Inspection Reports for
Creekside Inn Memory Care
240 E Kathleen Ave, Coeur d'Alene, ID 83815, United States, ID, 83815
Back to Facility Profile13 Reports
Inspection Report — Mar 28, 2025
Routine
Date: Mar 28, 2025
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with applicable regulations.
Findings
One non-core deficiency was identified related to improper infection control procedures during medication passes by staff.
Deficiencies (1)
.335.02 Standard Precautions: the facility did not follow correct infection control procedures when three staff who passed medications were observed not washing or sanitizing their hands prior to or after passing residents' medications, including failure to perform hand hygiene between tasks and glove usage.
Inspection Report — Oct 7, 2024
Life Safety
Date: Oct 7, 2024
Visit Reason
Fire life safety and sanitation licensure survey conducted to assess compliance with fire and life safety standards.
Findings
Four non-core deficiencies were found related to missing inspection records, facility compartmentation issues, fire suppression maintenance, electrical installation safety, and lack of documented fuel-fired heating inspection.
Deficiencies (4)
.330.15 Fire and Life Safety Records: the facility lacked inspection records including one of two semi-annual UL 300 hood system inspection/cleaning reports and documentation of fuel-fired heating inspection reports.
.404 Fire and life safety standards: facility compartmentation had unsealed openings and penetrations, fire suppression heads were obstructed by paint and corrosion, requiring replacement of three loaded sprinkler pendants.
.405.01 Electrical Installations and Equipment: electrical connections lacked protective covers, with exposed wiring on two outside GFI outlets by the rear of the kitchen and laundry area.
.405.04 Fuel-Fired Heating: no documented annual fuel-fired heating inspection was conducted.
Inspection Report — Apr 27, 2023
Routine
Date: Apr 27, 2023
Visit Reason
A health care licensure and follow-up survey with complaint investigation was conducted to assess compliance with regulations and investigate complaints.
Complaint Details
The survey included a complaint investigation; however, specific complaint details and substantiation status were not stated in the report.
Findings
Four deficiencies were identified related to licensed nurse assessments, medication refrigerator temperature maintenance, negotiated service agreements, and delegation of medication passing.
Deficiencies (4)
.300.01 Licensed Registered Nurse (RN): the facility's RN did not perform quarterly assessments for 7 sampled residents; assessments were completed by the LPN instead.
.310.01.c Medication Distribution System: the medication refrigerator containing insulin was not maintained between 38 to 45 degrees F, with documented temperatures below 38 degrees F twenty-six times in April 2023.
.320 Negotiated Service Agreement (NSA) Requirements: NSAs were not updated to reflect residents' current needs, were unsigned by POAs, guardians, or family, and were not developed within 14 days of admission.
.645.02 Delegation: four staff who passed medications were not delegated by the facility's RN as required.
Report Facts
temperature: 38
temperature: 45
count: 7
count: 26
count: 4
Inspection Report — Mar 25, 2022
Life Safety
Date: Mar 25, 2022
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable regulations.
Findings
One non-core deficiency was found related to the lack of documentation for the inspection and servicing of fusible-linked fire dampers in the laundry and kitchen areas.
Deficiencies (1)
.250.10.d. Heating, Ventilation, and Air-Conditioning (HVAC): no documentation was provided for the testing of installed fusible-linked fire dampers observed in the laundry and kitchen; fire and smoke dampers must be inspected, serviced, and cleaned every four years by a professional.
Inspection Report — Jan 29, 2021
Life Safety
Date: Jan 29, 2021
Visit Reason
Fire life safety and sanitation licensure survey conducted to assess compliance with fire and life safety standards.
Findings
Six deficiencies were found related to relocation agreements, fire and life safety standards, emergency generators, fuel-fired heating, and automatic fire extinguishing system service and testing. Several items were noted as repeated deficiencies from previous inspections.
Deficiencies (5)
.155.01 Relocation Agreements: documented relocation agreements shall be with two separate locations and reviewed annually. Documentation was last dated December of 2018, and one agreement is with a facility administrator who no longer works for that company.
