cited on 2/26/2021 and 10/22/2021).

.305.02.b Current Medication Orders and Treatment Orders: Resident #3 received Percocet on a scheduled basis instead of as needed, diet orders were not followed, resulting in weight loss, and Resident #4 did not receive ordered diet (previously cited on 2/26/2021 and 10/22/2021).

.305.02.c Current Medication Orders and Treatment Orders: several residents did not have signed physician orders for medications, and discontinuation orders were not obtained for unused medications (previously cited on 2/26/2021).

.305.03 Resident Health Status: nursing assessments were not conducted for residents with changes in health status, including wounds, pain, and falls (previously cited on 8/25/2017 and 2/26/2021 and 10/22/2021 at rule 300.02).

.310.01.c Medication Distribution System: medication refrigerator temperatures were frequently out of range from October 2022 through January 2023, and staff did not notice the issue.

.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or services, with outdated or inaccurate information (previously cited on 2/26/2021 and 10/22/2021).

.330.04 Resident Care Records: care records were not maintained properly, documentation errors were not corrected, and refusals of medications were not consistently documented (previously cited on 6/25/2018, 11/27/2018, 2/11/2019 at rule 711.08.c and on 2/26/2021).

.330.04.c.vii Resident Care Records: assessments of residents' conditions were not documented, including vomiting, rashes, blood in stool, and wounds.

.330.09 Resident Admission and Discharge Register: the admission and discharge register was not up-to-date and did not accurately document residents, with conflicting census reports.

.330.13.e Personnel Records: eight employees did not have documentation of required orientation or infection control training, and four employees lacked documentation of required continued training.

.330.13.f Personnel Records: six staff members did not have evidence of current CPR or first aid certifications, though training was completed.

.330.13.g Personnel Records: one medication technician did not have evidence of medication certification course completion (previously cited on 8/25/2017 at rule 645).

.330.14 As Worked Schedules: schedules did not document times staff were at the facility, lacked last names, and were not completed according to rule (previously cited on 8/25/2017 at rule 730.02.a and on 10/22/2021).

.450 REQUIREMENTS FOR FOOD AND NUTRITIONAL CARE SERVICES: the facility did not have a certified food protection manager.

.451.01.c Menu: the weekly menu was posted with the previous week's menu and not updated for seven days.

.451.02 Therapeutic Diets: therapeutic menus signed and dated by a registered dietitian were not available, and residents did not receive ordered therapeutic diets.

.630 TRAINING REQUIREMENTS FOR FACILITIES ADMITTING RESIDENTS WITH A DIAGNOSIS OF DEMENTIA, MENTAL ILLNESS, DEVELOPMENTAL DISABILITY, OR TRAUMATIC BRAIN INJURY: three staff did not have evidence of specialized training for caring for residents with these conditions (previously cited on 2/26/2021 at rule 630.02).

.645.02 Delegation: two of five staff who passed medications were not delegated by the current facility nurse.

.155.01 Relocation agreements: the relocation agreement is for only one location and is not dated or signed; the facility must have at least two relocation agreements reviewed annually.

.330.15 Fire and life safety records: the facility could not provide documentation for Alcohol-Based Hand Rub dispenser testing, fuel-fired heating inspections, fire alarm inspections, and emergency egress and relocation drills.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: transfer grille cut into wall under kitchen sink; stairwell door by room 241 would not fully close and latch; no documented annual fire alarm inspection or sensitivity testing; kitchen ceiling had an unsealed penetration; fire suppression equipment and activation devices blocked from view and access; no placard for Class K fire extinguisher; door to corridor from large records and supply storage would not self-close and latch.

.405.01 Electrical installations and equipment: two open junction boxes in fire suppression riser room and broken outlet cover in staff breakroom.

.405.01.a Electrical installations and equipment: extension cords and multiple plug adapters are prohibited; room 130 was using a 3-1 extension cord to supply power to personal electronics.

