Inspection Reports for
Grace Assisted Living – Grace Boise Englefield

.161.04 Designated smoking areas: the facility did not have a designated smoking area that was clearly marked; the smoking area near the garbage can lacked a sign, and the facility indicated a sign would be posted.

.310.01.c Medication distribution system: the medication refrigerator temperatures were not maintained between 38 and 45 degrees F, being below 38 degrees for multiple days in July through October 2025, and temperature documentation was inconsistent.

.320.01 Use of NSA: residents' negotiated service agreements did not clearly reflect needs or services; several residents' NSAs lacked documentation of correct home health services, use of transfer poles, tag alarms, or outside service companions, and needed updating.

.305.02.b Current medication orders and treatment orders: the facility failed to follow medication and treatment orders, including incorrect administration of cataract drops, incorrect dosing of furosemide, and residents receiving thickened liquids orders but given thin liquids.

.330.13.e Personnel records: nine of fifteen staff files lacked documentation of 16 hours of orientation training; seven of fifteen lacked evidence of mental illness and traumatic brain injury training, yet the facility retained residents with these diagnoses.

.645.01.a Training requirements: one of eight medication technicians did not have an Idaho Board of Nursing approved medication assistance course; their record contained a certification for a non-approved course.

.645.02 Delegation: one of eight staff who assisted with medications was not delegated by the current facility nurse; the administrator and nurse confirmed this was not completed.

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, including an unknown injury and multiple falls that were not investigated.

39-3308 Assessment (4)b Assessments: the facility nurse did not review and implement new orders, including changes to cataract drops, furosemide dosing, and new medications; some orders were implemented by office staff instead of the nurse.

.300.01 Licensed Registered Nurse (RN): a Licensed Practical Nurse (LPN) conducted multiple quarterly assessments for residents, and the Registered Nurse was unaware these assessments were required to be conducted by an RN.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: operational testing revealed two non-operational emergency lights, lack of a 90-minute annual test since 4/1/20, a 24" x 42" hole in the laundry room wall, and unsealed conduit in the electrical and riser rooms allowing smoke and fire to pass freely (repeat deficiency).

.250.10.b Heating, Ventilation, and Air-Conditioning (HVAC): the facility had two two-sided gas fireplaces with screens that do not provide an adequate safety barrier to prevent injury from exposure to the hot fireplace.

.405.01.a Electrical installations and equipment: an extension cord was in use in the activity room, which is prohibited.

.159.01 Complete and Accurate Records: the facility did not have a policy or procedure to ensure documentation was accurate and authentic, including discrepancies in medication administration records and documentation of Ted hose use.

.305.02.b. Current Medication Orders and Treatment Orders: the facility nurse did not ensure residents had medications available as ordered, including delayed antibiotic starts, unavailable pain medications, and delayed discontinuation of medications (previously cited 6/4/2018).

.305.03. Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including infections, injuries, and pain with low potassium levels (previously cited 6/4/2018).

.350.04. Written Response to Complaint Within Thirty Days: the administrator did not provide a written response to all complainants within 30 days despite several residents and family members voicing concerns.

.405.01.b Electrical installations and equipment: multiple unsafe electrical setups were found including refrigerators plugged into relocatable power taps, multi-plug adapters with improper adapters, extension cords, and daisy-chained power taps.

.405.05 Structure, maintenance, equipment to assure safety: several emergency lights were non-operational and self-closing doors were missing in the sprinkler riser and electrical/fire alarm rooms which contain fuel-fired equipment.

.161.01 Policy on smoking: resident smoking areas in courtyards and patios lacked safety-type ashtrays or receptacles.

.250.13.j Resident sleeping rooms: resident room #160 door would not latch.

.250.01 Building character: an approximately 1-1/2 inch circular penetration in the janitor's closet next to the mop sink and an unsealed conduit in the sprinkler riser room by the kitchen would not resist the passage of smoke and fire.

.415.05 Automatic fire extinguishing system service and testing: a "loaded" fire sprinkler head was found in the kitchen above the mixer.

.305.02.b. Current Medication Orders and Treatment Orders: the facility nurse did not ensure physician's orders were implemented as ordered, including insulin administration errors, improper fentanyl patch changes, failure to implement diet orders for 85 days, and missed medication doses due to unavailability.

.305.03. Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including failure to assess a pressure sore after it was identified by a physician.

.600.06.a. Sufficient Personnel: residents and staff reported insufficient staffing to meet residents' needs, delays in call light responses, and lack of on-call float staff for weekends and increased care levels.

.630.03. Developmental Disability: eight of ten employees did not have specialized training for developmental disabilities despite residents with such diagnoses, and staff had not received the required training as of the survey date.