.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documented annual inservice for staff qualifications on oxygen risks; Ansul system documentation does not identify the last 12-year hydro testing on the wet-chemical fire suppression tank with conflicting dates of 2008 and 2012; no documented testing of installed fusible-linked fire dampers, which must be inspected and tested at least every four years.
.155.03 Emergency Generators: no documented monthly load testing for diesel-fired Emergency Power Supply System generator set; four-hour load test is past due with last documented test on January 6, 2017.
.405.04 Fuel-Fired Heating: no documented annual fuel-fired heating inspection; all fuel-fired heating systems shall be inspected at least annually by a certified entity.
.415.05 Automatic Fire Extinguishing System Service and Testing: missed fourth quarter sprinkler inspection on the NFPA 13 fire suppression system; no documentation for a full flow trip test on the dry system since June 2017; no documented testing or replacement of dry barrel sprinkler pendants within the past 10 years, with all past quarterly inspections and the current 2021 inspection noting pendants at overhangs and in walk-in cooler and freezer are past due.
Report Facts
date: 2018-12
date: 2008
date: 2012
date: Jan 6, 2017
date: 2017-06
year: 2021
duration: 12 years
duration: 10 years
Inspection Report — Sep 25, 2019
Follow-Up
Date: Sep 25, 2019
Visit Reason
Health Care Core Deficiency Follow-Up survey conducted to evaluate correction of previously cited deficiencies.
Findings
One non-core deficiency was found related to failure to implement mechanical soft diet orders for residents, including serving potato salad with raw onion and potato peelings. This deficiency was previously cited on March 1, 2019.
Deficiencies (1)
.305.02.b Current medication orders and treatment orders: the facility did not implement diet orders for Resident #2 and Resident #9, when their mechanical soft diet orders were not followed. For example, Resident #2 and Resident #9 were observed to be served potato salad that contained large pieces of raw onion and potato peelings (previously cited on March 1, 2019).
Inspection Report — Jun 28, 2019
Life Safety
Date: Jun 28, 2019
Visit Reason
A Fire Life Safety Survey was conducted to assess the facility's compliance with fire safety and sanitation licensure requirements.
Findings
Six non-core deficiencies were identified related to fire extinguisher inspections, fuel-fired heating system documentation, fire extinguishing system service, building penetrations, fire drills, and exit door locks.
Deficiencies (6)
.415.03 Portable Fire Extinguisher Service and Testing: fire extinguisher annual inspection was done November 2018; no monthly inspections were done in December 2018 or January 2019.
.415.02 Fuel-Fired Heating: no documentation for an annual inspection of fuel fired heating systems and devices.
.415.05 Automatic Fire Extinguishing System Service and Testing: no documentation for fourth quarter sprinkler inspections 2018, no documentation for a semi-annual inspection of the ANSUL system or kitchen hood cleaning the second half of 2018, and no documentation for weekly visual inspection of dry system gauges, monthly visual inspection of control valves and wet system gauges.
.250.01 Building Character: approximately 12" x 12" and 6" x 6" penetrations in the wall of the dryer ventilation room.
.410.02 Fire Drills: missing fire drills third shift, second quarter 2019 and first and third shifts third quarter 2018.
.405.07 Exit Door Locks: delayed egress component at the kitchen exit was non-operational and delayed egress signage was missing from the delayed egress door near room #34.
Report Facts
date: 2018-11
date: 2018-12
date: 2019-01
date: 2018-Q4
date: 2019-Q2
date: 2018-Q3
Inspection Report — Mar 1, 2019
Routine
Date: Mar 1, 2019
Visit Reason
A health care licensure and follow-up survey with complaint investigation was conducted to assess compliance with regulations and investigate allegations of abuse and inadequate care.
Complaint Details
The complaint investigation involved allegations of sexual abuse by Resident #9 towards Resident #8 and failure of the facility to protect residents, investigate incidents, notify appropriate agencies, and implement corrective actions. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility was cited for multiple deficiencies including failure to protect residents from abuse, inadequate supervision and care, failure to investigate and report incidents, insufficient staffing, and failure to provide appropriate assistance with eating, toileting, and grooming. Core deficiencies involved failure to protect residents from sexual abuse and inadequate interventions. Non-core deficiencies included failures in administrator responsibilities, resident care records, medication management, and notification procedures.