.405.02.a Prohibited applications: relocatable power taps are prohibited with medical appliances; room 121 was using a relocatable power tap to supply power to an oxygen concentrator.

.405.03 Medical gases: unsecured oxygen cylinders in rooms 121 and 219; no documented policy and procedure for elimination of ignition sources and misuse of flammable substances.

.405.04 Fuel-fired heating: no documentation for an annual fuel-fired heating inspection for the gas furnaces and fireplace.

.405.05 Natural or man-made hazards: front awning is collapsing due to damage and/or dry-rot; only caution tape present; residents had free access through three sets of French doors; no guards or protectives to limit access.

.410 Requirements for emergency actions and fire drills: only five drills documented; drills did not document evacuation to designated assembly point; only one drill during evening shift; drills did not demonstrate evaluation of participation and areas for improvement.

.161.04 Designated smoking areas: smoking permitted in designated areas but no smoking area was clearly marked or identified; three areas had snorkel-type ashtrays but no markings or signs.

.215.08.g. Identify and Monitor Patterns: the administrator did not monitor patterns of incidents nor develop interventions to prevent recurrences, including repeated falls by Resident #8 (previously cited 2/26/2021).

.260.06. Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe, and orderly manner with soiled carpets, odors, full garbage cans, and soiled laundry in multiple resident rooms (previously cited 2/26/2021).

.300.02. Licensed Nurse: the facility nurse did not complete change of condition assessments for Resident #7's surgical wound and Resident #8's leg wounds (previously cited 2/26/2021).

.305.02.b. Current Medication Orders and Treatment Orders: Resident #1 did not receive Lexapro for 8 days; Resident #8 received incorrect Coumadin doses; the facility LPN failed to monitor doctor orders closely (previously cited 2/26/2021).

.305.06.a. Self-Administered Medication: the facility nurse did not assess Resident #8's ability to self-inject insulin; Resident #5 and Resident #3 self-administered medications without assessments (previously cited 2/26/2021).

.310.04.e. Psychotropic or Behavior Modifying Medication: Residents #7 and #8 did not have required six-month psychotropic medication reviews completed (previously cited 2/26/2021).

.320.01. Use of NSA: NSA's were not updated to reflect current resident needs, including shower assistance and wound care documentation for several residents (previously cited 2/26/2021).

.320.02. Key Elements of the NSA: NSA's lacked required components such as dressing, toileting, money management, night needs, emergency evacuation, transportation, shopping, laundry, and housekeeping for multiple residents (previously cited 2/26/2021).

.320.03. Signature, Date, and Approval of Agreement: NSAs for Residents #1, #4, and #8 were not signed and dated by all responsible parties.

.330.06.c. Behavior Documentation: the facility did not document Resident #4's suicidal thoughts and self-isolation or Resident #6's yelling at other residents; behavior monitoring binder was missing.

.330.14. As Worked Schedules: the facility's as-worked schedules did not include last names or exact times for all staff, including nurses, marketing, business office manager, and receptionist.

.335. REQUIREMENTS FOR INFECTION CONTROL: staff were observed wearing masks below noses and on chins from 10/19/21 to 10/21/21, not following CDC recommendations to prevent Covid-19 transmission.

.645. ASSISTANCE WITH MEDICATIONS: the Business Office Manager was passing medications without a medication assistance certification, mistakenly believing her credentials were valid.

.215.03. Lapse of Administrator: the facility failed to retain a licensed administrator for day-to-day operations for 34 days from 9/9/21 to 10/13/21, including a period when the assigned administrator was unavailable due to COVID-19.

.155.01 Relocation agreements: the facility could not produce any written relocation agreements required to be reviewed annually.

.250.10.a Heating, ventilation, and air-conditioning (HVAC): Marketing Director's office had a portable space heater in use.

.250.10.b Heating, ventilation, and air-conditioning (HVAC): operational gas fireplaces in common areas; main lobby and dining room; did not have safety barriers.

