5 Reports
Inspection Report — Sep 15, 2026
Complaint Investigation
Date: Sep 15, 2026
Visit Reason
A health care complaint investigation survey was conducted due to concerns about deficient practices at the facility.
Complaint Details
The complaint investigation focused on medication errors, resident care documentation, staffing adequacy, and secure environment concerns. The deficiencies found substantiate the complaint.
Findings
The facility was found to have multiple deficiencies including failure to provide a secure environment for a resident with dementia, medication distribution errors, incomplete resident care records, insufficient staffing in detached buildings, failure to implement resident orders, outdated negotiated service agreements, and lack of investigations into medication errors. Several deficiencies were previously cited.
Deficiencies (8)
.250.10 Secure Environment: the facility did not provide a secure environment for Resident #7 with dementia; the exterior courtyard was unsecured and residents could exit unsupervised.
.310.01.f Medication Distribution: residents did not receive medications as ordered, including missed doses and incorrect frequency of medication administration; the current nurse lacked access to the medication system.
.330.03 Resident Care Records: the facility lacked documentation for Resident #2 regarding hospital visits and return dates; staff and administrator were unaware of these details.
.330.03.a.i Resident Care Records: the facility did not maintain current physician orders in Resident #2's record; orders had to be requested from the pharmacy.
.600.02 Detached Buildings or Units: the facility did not ensure sufficient staffing in all buildings at all times, resulting in unattended buildings during staff shift switches; this was confirmed by observations and schedule reviews (previously cited 10/8/25).
39-3308 Assessment (4)b Assessments: the facility nurse did not implement all residents' orders due to lack of nursing staff and access to the medication system; new orders were implemented by the resident care coordinator (previously cited 10/8/25).
39-3309.01 NEGOTIATED SERVICE AGREEMENT: residents' NSAs were not updated to reflect current status, including declines in abilities and hospice services without specific instructions (previously cited 10/8/25).
39-3321.2.c Qualifications and Requirements of Administrator: the facility did not ensure investigations were completed for medication errors involving Resident #3, including errors that led to hospitalization; the nurse was unaware of the second error and did not complete investigations (previously cited 10/8/25).
Report Facts
: 17
: 12
: 26
: 23
: 2
: 5
Inspection Report — Oct 8, 2025
Routine
Date: Oct 8, 2025
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with Idaho RALF regulations and identify any deficiencies.
Findings
The facility exhibited multiple non-core deficiencies including failure to provide necessary resources, unsafe storage of toxic chemicals, medication errors, incomplete resident assessments, inadequate documentation, and insufficient staffing and training. Repeat deficiencies from prior surveys were noted, and the facility failed to meet food safety and fire life safety standards.
Deficiencies (26)
.001.03. General Provider Responsibilities: the Licensee failed to provide necessary resources resulting in multiple non-core deficiencies including unsecured toxic chemicals, incomplete assessments, medication monitoring failures, outdated service agreements, infection control lapses, lack of certified food protection manager, insufficient staff training, and unattended buildings.
.260.07. Toxic Chemicals: toxic chemicals were stored in two unlocked cabinets accessible to cognitively impaired residents on multiple occasions (previously cited 1/12/2024).
.305.02.b. Current Medication Orders and Treatment Orders: the facility failed to ensure residents received medications as ordered, including missed doses and incorrect dosages; pharmacy and insurance issues were noted (previously cited 1/12/2024).
.305.03. Resident Health Status: residents were not assessed by a nurse after changes in mental or physical health status, despite multiple falls and injuries (previously cited 1/12/2024).
.310.01.c. Medication Distribution System: the facility did not monitor or document daily medication refrigerator temperatures consistently over the last three months (previously cited 1/12/2024).
.310.02. Discontinued and Expired Prescriptions: the facility did not keep records of drug disposals or document destruction methods and had an accumulation of unused medications.
.310.04.e. Psychotropic or Behavior Modifying Medication: residents on psychotropic medications for longer than six months did not have required medication reviews completed (previously cited 1/12/2024).
.320.01. Use of NSA: residents' negotiated service agreements did not clearly reflect needs or services, missing key elements and failing to document private duty caregivers and maladaptive behaviors; updates were needed.
.320.08. Periodic Review: negotiated service agreements were not updated to reflect significant health changes such as pressure injuries and use of pressure alarms (previously cited 1/12/2024).
