Inspection Reports for
Brookdale Pocatello
1501 Baldy Ave, Pocatello, ID 83201, United States, ID, 83201
Back to Facility Profile15 Reports
Inspection Report — Jan 8, 2026
Follow-Up
Date: Jan 8, 2026
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A health care non-core deficiency follow-up survey was conducted to evaluate previously cited deficiencies and ensure compliance with licensing requirements.
Findings
The facility's Registered Nurse did not have an active license during the survey period, resulting in unlicensed staff completing or failing to complete required assessments and medication implementations. Multiple deficiencies were previously cited and remain uncorrected, including incomplete change of condition assessments, self-administered medication evaluations, comprehensive assessments, personnel records, quarterly assessments, and medication order implementations.
Deficiencies (6)
.305.03 Change in Resident Health Status: the facility's RN did not have an active license during the survey period, resulting in changes in resident health status being completed by unlicensed or non-delegated staff or not completed at all, including multiple residents with falls and unassessed conditions (previously cited 7/24/2025).
.305.06.b Self-Administered Medication: residents who self-administer medications were not evaluated every 90 days by a licensed nurse; assessments were completed by an unlicensed RN during the RN's expired license period (previously cited 7/24/2025).
.319 Comprehensive Assessment Requirements: nursing pre-admission comprehensive assessments were completed by an unlicensed RN during the RN's expired license period (previously cited 7/24/2025).
.330.13.d Personnel Records: the facility did not maintain a current copy of the RN's license, which expired on 8/31/2025; management became aware of the expiration the previous week.
39-3308 Assessment (4)a Assessments: quarterly assessments were not completed by a licensed nurse for 7 of 10 sampled residents; some assessments were completed by an unlicensed RN or non-delegated LPN during the RN's expired license period (previously cited 7/24/2025).
39-3308 Assessment (4)b Assessments: the facility nurse did not review and implement new medication orders; all sampled residents' medications were implemented by unlicensed or non-delegated staff during the RN's expired license period (previously cited 7/24/2025).
Inspection Report — Jul 24, 2025
Routine
Date: Jul 24, 2025
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A health care licensure and follow-up survey was conducted to assess compliance with state regulations and identify deficient practices.
Findings
The facility was found to have multiple deficiencies including housekeeping issues, incomplete resident assessments, medication management problems, inadequate behavior documentation, and fire and life safety record deficiencies. The administrator and staff confirmed many of these issues and some were previously cited.
Deficiencies (19)
.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe, and orderly manner with cat emesis stains on carpet, worn dining chairs, stained and frayed carpeting creating trip hazards, and a scuffed exit door needing repainting.
.305.03 Resident Health Status: the facility nurse did not assess residents after changes in mental and health status, including falls and ulcers, and change of condition assessments were not completed.
.305.06.b Self-Administered Medication: residents self-administering medications were not evaluated every 90 days to ensure capability, with assessments not completed as required.
.310.02.d Discontinued and Expired Prescriptions: documentation for medication destruction was incomplete and did not include the method of destruction for resident medications.
.310.04.a Psychotropic or Behavior Modifying Medication: the facility did not attempt non-drug interventions prior to requesting psychotropic medications for residents, using medications as a first resort.
.310.04.e Psychotropic or Behavior Modifying Medication: four of five residents requiring six-month psychotropic medication reviews did not have them completed (previously cited 10/19/2022).
.319 Comprehensive Assessment Requirements: comprehensive assessments were not completed prior to admission for several residents.
.330.04 Resident Care Records: residents' care records were not maintained with current entries by caregivers; behavior plans lacked documented notes and tracking prior to 7/3/25.
.330.06.b Behavior Documentation: the facility did not develop behavior plans including at least one intervention specific to each maladaptive behavior, with plans still in development.
.330.06.c Behavior Documentation: the facility did not track behaviors with documentation of date, time, specific behavior, interventions used, and effectiveness prior to 7/3/25.
.330.15 Fire and Life Safety Records: the facility could not provide documentation that sprinkler dry system gauges were replaced after failed inspections.