.405.01 Electrical installations and equipment: facility had multiple blocked electrical panels in multiple mechanical/electrical rooms.

.405.02.b Prohibited applications: two extension cords were "daisy chained" together providing power to a TV in the dining room.

.405.02.c Prohibited applications: Business Manager's office had a refrigerator plugged into a Relocatable Power Tap (RPT).

.404 Fire and life safety standards: facility did not maintain compliance with the 2018 edition of NFPA 101, Life Safety Code, Chapter 33, Existing Residential Board and Care Occupancies, Large Facilities as evidenced by lack of annual fire/smoke rated door inspection/testing, blocked exit access corridor reducing width to 33 inches, non-operational emergency light near kitchen, undocumented testing of wall mount Alcohol Based Hand Rub dispensers, blocked Class K fire extinguisher without required placard, ABC fire extinguisher not serviced since November 2019, and missing documentation for weekly and monthly visual inspections of dry suppression system gauges and control valves (previously cited).

.405.04 Fuel-fired heating: facility could not produce documentation for an annual inspection of fuel fired heating systems/devices.

.009.06.c Use of Previous Criminal History and Background Check: one of three staff members requiring a state-only background check did not have evidence a background check was completed.

.215.05 Responsibility for Acceptable Admissions: the facility admitted and retained Resident #5 who required a secure environment.

.215.08.b Investigation within Thirty Days: the facility did not investigate all incidents and accidents for Residents #1, #3, #4, #5, #8, and #10, including falls and an elopement.

.215.08.f Notification to Licensing Agency within One Business Day: the facility failed to notify Licensing & Certification of three reportable incidents involving falls with injuries on 12/12/20, 12/17/20, and 2/13/21.

.215.08.g Identify and Monitor Patterns: the facility did not implement preventive measures after residents had incidents and accidents as listed in 215.08.b.

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a safe, clean, and orderly manner with soiled carpets, odors, dirty walls, torn flooring, dusty vents, peeling paint, missing soffit, broken closet door track, missing heater knob, sink without stopper, and a loud main door.

.300.01 Licensed Registered Nurse (RN): the facility nurse did not complete 90 day assessments for Residents #1, #4, #5, #6, and #8.

.300.02 Licensed Nurse: the facility nurse did not complete change of condition assessments for Residents #7, #8, #5, #1, #4, and #10, and residents who tested positive for COVID-19 were not assessed.

.305.02.b Current Medication Orders and Treatment Orders: Resident #1 was not receiving Ativan as ordered for 23 days; Resident #6 was prescribed 900 mg Gabapentin but only received 100 mg; methotrexate was not given for February; multiple medications were not transcribed to the MAR for Resident #6.

.305.02.c Current Medication Orders and Treatment Orders: Resident #1 did not have signed physician orders and Resident #8 did not have physician orders for morphine.

.305.06.a Self-Administered Medication: two residents (#2 and #6) did not have assessments completed prior to self-administering medications.

.310.04.e Psychotropic or Behavior Modifying Medication: Residents #1, #2, #3, and #6 did not have completed 6 month psychotropic medication reviews.

.319.04 Maladaptive Behaviors: Residents #3 and #5 did not have their behaviors evaluated despite verbal abuse and inappropriate behavior.

.320.01 Use of NSA: Negotiated Service Agreements were not updated to reflect current resident needs including assistance to meals, weight loss prevention, elopement risk, wound and fall prevention, and changes in independence.

.320.02 Key Elements of the NSA: Negotiated Service Agreements lacked required components such as housekeeping, laundry, night needs, and emergency response.

.330.04 Resident Care Records: individual care record documentation was not maintained with all entries current and completed by the person providing care; caregivers reported information to medication technicians who documented electronically.

.330.11.b Dietary Records: the facility created their own menu without documenting substitutions to the dietician approved menu.

.404 Fire and Life Safety Standards: multiple cots and a Hoyer lift were stored in a downstairs stairway hall leading to an emergency exit.