Deficiencies (24)
.153.01 Response of Staff to Abuse, Neglect or Exploitation of Residents: the facility's undated policy did not provide clear instructions on what, who, and when to report allegations of abuse, neglect or exploitation, nor how to protect residents during investigations.
.215.01 Administrator Responsibility: incident and accident reports lacked documentation on safety measures and preventive actions; the administrator confirmed not all incidents were investigated and did not follow emergency medical policy for Resident #2's hospital transport due to low oxygen.
.215.09 Identify and Monitor Patterns of Incidents and Accidents: the administrator failed to identify or monitor patterns of incidents including multiple falls and resident-to-resident altercations, preventing development of interventions to avoid recurrences.
.225.01 Evaluation for Behavior Management: the facility did not assess behaviors of Residents #3 and #9; Resident #3 continued exhibiting combative behaviors without a behavior management plan, and Resident #9 lacked a plan for sexually inappropriate behaviors.
.225.02.c Intervention: behavior management plans for Residents #3 and #4 were not updated to include alternative interventions when existing ones were ineffective; Resident #4's intervention to separate her for 72 hours was not effectively implemented due to insufficient staff.
.300.01 Licensed Professional Nurse (RN): the facility nurse did not conduct required 90-day nursing assessments for all sampled residents since September 2018.
.305.02.b Current Medication Orders and Treatment Orders: residents were served incorrect diets; medication to treat constipation was unavailable for Resident #7; Resident #2 was given medication at incorrect times contrary to physician orders.
.310.03 Requirements For Medication. Controlled Substances: medication carts contained at least 16 cards of benzodiazepines not tracked by the facility.
.320.01 Use of Negotiated Service Agreement: assistance with activities of daily living for Residents #1, #3, #4, and #5 was inconsistent with their negotiated service agreements, including lack of repositioning, hygiene, and toileting assistance.
.350.01 Notification of Accidents, Incidents, and Complaints: the administrator was not notified timely of a sexual abuse allegation occurring on February 15, 2019, preventing timely investigation.
.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator failed to investigate incidents including skin tears, bruises, and multiple falls for Residents #2, #6, and #7.
.350.03 Resident Protection: the administrator was not informed of the sexual abuse allegation, had not read witness statements, and failed to implement protective interventions.
.350.04 Written Response to Complaint Within Thirty Days: the administrator addressed complaints verbally and was unaware of the requirement to provide written responses.
.350.05 Facility Notification to Appropriate Agencies: the facility failed to report the sexual abuse incident to Adult Protection despite documentation by caregivers and nurses.
.350.06 Corrective Action for Known Allegations: the administrator was unaware of the sexual abuse incident and had not implemented corrective actions.
.451.03 Therapeutic Diets: residents with orders for mechanical soft diets did not have therapeutic menus or Idaho Diet Manual to ensure proper diet preparation.
.600.06.a Sufficient Personnel: the facility lacked sufficient staff to assist residents with eating and toileting, resulting in residents being left unattended, disheveled, and in soiled clothing.
.711 Ongoing Resident Care Records: caregivers documented multiple residents' information on one form, preventing individual resident care notes.
.711.01 Ongoing Resident Care Records: staff failed to document observed resident behaviors, dates, times, interventions used, or effectiveness.
.711.08 Care Notes: caregivers verbally reported incidents but nurses wrote the notifications instead of caregivers who provided care or observed incidents.
.730.02.a Work Records: the facility only had original work schedules, not as-worked schedules documenting hours worked.
.730.02.b Work Records: as-worked schedules for January and February 2019 did not include first and last names of employees.
.510 Requirements To Protect Residents From Abuse: the facility failed to protect Resident #8 and all female residents from Resident #9's sexually inappropriate behaviors, did not conduct investigations, notify appropriate agencies, or implement corrective actions, resulting in abuse.