.330.06.a. Behavior Documentation: the facility did not evaluate behaviors of residents exhibiting refusals of care, aggression, or hitting and scratching staff (previously cited 11/19/2024).
.330.06.b. Behavior Documentation: the facility did not develop interventions after residents engaged in maladaptive behaviors (previously cited 1/12/2024).
.330.06.c. Behavior Documentation: the facility did not document interventions used or their effectiveness after residents engaged in maladaptive behaviors; progress notes lacked intervention documentation (previously cited 11/19/2024).
.330.13.e. Personnel Records: staff files lacked documentation of required orientation and continued training hours.
.335.02. Standard Precautions: medication technicians administered medications without hand hygiene between residents; staff failed to wear aprons during meal prep after providing care (previously cited 1/12/2024).
.404. Fire and Life Safety Standards: the facility missed the kitchen hood suppression semi-annual inspection and cleaning report; last inspection was in 2023 and was not completed.
.450. Requirements for Food and Nutritional Care Services: the facility failed the kitchen inspection on 10/6/25 and lacked a Certified Food Protection Manager (previously cited 1/12/2024).
.600.02. Detached Buildings or Units: buildings were left unattended for short periods during night shifts due to insufficient staffing and medication technician role limitations.
.600.04.b. Sufficient Personnel: five of eight employees lacked current First Aid and CPR certifications; staff worked alone during night shifts (previously cited 1/12/2024).
.645.02. Delegation: staff passing medications were not delegated by a current facility nurse; no re-delegation occurred after previous nurse departure (previously cited 1/12/2024).
39-3308 Assessment (1) Initial Assessments: the facility nurse did not conduct assessments within 30 days prior to admission for several residents.
39-3308 Assessment (4)a Assessments: quarterly nursing assessments were not conducted at least once every 90 days for sampled residents; prior nurse was unable to complete required assessments.
39-3308 Assessment (4)b Assessments: the facility nurse did not implement all residents' orders; orders were implemented only when no nurse was available.
39-3321.2.c. Qualifications and Requirements of Administrator: the facility did not ensure investigations were completed for multiple resident injuries and incidents.
39-3321.4. Qualifications and Requirements of Administrator: the administrator did not immediately implement corrective actions to prevent recurrence of incidents such as resident falls.
39-3321.5. Qualifications and Requirements of Administrator: the facility did not notify the licensing agency within one business day of reportable incidents involving resident injuries.
.330.04.a. Resident Care Records: facility staff documentation was not completed by the staff making observations; medication technicians charted for caregivers including incident witnessing.
Report Facts
date: Oct 6, 2025
date: Oct 7, 2025
count: 3
count: 7
count: 8
count: 2
count: 5
count: 4
count: 6
count: 7
Inspection Report — Nov 19, 2024
Complaint Investigation
Date: Nov 19, 2024
Visit Reason
A complaint investigation was conducted regarding the facility's handling of Resident #5's behaviors.
Complaint Details
The complaint concerned the facility's failure to properly evaluate and track Resident #5's maladaptive behaviors, including physical aggression, intrusive wandering, and refusals of care. These issues were substantiated by the findings.
Findings
Two deficiencies were found related to behavior documentation. The facility failed to evaluate and track Resident #5's physical aggression, intrusive wandering, and refusals of care as required by rule.
Deficiencies (2)
.330.06.a Behavior Documentation: the facility did not evaluate Resident #5's behaviors of physical aggression, intrusive wandering, and refusals of care; the administrator stated Resident #5 had not been adequately evaluated.
.330.06.c Behavior Documentation: the facility did not track ongoing behaviors or the effectiveness of interventions after Resident #5 engaged in maladaptive behaviors; the administrator acknowledged behaviors were not tracked according to rule.
Inspection Report — Oct 10, 2024
Life Safety
Date: Oct 10, 2024
Visit Reason
A fire life safety and sanitation licensure survey was conducted to evaluate compliance with fire safety and emergency procedures.
Findings
Six deficiencies were identified related to emergency planning, fire suppression system maintenance, emergency lighting, walking surface hazards, and emergency drill procedures.
Deficiencies (3)
.155.02.b. Written Procedures: the emergency plan did not document or provide the location of the area of assembly for resident evacuation.
