Inspection Reports for
Brookdale Lewiston

.260.05 Housekeeping and Maintenance Services: the facility failed to maintain cleanliness and safety, with food debris, stains, urine odors, and soiled items observed throughout multiple areas and resident rooms.

.335.02 Standard Precautions: staff did not follow infection control standards, including failure to perform hand hygiene between residents during medication pass and not wearing aprons while serving food after providing care.

39-3322.1 Qualifications and Requirements for Facility Staff: the facility did not provide sufficient staff to meet residents' needs, resulting in delayed laundry, infrequent showers, uncollected trash, and inadequate personal care.

.310.01.f Medication Distribution: residents did not receive medications as ordered, including multiple missed doses and unavailable PRN medications; this deficiency was previously cited.

.305.03 Change in Resident Health Status: nursing assessments were not conducted when residents experienced changes in physical or mental health status, including falls and medication errors.

39-3316 Resident Rights (3) b.iii. Dignity and Respect: the facility failed to protect residents' rights by allowing a visitor to harass residents and staff, interfere with care, enter other residents' rooms, and cause distress and safety concerns.

39-3309.01 Negotiated Service Agreement: the facility failed to update residents' negotiated service agreements to reflect current status, including diet, medication orders, functional abilities, and hospice services.

.009.06.c Use of previous criminal history and background check: three of seven employees did not have an Idaho State Police background check completed because the previous business office coordinator had not been completing all background checks.

.161.04 Designated smoking areas: the facility did not have clearly marked designated smoking areas; the back patio was used but had no smoking sign posted.

.260.06 Housekeeping and maintenance services: the facility was not maintained in a clean, safe, and orderly manner with issues including missing sink plugs, clogged sinks, missing window screens, carpet stains, foul odors, and urine smell in hallways.

.305.02.b Current medication orders and treatment orders: residents' medications were not always available or given as ordered, including discrepancies in morphine dosing and missing scheduled medications; previously cited on 1/8/25.

.305.06 Self-administered medication: residents were not assessed prior to or every 90 days for self-administration capability; assessments were behind schedule; previously cited on 1/13/23.

.310.01.c Medication distribution system: the medication refrigerator containing insulin was not monitored or documented daily, missing documentation for multiple days; previously cited on 1/13/23.

.310.01.g Medication distribution system: four of eleven sampled residents did not have their PRN medications available in the facility, including eye drops and pain relievers.

.310.02 Discontinued and expired prescriptions: the facility did not keep records of drug disposals, lacking documentation of resident name, drug description, amount, reason, method, date, and signatures; previously cited on 1/13/23.

.310.04.e Psychotropic or behavior modifying medication: four of ten residents did not have required six-month psychotropic medication reviews completed; facility was behind on completing reviews; previously cited on 1/13/23.

.319 Comprehensive assessment requirements: two residents did not have comprehensive assessments completed prior to admission; assessments were incomplete.

.330.04.a Resident care records: staff notes and incident reports were not consistently dated or signed by the person writing them, including multiple residents' records.

39-3308 Assessment (4)a Assessments: quarterly nursing assessments were not conducted at least once every 90 days for nine of ten residents sampled; facility was behind and receiving help to catch up.

39-3308 Assessment (4)b Assessments: the facility nurse did not implement all residents' orders; some PRN medication labels and dose frequencies were inconsistent with the medication administration record.

.305.02.b. Current Medication Orders and Treatment Orders: the facility did not ensure residents received medications as ordered; Resident #6 missed fluticasone nasal spray doses on 1/5/25 and 1/7/25, and Resident #7 missed multiple medications during the medication pass observation.

.305.03. Resident Health Status: the facility nurse did not assess residents after changes in mental and health status, including falls and surgery, and change of condition assessments were not completed.

.216.02 Written Agreement: the facility did not provide residents with a complete breakdown of charges, including personal care fees, prior to or on the date of admission.

.320.01 Use of NSA: residents did not consistently receive cares as outlined in their Negotiated Service Agreements, including missed showers, medication doses, housekeeping, and laundry services (previously cited 1/13/2023).

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe, and orderly manner with stained carpets, piles of laundry, trash in hallways, soiled sheets, and urine odors in multiple rooms (previously cited 01/13/2023).

.250.04 Walls and floor surfaces: the vinyl tile floor at the 2nd floor utility mop sink/housekeeping closet is no longer washable and is badly damaged, exposing the plywood sub-flooring below.

.330.15.c Fire and life safety records: the fire extinguisher at the designated smoking area had not been serviced since February 2022.