.520-04 Inadequate Care - Supervision: the facility failed to provide appropriate supervision and assistance with eating, toileting, and grooming for multiple residents, resulting in residents waiting long periods for care, wearing soiled clothing, and experiencing inadequate care.
Report Facts
date: Mar 1, 2019
phone_number: 208-665-2444
license_number: RC-954
count: 33
count: 13
count: 7
count: 5
count: 16
count: 20
count: 9
count: 5
count: 7
Inspection Report — May 7, 2018
Life Safety
Date: May 7, 2018
Visit Reason
A Fire Life Safety Survey was conducted to assess the safety environment of the facility.
Findings
Two non-core deficiencies were identified related to fire safety and equipment maintenance, including unsealed penetrations in fire resistive walls and inadequate fire extinguishing system inspections and supplies.
Deficiencies (2)
.405.05 Structure, Maintenance, Equipment to Assure Safety: approximately two inch, unsealed penetration through both sides of the 1-hour fire resistive wall, from the mechanical room, passing into the corridor above the suspended ceiling due to cabling installation.
.415.05 Automatic Fire Extinguishing System Service and Testing: facility failed to perform third quarter water alarm flow test for full NFPA 13 system in accordance with NFPA 25 2-3.3, no weekly dry gauge inspection in accordance with NFPA 25 Section 2-2.4, and only ten replacement sprinkler pendants in spare pendant box in riser room instead of minimum twelve required for sprinkler systems having 300-1000 heads in accordance with NFPA 25 Section 2-4.1.5.
Report Facts
timeframe: 30
timeframe: 7
count: 10
count: 12
Inspection Report — Mar 14, 2017
Follow-Up
Date: Mar 14, 2017
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Health Care Core Deficiency Follow-Up survey to assess correction of previously cited deficiencies.
Findings
Five deficiencies were found related to fingerprint submission, behavior management evaluations, medication orders, resident health status documentation, and administrator investigations of incidents.
Deficiencies (5)
.009.04 Submission of Fingerprints: the facility did not submit 1 of 1 employees' fingerprints within 21 days of hire.
.225.01 Evaluation for Behavior Management: the facility did not evaluate residents' behaviors, including agitation and use of psychotropic medications without exhibited behaviors.
.305.02 Current Medication Orders and Treatment Orders: the facility did not have PRN medications available for multiple residents (Residents #3, #4, #5, #7, #8, #9 and #10) (previously cited 12/6/16).
.305.03 Resident Health Status: there was no documentation the facility RN assessed Resident #8, a diabetic, after she received an injury to her foot.
.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not complete an investigation and written report for multiple incidents involving Residents #1, #2, #5, and #8.
Inspection Report — Dec 6, 2016
Routine
Date: Dec 6, 2016
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with regulations and investigate resident care and safety.
Findings
The facility failed to protect residents from verbal, physical, and sexual abuse by other residents, failed to conduct investigations or notify appropriate authorities, and did not provide sufficient supervision during meals or timely interventions for significant weight loss in residents.
Deficiencies (23)
.009.01 Criminal history and background check: two of ten employees did not have evidence of a completed criminal history and background check.
.009.06.c Use of previous criminal history and background check: four of four employees did not have evidence of an Idaho State Police only background check.
.215.01 Administrator responsibility: the administrator did not ensure the weight change policy was implemented (previously cited 6/17/14).
.215.08 Procedures for investigations: the administrator did not ensure investigations were conducted of all accidents and incidents.
.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 for 9 of 10 residents.
.225.01.a Evaluation for behavior management: residents #1, #2, #3, #4, #6, #7, #8, #9 and #10 exhibited verbal and physical aggressive behaviors and the facility did not develop behavior management plans or evaluate whether behaviors were transitory or permanent.
.225.01.b Evaluation for behavior management: the facility did not review 9 out of 10 residents' previous behaviors or activities to develop a behavior management program for their physical and verbal assault on others.
.225.01.c Evaluation for behavior management: the facility did not review baseline data including intensity, duration and frequency of 9 out of 10 residents' behaviors.