.630.02 Mental Illness: five of seven staff records lacked documentation of mental illness training and management could not provide evidence training was provided.

.520-11 Inadequate Care - Acceptable Admission and Retention: the facility admitted and retained Resident #5 who had moderate cognitive impairment and history of wandering to an unsecured facility, placing the resident at risk for injury or death due to elopement, resulting in inadequate care.

.405.01.b Electrical installations and equipment: multiple plug adapters and extension cords were used improperly in Room 141 and by the Business Office manager.

.405.03 Medical gases: oxygen cylinders were improperly used to support storage, with tables and chairs stored on top of six oxygen cylinders inside a closet in Room 124.

.405.05 Structure, maintenance, equipment to assure safety: exit doors were improperly signed, stair doors did not self-close and latch, fire dampers lacked inspection records, and doors to hazardous areas failed to self-close and latch.

.415.04 Fire alarm smoke detection system service and testing: no record of the last five-year sensitivity testing was found, which is required to be conducted within one year of installation and periodically thereafter.

.415.05 Automatic fire extinguishing system service and testing: a corroded head in the mechanical room required replacement, post indicator valves were unsecured and obscured, weekly and monthly inspection records were missing, and a dry quick opening device was out of service with no record of correction.

.215 Requirements for a facility administrator: the facility did not have a licensed administrator from 1/4/19 when the previous administrator left to 1/28/19 when the current administrator started.

.215.01 Administrator responsibility: the facility did not ensure policies were implemented for 24 days when they did not have an administrator, including failure to protect residents from alleged verbal and physical abuse and failure to complete an investigation.

.350.03 Resident protection: the facility did not protect residents after an allegation of verbal and physical abuse was reported and allowed alleged perpetrators to continue working with residents; a confused resident was found wandering in the parking lot with no interventions to prevent further elopements (previously cited 6/25/18 and 11/27/18).

.711.08.c Care notes: multiple caregiver notes were documented on the same shift report, preventing proper placement in individual residents' records; notes documented elevated temperatures, diarrhea, stomach cramps, wandering, sore throats, fevers, aches, and pains (previously cited 6/25/18 and 11/27/18).

.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not complete an investigation of incidents or accidents between 1/19/18 and 6/22/18 when residents and caregivers made verbal complaints regarding a male caregiver who was inappropriate with female residents on multiple occasions (previously cited 8/25/2017).

.350.03 Resident Protection: the facility did not protect all female residents, including eleven identified female residents, from sexual abuse when they allowed a caregiver to continue to work after allegations of abuse were made known.

.350.05 Facility Notification to Appropriate Agencies: the facility did not notify Law Enforcement and Adult Protection immediately when sexual abuse was reported to staff members and nurses.

.350.06 Corrective Action for Known Allegations: there were no corrective actions implemented to protect all female residents when a male caregiver repeatedly made unwanted sexual advances to at least eleven identified female residents.

.711.08.c Care Notes: between 6/20/18 and 6/25/18, seven staff members and the facility nurse stated they did not complete incident reports or document when they received verbal complaints from eleven female residents who had been subject to sexual advances and sexual touching by a male caregiver.

.215.03 Thirty Day Operation Limit: the facility failed to retain a licensed administrator responsible for day-to-day operations for more than 30 days, operating without a licensed administrator from 10/6/17 until 2/23/18 for a total of 139 days minus 6 days, resulting in a core deficiency.

.510 Requirements To Protect Residents From Abuse: the facility did not protect 11 sampled residents from unwanted and inappropriate sexual advances by a male caregiver, failed to conduct proper investigations, failed to suspend the alleged perpetrator, and failed to notify Adult Protection until 4/11/18, placing 100% of female residents at risk for abuse.

.405.01.b Electrical installations and equipment: extension cords and appliances were plugged into relocatable power taps in multiple locations including the Dining Services Director's office, first floor laundry, and Business Office.