.330.15.c Fire and Life Safety Records: monthly inspections of portable fire extinguishers were not completed by the former maintenance supervisor.
.404 Fire and Life Safety Standards for Existing Buildings Licensed for Seventeen or More Residents and Multi-Story Buildings: Life Safety Code standards were not met due to failed dry system pressure gauge inspections without documentation of replacement and passing inspection.
.405.04 Fuel-Fired Heating: the facility had a gas fireplace and other fuel-fired heating devices that were not inspected annually.
.410 Requirements for Emergency Actions and Fire Drills: fire drills were not conducted as required, with only four drills completed and none during night sleeping hours.
39-3308 Assessment (4)a Assessments: quarterly nursing assessments were not conducted at least once every 90 days for all sampled residents.
39-3308 Assessment (4)b Assessments: the facility nurse did not review and implement new orders correctly, including transcription errors and failure to implement scheduled medications.
39-3321.2.e Qualifications and Requirements of Administrator: the administrator did not complete investigations and written reports within 30 days of accidents and incidents involving resident falls.
39-3321.4 Qualifications and Requirements of Administrator: the administrator did not implement immediate corrective action to prevent recurrence of problems related to resident falls.
Report Facts
date: 12/7/24
date: 5/12/25
date: 1/3/25
date: 1/14/25
date: 1/28/25
date: 2/25/25
date: 4/25/25
date: 5/26/25
count: 4
count: 10
Inspection Report — Feb 7, 2024
Complaint Investigation
Date: Feb 7, 2024
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A health care complaint investigation was conducted to determine compliance with regulations and address reported concerns.
Findings
Four deficiencies were identified related to corrective actions for resident falls, medication distribution system security, updating residents' negotiated service agreements, and staff delegation for medication administration.
Deficiencies (4)
.215.08.e. Corrective Action: the administrator did not ensure effective corrective actions were put into place to prevent recurrence of incidents, including multiple falls by residents with inadequate interventions.
.310.01.a. Medication Distribution System: medications were observed left unattended on medication carts and in the nurse's office with the door left open, and facility nurses were unaware of this practice.
.320.08. Periodic Review: residents' negotiated service agreements were not updated to reflect significant changes in health status, including hospice care and increased assistance needs.
.645.02. Delegation: eight staff members who passed medications were not delegated by the current facility nurse, who had worked less than two weeks and had not completed delegation; previously cited on 10/19/2022.
Inspection Report — Dec 8, 2022
Life Safety
Date: Dec 8, 2022
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A fire life safety and sanitation licensure survey was conducted to assess compliance with fire and life safety standards and electrical installations.
Findings
Six deficiencies were found related to fire and life safety standards, electrical installations, prohibited applications, medical gases, and fire and life safety records. Several issues were repeat citations and included unsealed holes, exposed wiring, unsecured oxygen cylinders, and missing documentation for inspections.
Deficiencies (5)
.404 Fire and life safety standards for existing buildings: mechanical room had an unsealed hole in the one-hour separation to the attic, smoke detector was removed leaving exposed wiring, 28 smoke detectors failed with no replacement documentation, emergency lighting testing was undocumented for several months, and no documentation for last full trip of the dry system (previously cited).
.405.01 Electrical installations and equipment: maintenance office had an open electrical panel exposing wiring, and boiler panel cover was off exposing wiring.
.405.02.c Prohibited applications: relocatable power taps were used to supply power to a mini-fridge in Room 28 (corrected on site).
.405.03 Medical gases: no documented policy for elimination of ignition sources, resident with respiratory therapy possessed smoking materials, volumes of stored medical gases exceeded 300 cubic feet without adequate storage and ventilation, and unsecured oxygen cylinders in Room 70.
.330.15 Fire and life safety records: missing documentation for first and second quarter fire suppression system inspections.