.225.01.d Evaluation for behavior management: the facility did not identify recent changes in the residents' life or daily routine or changes in the NSA for 9 of 10 residents.
.225.01.e Evaluation for behavior management: the facility did not identify environmental causes for 9 out of 10 residents' behaviors such as staffing, overcrowding and noise.
.225.01.f Evaluation for behavior management: the facility did not rule out medical causes, such as pain, medication side-effects and infection, for 9 out of 10 residents who had behaviors.
.225.01.g Evaluation for behavior management: the facility did not attempt to identify triggers for 9 out of 10 residents' behaviors.
.225.02.a Intervention: the facility did not develop an intervention for each behavioral symptom for 9 out of 10 residents.
.225.02.c Intervention: the facility did not review interventions to determine if they were effective to address behaviors for 9 out of 10 residents.
.300.01 Licensed professional nurse (RN): the facility RN did not visit the facility every 90 days or when residents had changes of condition.
.305.02 Current medication orders and treatment orders: the facility did not have current medication orders for Resident #4 and #6 and did not have all PRN medications available for residents' use.
.320.01 Use of negotiated service agreement: negotiated service agreements did not describe the residents' needs for 10 of 10 residents, including wound preventative measures, hospice services, mobility, eating and transferring needs.
.350.01 Notification of accidents, incidents, and complaints: the administrator was not notified of all accidents and incidents.
.350.03 Resident protection: the administrator did not ensure residents were protected from abuse during the course of the investigation.
.350.05 Facility notification to appropriate agencies: the administrator did not notify Adult Protection or law enforcement when staff documented resident to resident altercations.
.600.06.a Sufficient personnel: the administrator did not schedule sufficient staff to provide supervision in the Rose dining room to ensure assistance was provided in a dignified manner and to monitor residents' behaviors.
.510 Requirements to protect residents from abuse: the facility failed to protect residents from verbal, physical and sexual abuse by other residents, failed to conduct investigations, and did not notify Adult Protection or law enforcement as required.
.520-04 Inadequate care - supervision: the facility failed to provide appropriate supervision to ensure sufficient staff to assist 13 of 14 residents requiring total assistance with eating and failed to provide appropriate supervision for residents #1, #5 and #7 when they experienced significant weight loss, resulting in inadequate care.
Report Facts
: 55
: 70
: 26
: 31
: 31
Inspection Report — Oct 28, 2016
Life Safety
Date: Oct 28, 2016
Visit Reason
A Fire Life Safety Survey was conducted to assess the safety environment of the facility.
Findings
Non-core issue deficiencies were identified related to fire safety equipment and maintenance, including hazardous area doors not interconnected with the fire alarm, removal of a self-closing device, use of a portable heater in the riser room, and a missing outlet cover in the staff breakroom.
Deficiencies (3)
.405.05 Structure, Maintenance, Equipment to Assure Safety: hazardous area doors equipped with hold-open devices were not interconnected with the fire alarm, including the kitchen door to corridor and storage across from room 23 (repeat), and the storage across from room 23 self-closing device has been removed.
.405.05.f Structure, Maintenance, Equipment to Assure Safety: portable heater in use in riser room.
.405.01 Medical Gases: missing outlet cover in staff breakroom.
Inspection Report — Jan 29, 2016
Life Safety
Date: Jan 29, 2016
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with safety standards.
Findings
Five deficiencies were found related to electrical installations, medical gases, building character, exit door locks, and structure maintenance.
Deficiencies (5)
.405.01.b Electrical installations and equipment: extension cord found in use in Room 9.
.405.03 Medical gases: oxygen cylinder found unsecured in Room 37; one 1 inch circular hole above cross corridor doors near Room 28/29 unsealed and would not prevent passage of smoke.
.250.01 Building character: three 1 inch circular holes above cross corridor doors near Room 15/16 unsealed and would not prevent passage of smoke.
.405.07 Exit door locks: the delayed egress doors located in the kitchen would not operate correctly; irreversible process would not begin to unlock door.
.405.05 Structure, maintenance, equipment to assure safety: activities office requires a self closing door due to the amount of combustible materials stored in the office and closet area.
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