Inspection Reports for
Harbor Assisted Living

39-3321.2.b. Qualifications and Requirements of Administrator: the administrator did not ensure all facility policies were implemented when they failed to notify adult protective services of an allegation of abuse involving Resident #3 on 5/26/25 and did not report the incident because they did not believe it constituted potential abuse.

39-3321.2.e. Qualifications and Requirements of Administrator: the administrator did not complete an investigation to determine if abuse occurred after a staff member told a resident, "You don't tell us to be quiet" and forcefully moved Resident #3 to their room resulting in a large skin tear; the administrator failed to interview all witnesses or complete investigative tasks and stated the resident threw themselves on the floor.

39-3321.3. Qualifications and Requirements of Administrator: the administrator was not notified of all allegations of abuse at the facility; multiple caregivers witnessed potential abuse but did not report incidents to the administrator due to discomfort.

39-3321.4. Qualifications and Requirements of Administrator: the administrator did not protect residents from potential further abuse after being aware Resident #1 was allegedly treated inappropriately by a staff member who continued to work unsupervised at the facility.

.510. REQUIREMENTS TO PROTECT RESIDENTS FROM ABUSE: the facility did not protect residents when the administrator failed to immediately notify APS, complete thorough investigations, and protect residents after caregivers allegedly abused residents; this had the potential to affect 100% of residents and included failure to follow facility abuse policies and Idaho Code requirements.

.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: the sprinkler pendant above the doorway in room #8 was covered in non-factory applied paint and must be replaced; fire suppression system gauges were not calibrated or replaced as required since the last documented inspection in 2018; smoke detectors were not tested for sensitivity every five years and documentation was missing.

.405.03 Medical gases: the facility failed to maintain handling, use, and storage of medical gases in accordance with NFPA 99, including the absence of precautionary signs where supplemental oxygen is in use and in aisles and walkways leading to such areas.

.250.13 Secure Environment: the facility did not provide a secured exterior environment for residents at risk for elopement; the exterior gate leading out of the courtyard was not secured and the administrator was unaware.

.260.07 Toxic Chemicals: toxic chemicals were stored in an unlocked area accessible to cognitively impaired residents, including bleach mixture and various cleaners under the kitchen sink and in the shower room.

.305.03 Resident Health Status: the facility nurse did not assess all residents when they experienced a change of condition, including multiple falls and diarrhea incidents without proper nursing assessments or documentation.

.319.03 Nursing Assessment: three sampled residents did not have a comprehensive nursing assessment completed prior to admission; the nurse was unavailable for interview and assessments were not provided.

.320.01 Use of NSA: residents' negotiated service agreements did not clearly reflect their needs or describe services to be provided, missing details on assistance required for transfers, eating, bathing, grooming, and hospice coordination.

.320.03 Signature, Date, and Approval of Agreement: three resident records had NSAs that were not signed by the resident or their legal guardians; the administrator confirmed the lack of signatures.

.009.05.b New Criminal History and Background Check: one staff member did not complete a new background check after starting work on 10/28/2020, which was over three years after the previous check; the administrator confirmed the caregiver should have had a new check completed.

.009.06.c Use of Previous Criminal History and Background Check: one of five employees required to have Idaho State Police background checks did not have documentation of those checks; the administrator confirmed the checks were not completed.