Report Facts
date: 12/08/2022
measurement: 24 inch by 24 inch
count: 28
count: 2
measurement: 10 inch by 10 inch
count: 4
measurement: 484
measurement: 316
Inspection Report — Oct 19, 2022
Routine
Date: Oct 19, 2022
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A health care licensure and follow-up survey with complaint investigation was conducted to assess compliance with state regulations and investigate complaints.
Complaint Details
The complaint investigation was combined with the routine survey; the complaint involved missing money from a resident's room and failure to report abuse.
Findings
Six deficiencies were found related to background checks, failure to report abuse, HVAC issues, medication storage, psychotropic medication reviews, and delegation of medication administration.
Deficiencies (6)
.009.06.c Use of previous criminal history and background check: three of six employees did not have required state police background checks completed, confirmed by the business office coordinator.
.215.07 Notification to Adult Protection and Law Enforcement: the administrator failed to report all allegations of abuse, neglect, and exploitation; money missing from Resident #4's room was not reported to Adult Protection.
.250.10 Heating, Ventilation, and Air-Conditioning (HVAC): the facility did not have working heating and air conditioning in all residents' rooms, with temperatures ranging from 66.9 to 83.3 degrees F causing discomfort.
.310.01.c Medication Distribution System: the medication refrigerator containing insulin was not maintained within the required temperature range; temperatures were below 38 degrees F nine times with no corrective action.
.310.04.e Psychotropic or Behavior Modifying Medication: Residents #2, #4, and #5 were taking psychotropic medications longer than six months without required six-month medication reviews; staff were unaware of this requirement.
.645.02 Delegation: five staff who passed medications were not delegated by the current facility nurse; the nurse confirmed delegations had not been completed.
Report Facts
temperature: 66.9
temperature: 68.6
temperature: 83.3
count: 3
count: 9
count: 3
count: 5
count: 6
Inspection Report — Jul 26, 2021
Life Safety
Date: Jul 26, 2021
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A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable fire and life safety standards.
Findings
Six deficiencies were identified related to fire and life safety standards, medical gases, prohibited appliance use, fuel-fired heating inspection, and hood cleaning documentation.
Deficiencies (5)
.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documented testing for manually activated Alcohol-Based Hand Rub dispensers upon refill, sprinkler pendant above kitchen grill loaded with hard water deposits, and no documentation for dry system full flow trip since May 2017.
.405.03 Medical Gases: oxygen storage in room 51 and breakroom exceeded 300 cubic feet and was not provided with required ventilation as outlined in NFPA 99 and Chapter 9.
.405.02.c Prohibited Applications: appliances are prohibited for power strips; a microwave was plugged into a power strip in room 43.
.405.04 Fuel-Fired Heating: no documented fuel-fired heating inspection for gas fireplace since 2019.
.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documentation for 1 of 2 hood cleaning/inspections in the past twelve months in accordance with NFPA 96, Chapter 11, Section 11.4.
Report Facts
year: 2017
year: 2019
quantity: 300
quantity: 36
quantity: 42
quantity: 1575
count: 2
timeframe: 12
Inspection Report — Jan 9, 2020
Life Safety
Date: Jan 9, 2020
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A Fire Life Safety Survey was conducted to assess compliance with fire safety and sanitation licensure requirements.
Findings
Eight non-core deficiencies were identified related to accessibility, medical gases, policy content, fire drills, fire alarm testing, and fire extinguishing system maintenance. No core deficiencies were cited in the report.
Deficiencies (8)
.250.07 Accessibility for Persons With Mobility and Sensory Impairments: resident rooms lacked audible/visible notification devices; no current resident hearing loss assessments; 20% of residents identified with excessive hearing loss and six residents could not hear loud conversation; facilities must provide visual notification devices to meet fire alarm notification needs.
.405.01 Medical Gases: relocatable power taps (RPTs) were misused with multiple plug adapters and microwaves plugged into RPTs; one issue was corrected on site.
.405.03 Medical Gases: oxygen storage in room 60 exceeded 300 cu. ft. inside a closet not within a 1-hour enclosure and filled with combustibles including clothing.