.403. Fire and life safety standards for existing buildings: non-sprinklered combustible overhangs exceeding four feet in depth were identified; fire suppression system pendants were obstructed by paint, corrosion, or loading and require replacement; stacked combustible storage obstructed pendants (corrected on site); emergency lighting was non-operational at Bldg 3; and a large section of concrete was missing at the front door creating a tripping hazard.
.410. Requirements for emergency actions and fire drills: emergency egress and relocation drills did not identify the location of the area of assembly; drills did not actually evacuate residents on each occasion; and drills were not evaluated for performance or areas of improvement.
Inspection Report — Jan 12, 2024
Original Licensing
Date: Jan 12, 2024
Visit Reason
A health care initial licensure survey combined with a complaint investigation was conducted to assess compliance with licensing requirements and investigate complaints.
Complaint Details
The complaint investigation was combined with the initial licensure survey; specific complaint details were not stated in the report.
Findings
Multiple deficiencies were found including incomplete criminal background checks, lack of consistent activities for residents, failure to conduct timely investigations and corrective actions for resident falls, incomplete admission agreements after ownership change, maintenance and housekeeping issues, unsafe storage of toxic chemicals, medication administration and monitoring failures, inadequate behavior and infection control plans, insufficient staffing and training, and food service violations.
Deficiencies (19)
.009.01 Criminal History and Background Check: three of seven employees did not have Department Criminal History and Background Checks completed.
.151 Activity Requirements: no activities were offered in the memory care unit and activities were inconsistently offered in other houses.
.215.08.b Investigation within Thirty Days: investigations were not conducted within 30 days for multiple resident falls including a fracture.
.215.08.e Corrective Action: corrective actions were not implemented to prevent recurrence of falls and injuries for several residents.
.216.02 Written Agreement: residents did not receive new admission agreements after a change of ownership.
.260.06 Housekeeping and Maintenance Services: facility was not maintained clean and safe with dirty vents, damaged tile, scratched baseboards, debris, and a broken sink faucet with no running water.
.260.07 Toxic Chemicals: toxic chemicals were stored in unlocked areas accessible to cognitively impaired residents in multiple houses.
.300.01 Licensed Registered Nurse (RN): the RN did not perform quarterly assessments for six of nine sampled residents.
.305.02.b Current Medication Orders and Treatment Orders: residents did not consistently receive medications as ordered due to pharmacy issues and lack of discontinue orders.
.305.03 Resident Health Status: nursing assessments were not conducted when residents experienced changes in physical or mental health status including multiple falls and fractures.
.310.01.c Medication Distribution System: medication refrigerator temperatures were not monitored and documented accurately daily, with multiple days below required temperature and missing documentation.
.310.04.e Psychotropic or Behavior Modifying Medication: residents were taking psychotropic medications longer than six months without required six-month reviews.
.320.08 Periodic Review: residents' Negotiated Service Agreements did not clearly reflect needs or services, with inadequate instructions for care and observed neglect of a bedbound resident.
.330.06.b Behavior Documentation: no behavior plan with specific interventions was developed for a resident who refused multiple meals.
.335.02 Standard Precautions: infection control procedures were not followed including allowing ingestion of dropped medication, glove misuse, and lack of soap and paper towels in resident and staff bathrooms.
.450 Requirements for Food and Nutritional Care Services: kitchen inspection failed, mandatory reinspection required, and no Certified Food Protection Manager was present.
.600.04.a Sufficient Personnel: insufficient staff were scheduled on night shifts, with staff leaving buildings unsupervised and residents not always receiving timely care.
.600.04.b Sufficient Personnel: five of six employees did not have current first aid and CPR certification, and no direct care staff with certification was provided in each building at all times.
.645.02 Delegation: medication technicians were not properly delegated by the current facility nurse, and delegation between RN and LPN was not completed.
Report Facts
date: Apr 26, 2023
date: Jul 6, 2023
date: Aug 26, 2023
date: Sep 8, 2023
date: Jun 18, 2023
date: Aug 3, 2023
date: Sep 9, 2023
date: Apr 29, 2023
date: Jul 25, 2023
date: Aug 10, 2023
date: Aug 18, 2023
date: Aug 19, 2023
date: Dec 16, 2023
date: Jan 11, 2024
date: 2024-01
date: Jan 9, 2024
date: 2023-12-01 to 2023-12-31
date: 2023-11-01 to 2023-11-30
count: 3
count: 2
count: 7
count: 18
count: 1
count: 5
count: 6
count: 5
Viewing
Loading inspection reports...