.405.03 Medical gases: unsecured oxygen E-Tanks were found in resident rooms #143 and #130.

.415.02 Fuel-fired heating: no documentation was available for an inspection of the fuel-fired systems.

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

.009.06.c Use of Previous Criminal History and Background Check: one of one current employees required to have Idaho State Police background checks did not have documentation of the check in their records.

.215.09 Identify and Monitor Patterns of Incidents and Accidents: the administrator did not have a method for monitoring patterns of incidents and accidents to develop interventions to prevent recurrences, including verbal altercations between residents and medication errors during June, July, and August.

.225.01 Evaluation for Behavior Management: the facility did not evaluate behavioral symptoms of residents #2, #4, #5, and #6 to develop a behavioral management plan.

.225.02 Intervention: the facility did not develop interventions for each behavioral symptom for residents #2, #4, #5, and #6.

.305.03 Resident Health Status: the facility nurse did not assess or document the condition of resident #1's rash covering her back.

.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not provide two residents' physicians with behavioral updates for psychotropic medication reviews.

.350.01 Notification of Accidents, Incidents, and Complaints: the administrator was not notified of all incidents or accidents, including several incidents/accidents from 6/2/2017 through 6/17/2017.

.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not complete an investigation and written report when resident #2 had numerous name calling incidents with another resident and did not consistently investigate all incidents at the facility.

.350.04 Written Response to Complaint Within Thirty Days: the administrator did not provide a written response to all complainants, verbally responding but not documenting or providing written responses.

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

.600.06.a Sufficient Personnel: the facility nurse was required to work one to two times per week as a nighttime caregiver, leaving insufficient time to perform nursing tasks such as training caregivers and providing oversight.

.645 Assistance With Medication Certification Requirement: one of three caregivers who passed medications did not have documented evidence of passing a medication assistance course.

.711 Ongoing Resident Care Records: resident care notes were not stored in each resident's record due to multiple residents' care notes being documented on a single sheet of paper.

.730.02.a Work Records: the facility work records failed to document the times the administrator, nursing staff, caregivers, and maintenance staff worked at the facility.

.405.01.b. Electrical installations and equipment: maintenance office had relocatable power taps plugged into other power taps creating 'daisy chains' under the desk and behind the microwave; microwave and refrigerator were plugged into relocatable power taps; resident room #143 had an oxygen concentrator plugged into a relocatable power tap.

.350.02 Administrator or designee investigation within thirty days: the administrator did not investigate or write a report of incidents or accidents.

.350.07 Notification of Licensing and Survey Agency within twenty-four hours: the facility did not notify Licensing and Certification of reportable incidents.

.215.03 Thirty day operation limit: the facility operated without a licensed administrator for more than 30 days, from 9/11/15 until 3/2/16, a total of 172 days.

.415.01 Maintenance of Equipment and Systems: sprinkler escutcheons missing near reception desk and maintenance room, no documentation of annual 90-minute emergency lighting testing, multiple exit signs and emergency exit lights not operational near room 202 and dining room.

.405.05 Structure, Maintenance, Equipment to Assure Safety: doors to activities room and laundry room do not self-close properly, maintenance shop door broken deteriorating rating, smoke doors in stairwell do not close properly, door to Residential Care Director's office damaged and not closing properly.

.415.05 Automatic Fire Extinguishing System Service and Testing: multiple loaded sprinkler heads found throughout the facility.

.415.03.d Portable Fire Extinguisher Service and Testing: fire extinguishers in elevator rooms are not inspected monthly and signed off.

.415.01 Maintenance of Equipment and Systems: heat detector in second floor HVAC room appeared damaged and not operational.

.410.02 Fire Drills: fire drills not conducted one per shift per quarter; missing documentation for 1st through 3rd quarter night shifts and 3rd quarter AM and PM shifts.

.405.03 Medical Gases: unsecured oxygen bottle found in room 310.