.161.03 Policy Content: smoking was conducted in the presence of oxygen with a resident observed smoking near an O2 cylinder; required no-smoking signs within 10 feet of entrances, exits, windows, and air intakes were missing.
.405.05 Structure, Maintenance, Equipment to Assure Safety: towels placed in front of two exits created tripping hazards; corrected on site.
.410.02 Fire Drills: fire drills were not performed on each shift each quarter as required; day shift fire drills lacked audible activation; no fire drill was conducted on the evening shift of the second quarter.
.415.04 Fire Alarm Smoke Detection System Service and Testing: no record of sensitivity tests performed within the past five years as required by NFPA 72; testing schedule and documentation were not maintained.
.415.05 Automatic Fire Extinguishing System Service and Testing: painted fire suppression system head in kitchen obstructed; sprinkler in walk-in cooler described as wet and not replaced or tested per standards; must be replaced and installed to protect against freezing.
Report Facts
: 20
: 6
: 660
: 1
: 5
Inspection Report — Dec 4, 2019
Routine
Date: Dec 4, 2019
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A health care licensure and follow-up survey was conducted to assess compliance with regulations.
Findings
Three deficiencies were found related to policies of acceptable admissions, administrator investigations, and facility notifications to appropriate agencies.
Deficiencies (3)
.152.05.a. Policies of Acceptable Admissions: the facility did not arrange for the private caregiver services Resident #1 was receiving and did not ensure the caregiver had a criminal history background check; the caregiver assisted Resident #1 to get dressed and changed incontinent briefs on 12/2/19.
.350.02. Administrator or Designee Investigation Within Thirty Days: the administrator did not complete investigations for all incidents, accidents or complaints; four residents complained of money missing from their rooms between 2/11/19 and 11/15/19 and no investigation was completed (previously cited 2/12/2016).
.350.05. Facility Notification to Appropriate Agencies: the facility administrator did not notify law enforcement of four residents missing various amounts of money between 2/11/19 and 11/15/19.
Report Facts
date_range: 2019-02-11 to 2019-11-15
date: Dec 2, 2019
date: Feb 12, 2016
Inspection Report — Jan 31, 2019
Life Safety
Date: Jan 31, 2019
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A Fire Life Safety Survey was conducted at Brookdale Pocatello on January 31, 2019.
Findings
Non-core issue deficiencies were identified related to missing breaker covers, prohibited extension cords and multiple plug adapters, lack of fire damper testing records, and missing records for fire extinguishing system testing.
Deficiencies (4)
.405.01 Medical Gases: missing breaker number 23, panel P3A, without blank cover; O2 concentrator into RPT Room 86 (corrected on site 1/31).
.405.01.b Electrical Installations and Equipment: prohibited extension cords and multiple plug adapters found in Rooms 30, 32, 45, and Kitchen, including non-grounded cords and daisy-chained power taps (some corrected on 1/31).
.405.05 Structure, Maintenance, Equipment to Assure Safety: no record of fire damper testing within last four years; recent kitchen swamp cooling unit replacement lacks permits or mechanical inspection records.
.415.05 Automatic Fire Extinguishing System Service and Testing: no record of last 10 year replacement or testing of dry barrel pendants and dry system heads as required by NFPA 25.
Inspection Report — Apr 12, 2018
Complaint Investigation
Date: Apr 12, 2018
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A health care complaint investigation survey was conducted to evaluate compliance with regulations.
Findings
One non-core deficiency was found related to resident record retention; records were not preserved for at least 3 years as required.
Deficiencies (1)
.330.02 Resident record retention: residents' records were not preserved for at least 3 years when the newly hired administrator could not locate previous incident and accident reports and nursing assessments.
Inspection Report — Oct 12, 2017
Life Safety
Date: Oct 12, 2017
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A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety standards.
Findings
Six non-core deficiencies were found related to medical gases, structure maintenance, exit door locks, fire alarm smoke detection, and automatic fire extinguishing system service and testing.
Deficiencies (6)
.405.01 Medical Gases: exposed 220 Volt power for A/C unit in attic with covers removed during summer, open electrical box with exposed wiring above ceiling at resident units, and multiple appliances plugged into relocatable power taps in various rooms.