.404 Fire and life safety standards: the facility did not maintain compliance with NFPA 101, Chapter 33, including overdue sensitivity testing of smoke detectors, lack of documentation for sprinkler pendant testing, and missing emergency lighting test records.

.405.03 Medical gases: one unsecured oxygen cylinder was found in resident room #220.

.410 Requirements for emergency actions and fire drills: drill records lacked required details such as drill description, personnel and resident responses, problems encountered, and recommendations; only location and staff participation were documented.

.405.04 Fuel-Fired Heating: the facility could not produce documentation showing these systems had been inspected in the past 12 months.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: the facility did not document testing/inspection of alcohol-based hand rub dispensers when refilled, emergency lighting testing was not documented, and a corridor door to the kitchen was chocked open and would not self-close and latch properly.

.215.08 Procedures for Investigations: the facility administrator did not complete investigations for incidents or accidents, including multiple resident falls (previously cited 3/15/2019).

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe, and orderly manner with stained carpets, odors, trash, soiled briefs, dirty laundry, and unclean toilets, floors, and furniture.

.300.01 Licensed Registered Nurse (RN): the RN did not perform quarterly assessments for all sampled residents requiring them and was behind on completing these assessments.

.305.02.c Current Medication Orders and Treatment Orders: the facility did not have current, signed medication orders in three of ten sampled residents' records.

.305.06 Self-Administered Medication: the facility nurse did not assess residents to self-administer medications or prescription creams as required.

.310.01.c Medication Distribution System: medication refrigerator temperatures were not monitored and documented daily, with missing logs for November and December 2022 and inconsistent documentation in January 2023.

.310.02 Discontinued and Expired Prescriptions: the facility had an accumulation of unused, discontinued, or expired medications for more than 30 days that had not been destroyed.

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

.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or services, were not updated for condition changes, and did not include night needs or emergency evacuation.

.330.04.c.vii Resident Care Records: resident assessments, including for falls, were conducted but not consistently documented.

.330.13.f Personnel Records: nine staff members' records lacked evidence of current CPR or first aid certifications despite staff confirming training completion.

.330.14 As Worked Schedules: the facility's as-worked schedules did not document dates and times for various staff, and were not completed.

.460.02.d Frequency of Meals: the facility did not offer snacks between meals over multiple days, as confirmed by residents and the administrator.

.645.02 Delegation: six staff who passed medications were not delegated by the facility nurse as required.

.404 Fire and life safety standards for existing buildings: the facility failed to maintain compliance with NFPA 101 and related codes, including missing documentation for smoke detector repairs, quarterly waterflow alarm testing, visual inspections of suppression system gauges, staff training on oxygen safety, inspection of alcohol-based hand rub dispensers, and a rated door that did not self-close and latch.

.405.04 Fuel-fired heating: the facility could not produce documentation showing fuel-fired heating devices had been inspected, serviced, and cleaned in the past 12 months.

.250.04 Walls and floor surfaces: utility closets on both upper and lower levels had badly damaged vinyl floors with missing and broken tiles exposing non-washable sub-flooring.

.405.01 Electrical installations and equipment: observations revealed a daisy chain of a relocatable power tap plugged into an extension cord in the nurse's station and admin office, and a prohibited multi-plug adapter in the storage room adjacent to the sprinkler riser room.

.215.08 Procedures for investigations: the administrator had not investigated an allegation of a caregiver being rough and had not investigated Resident #3's choking incident which resulted in aspiration pneumonia.

.215.09 Identify and monitor patterns of incidents and accidents: interventions were not effective in preventing falls, including 20 falls by Resident #3 in six months, ineffective reminders for Resident #5 with dementia, and unaddressed call light issues for Resident #4.

.305.02.a Current medication orders and treatment orders: the Coumadin order for Resident #7 was not correctly written on medication labels, resulting in incorrect dosing (previously cited 2/9/17).

.305.02.b Current medication orders and treatment orders: medications were not given or available as ordered, including PRN pain medications for Residents #3, #5, #8, and #9, and bowel medications and Flonase for Residents #5, #7, and #9.

.305.03 Resident health status: nursing assessments were not completed after changes in health status, including unstaged pressure ulcer for Resident #1, no assessment after choking incident for Resident #3, and no assessments after multiple falls for Residents #3, #5, #9, and #10, with injuries to Residents #5 and #9 (previously cited 2/9/17).

.350.05 Facility notification to appropriate agencies: the administrator had not notified Adult Protection of abuse allegations on 5/2/18 and 10/27/18.