.405.03 Medical Gases: oxygen transfilling over linoleum instead of concrete or stainless steel pan, non-operational fan to oxygen transfilling room, insufficient oxygen signage in the facility, and unsecured oxygen in multiple resident rooms.
.405.05 Structure, Maintenance, Equipment to Assure Safety: attic spaces used for combustible storage, fire/smoke doors in attic not self-closing, laundry door missing self-closing device, no record of electric smoke damper testing within four years, ABHR dispensers over ignition sources, and unsealed penetrations in smoke/fire rated construction.
.405.07 Exit Door Locks: non-single operational locking arrangements at common bath, main offices serving residents, and laundry door marked 'storage'.
.415.04 Fire Alarm Smoke Detection System Service and Testing: smoke detectors not shown as tested on annual fire alarm report, with only hallway detectors tested and none in resident rooms.
.415.05 Automatic Fire Extinguishing System Service and Testing: corroded sprinkler pendants in janitor closet and kitchen, with some sprinklers loaded with grease and lint; corroded or loaded sprinklers must be replaced per NFPA 25 standards.
Inspection Report — May 25, 2017
Routine
Date: May 25, 2017
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with regulations and identify any deficient practices.
Findings
Seven deficiencies were identified related to incident monitoring, medication management, resident health assessments, medication destruction documentation, psychotropic medication reviews, negotiated service agreements, and medical gas safety.
Deficiencies (7)
.215.09 Identify and monitor patterns of incidents and accidents: the facility did not implement interventions to prevent recurrences despite multiple thefts since December 2016 and Resident #2 having at least thirteen falls in five months.
.305.02.b Current medication orders and treatment orders: residents were not assisted with medications according to physician orders, including missed acid-reflux medication for 24 days, wrong doses, missing PRN medications, and outdated medication lists.
.305.03 Resident health status: nursing assessments were not conducted when residents experienced changes in physical or mental health, including choking, edema, wounds, infections, and significant weight loss.
.310.02.f Unused medication: at least fifty entries in the medication destruction log were not signed by two parties involved in the destruction.
.310.04.e Psychotropic or behavior modifying medication: psychotropic medication reviews were not conducted on Residents #2 and #5.
.320.01 Use of negotiated service agreement: service agreements were not updated to reflect residents' specific needs, including behaviors, wound prevention measures, and accurate description of outside service providers.
.405.03 Medical gases: staff were transfilling oxygen in a resident's room that did not meet NFPA Standard 99 requirements, such as non-combustible flooring.
Inspection Report — Aug 26, 2016
Life Safety
Date: Aug 26, 2016
Visit Reason
A Fire Life Safety Survey was conducted to evaluate the facility's compliance with fire safety and sanitation licensure requirements.
Findings
Non-core deficiencies were identified related to building penetrations, plumbing water temperatures, medical gases, electrical installations, fuel-fired heating inspections, and fire extinguisher service and testing.
Deficiencies (9)
.250.01 Building Character: multiple penetrations were found in the kitchen area, kitchen office, kitchen mop sink closet, and mechanical room ceiling with gaps around piping.
.250.10 Plumbing: water temperatures throughout the SE Wing were found to be above the maximum temperature of 120 degrees.
.405.01 Medical Gases: appliances were plugged into relocatable power taps in multiple rooms and electrical panels were blocked in the kitchen mop sink closet and marketing office.
.405.01.b Electrical Installations and Equipment: daisy chaining of relocatable power taps was found in the mechanical room and activities room.
.405.03 Medical Gases: unsecured oxygen tanks were found in resident rooms 88, 70, and the nurses office.
.405.05.f Structure, Maintenance, Equipment to Assure Safety: a portable space heater was in use in resident room 42.
.415.02 Fuel-Fired Heating: the fuel-fired heating systems had not been inspected annually; last inspection was on 1-15-2015.
.415.03 Portable Fire Extinguisher Service and Testing: multiple fire extinguishers were found installed above 60 inches throughout the facility.
.415.05 Automatic Fire Extinguishing System Service and Testing: no record was found for quarterly fire suppression inspection testing for the last quarter of 2015 and the five-year internal inspection was overdue; last inspection was on 8-17-2011.
Report Facts
date: Jan 15, 2015
date: Aug 17, 2011
temperature: 120
count: 3
count: 1
count: 1
count: 3
count: 1
count: 1
count: 7
length: 5 feet
length: 18 inches
length: 3/4 inch
Inspection Report — May 18, 2016
Routine
Date: May 18, 2016
Visit Reason
A health care core deficiency follow-up survey was conducted to evaluate correction of previously cited deficiencies and investigate complaints.
Complaint Details
The survey included a complaint investigation component, but no specific complaint details or substantiation were provided in the report.
Findings
Five deficiencies were found related to facility administration, negotiated service agreements, complaint responses, medication documentation, and medication assistance.
Deficiencies (5)
.215 Requirements For A Facility Administrator: the administrator's license was not current.
.320.01 Use of Negotiated Service Agreement: the facility did not implement Resident #1's NSA; oral care was not provided as documented.
.350.04 Written Response to Complaint Within Thirty Days: the administrator did not provide a written response to all complainants within 30 days.
.711.11 Medications Not Taken: facility staff did not always document why medications were not given or taken by residents.
.305.02.b Current Medication Orders and Treatment Orders: residents were not assisted with medications as per their physicians' orders; Resident #1's Coumadin was not given as ordered.
Inspection Report — Feb 12, 2016
Complaint Investigation
Date: Feb 12, 2016
Visit Reason
A health care complaint investigation survey was conducted to evaluate the facility's compliance with regulations and to investigate complaints regarding resident care and safety.
Complaint Details
The complaint investigation focused on the facility's failure to provide adequate care and supervision, including incidents of elopement, inadequate behavior management, and inappropriate admissions. The complaint was substantiated based on the findings.
Findings
The facility was found deficient in multiple areas including failure to evaluate and manage resident behaviors, inadequate housekeeping, failure to assess residents properly, and failure to investigate complaints. Core deficiencies included failure to provide a safe living environment for a resident with a history of elopement and admitting a resident without the capability to provide appropriate care.
Deficiencies (10)
.215.05 Responsibility for Acceptable Admissions: the administrator admitted a resident whose social and emotional needs were not compatible with other residents.
.225.01 Evaluation for Behavior Management: the facility did not evaluate Resident #1's behaviors.
.225.02 Intervention: the facility did not develop interventions for each of Resident #1's behaviors including exit seeking, wandering into female residents' rooms, hitting at staff, urinating and defecating in inappropriate places.
.260.06 Housekeeping Services and Equipment: the facility was not maintained in a clean and orderly manner with issues including worn carpeting, dirty bathrooms, clogged sinks, cigarette butts, feces on shower chair and toilet riser, cracked toilet riser, off-track closet door, strong odors, unmade beds, torn box spring, yellow caulking, and a spongy floor area.
.300.01 Licensed Professional Nurse (RN): the facility RN did not assess Residents #1 or #4 and did not assess Resident #2 every 90 days.
.305.03 Resident Health Status: the facility RN did not assess the status of Resident #2 and #4's wounds to ensure they were showing improvement biweekly.
.320.01 Use of Negotiated Service Agreement: the facility did not develop an NSA for Resident #4 and did not update NSAs to describe the services residents required, such as Resident #2's wound preventative measures.
.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not investigate or respond in writing to a complaint regarding a family being charged for medications ordered by the facility but provided by hospice.
.350.07 Notification of Licensing and Survey Agency Within Twenty-Four Hours: the facility did not report all incidents (elopements) to Licensing and Certification.
.520-09 Inadequate Care - Safe Living Environment: the facility failed to provide a safe living environment for Resident #2 who had a history of elopement and admitted Resident #1 without the capability or capacity to provide appropriate care, resulting in inadequate care.
Report Facts
: 68
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