.711.08.f Care notes: the facility was unable to provide wound clinic documentation for Resident #5 after multiple requests in March 2019 (previously cited 2/9/17).

.415.05 Automatic Fire Extinguishing System Service and Testing: the sprinkler pendant above the kitchen dishwasher is corroded and must be replaced, and there is no record of weekly dry system gauge inspection as required by NFPA 25.

.405.01 Medical Gases: Room 236 oxygen concentrator was plugged into a relocatable power tap not in accordance with NFPA 70, and an open electrical box with exposed wiring was found in the mechanical room adjacent to the library.

.405.05 Structure, Maintenance, Equipment to Assure Safety: stairwell door by room 126 would not fully self-close (corrected on site), and library doors at second floor would not fully self-close leaving a 12 inch gap.

.405.05 Structure, Maintenance, Equipment to Assure Safety: no record for fire damper testing report on site.

.415.04 Fire Alarm Smoke Detection System Service and Testing: no record for five year sensitivity testing on site.

.250.13.l Resident sleeping rooms: resident rooms #111 and #126 did not have closet doors and there was no variance on record for the approval of the doors to be removed.

.415.02 Fuel-fired heating: no documentation could be produced for an annual inspection of the fuel fired systems.

.220.02 Written Agreement: Resident #4's admission agreement was not clear and transparent regarding her $262 monthly charge for cognitive/psychological services; the personal service rate form stated she needed assistance with daily routines including dressing, grooming, showering, bathing and bathroom help, but staff interview, observation, and facility records indicated she did not need assistance in these areas.

.009.01 Criminal History and Background Check: one of ten staff, who required a criminal history and background check, did not have one.

.009.06.c Use of Previous Criminal History and Background Check: three of three current employees, who were required to have Idaho State Police background checks, did not have documentation of those checks in their records.

.250.10 Plumbing: the facility's plumbing was in need of repair; several residents' rooms had toilets that would not flush or would continually run, Resident #8's toilet was leaking and the linoleum around the base was discolored, a resident's bathroom sink had a slow drain, and public restrooms had toilets not flushing properly.

.260.06 Housekeeping Services and Equipment: the facility was not maintained in a clean, safe and orderly manner with worn and stained carpets, fecal matter in toilets and on toilet seats and risers, foul odors, full trash cans of soiled incontinent products, shower drains with black substance buildup, lint accumulation behind washers and dryers, gouges in walls and doors, and cigarette butts disposed behind and inside a planter near the front entrance.

.305.02.a Current Medication Orders and Treatment Orders: Resident #8 was given the incorrect dose of Coumadin from 11/29/16 to 2/8/17.

.305.03 Resident Health Status: the facility nurse did not assess or document the status of residents' wounds; Resident #1 had three wounds not assessed and Resident #9 had open sores that were red, bleeding and areas of excoriation not assessed.

.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not provide Resident #2, #4, #7 and #9's physicians with behavioral updates related to their use of psychotropic medications.

.320.01 Use of Negotiated Service Agreement: NSA's did not clearly describe care needs and services; Residents #1, #3, #5, #7 and #9 did not receive assistance with grooming including removing facial hair and oral hygiene, interventions to prevent skin breakdown were not listed for Residents #1 and #9, Resident #9's preference to sleep in her recliner was not documented, and preventive weight loss measures were not included for Resident #10.

.711.08 Care Notes: the facility did not ensure care notes were signed and dated by the person providing care and services and did not ensure this information was included in the resident's record.

.711.08.e Care Notes: caregivers did not document when they had notified the nurse of residents' changes of condition; Resident #9 had open sores and Resident #6's blood pressure was not within normal limits.

.711.08.f Care Notes: outside agency care notes were not available in Resident #1's record regarding the status of her wounds or interventions to prevent further skin breakdown.

.250.01 Building Character: multiple penetrations were found including a hole in the records storage closet wall by mop sink, a circular hole under stairs at a pipe, penetrations at sprinkler heads in resident room 226 and upper floor laundry, and a gap at the mechanical room ceiling where the wall and ceiling meet.

.410.02 Fire Drills: missing fire drills for first quarter second shift and third quarter second shift.

.405.05 Structure, Maintenance, Equipment to Assure Safety: self-closing doors at the kitchen and upper stairs (door to stairwell) did not close and latch when the self-closing mechanism was activated.

.415.01 Maintenance of Equipment and Systems: smoke detector in main level laundry was hanging down from the ceiling with exposed wires; escutcheon rings at front entry, in front of fireplace, and administrator's office needed to be pushed back up to seal penetrations at the ceiling.