Inspection Reports for
Hearthstone Village, LLC

.009.01 Criminal History and Background Check: three of six employees did not have a Department Criminal History and Background Check, confirmed by the facility manager (previously cited 7/28/2023).

.009.06.b Use of Previous Criminal History and Background Check: one of three employees required to have an Idaho State Police Background Check did not have it completed, confirmed by the facility manager.

.161 Smoking Requirements: the facility lacked a clearly marked designated smoking area; combustible trash mixed with ashes was improperly disposed of, and residents and staff did not always smoke in the designated area.

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe, and orderly manner, including weeds outside, broken furniture, worn dining tables, ripped chair coverings, and missing paint on balconies (previously cited 7/28/2023).

.260.07 Toxic Chemicals: toxic chemicals were stored unlocked and accessible to cognitively impaired residents, including bleach and cleaners under kitchen sinks; the kitchen manager confirmed chemicals needed to be secured.

.305.02.b Current Medication Orders and Treatment Orders: residents did not receive medications as ordered, including missed doses of ketoconazole shampoo and olanzapine; the nurse acknowledged medications were unavailable (previously cited 7/28/2023).

.305.02.c Current Medication Orders and Treatment Orders: the facility did not have actual, written, signed, and dated medication orders for residents, including multiple medications for Resident #5; the nurse stated current physician orders were missing.

.305.03 Resident Health Status: nursing assessments were not conducted after residents experienced changes in health status, including falls, altercations, and choking incidents; the nurse was unaware assessments were required.

.310.01.c Medication Distribution System: medication refrigerator temperatures were not monitored and documented daily as required; only sixteen logs were recorded over nearly two months (previously cited 7/28/2023).

.310.01.g Medication Distribution System: PRN medications were not available for residents, including acetaminophen and bisacodyl suppository; staff stated all medications should be available at all times (previously cited 7/28/2023).

.310.02 Discontinued and Expired Prescriptions: the facility used expired urinalysis reagent test strips on residents and was unaware they were expired.

.310.02.d Discontinued and Expired Prescriptions: the medication destruction log did not document the method of destruction; the facility switched from electronic to paper logs and failed to document methods used.

.310.04.a Psychotropic or Behavior Modifying Medication: non-drug interventions were not attempted prior to requesting medications for Resident #2, who exhibited physical aggression and resistance to care.

.310.04.e Psychotropic or Behavior Modifying Medication: psychotropic medication reviews lacked updated behavioral data; staff were unaware behavioral updates were required.

.319 Comprehensive Assessment Requirements: several residents did not have comprehensive assessments completed prior to admission; the nurse stated assessments should be completed before admission.

.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or services, including diet and hospice status; the facility manager stated NSAs needed updating.

.330 Requirements for Facility Records: personnel and fire life safety records were incomplete or inaccurate, including missing medication certification records and incomplete relocation agreements; the administrator was unaware of missing records.

.330.04.a Resident Care Records: resident care records lacked documented caregiver notes; staff communicated by text and email but did not document in records; notes were deemed not authentic.

.335.02 Standard Precautions: medication technicians did not perform hand hygiene between residents during medication pass; oxygen concentrator and water filter were dirty and needed cleaning weekly.

.410 Requirements for Emergency Actions and Fire Drills: fire drills were not conducted during night sleeping hours as required; maintenance supervisor confirmed this practice (previously cited 2/3/2025 and 12/17/2021).

.451.01.d Menu: the facility did not document or maintain menu substitutions as required.

.600.04.a Sufficient Personnel: staffing was insufficient during all hours; staff had to leave houses unattended to assist elsewhere; family members reported inadequate assistance with grooming and dressing; nurse confirmed insufficient staffing.

.600.04.b Sufficient Personnel: five of six staff working alone lacked evidence of CPR or First Aid certification; multiple staff needed certification or re-certification (previously cited 7/28/2023).

.625.03.f Content for Training: one of six staff did not have training on reporting abuse, neglect, and exploitation; training was not completed.

.630.01 Dementia: five of six staff lacked documentation of dementia training; training was not completed.

.640 Continued Training Requirements: five of five staff lacked annual eight hours of job-related continued training; training was not completed.

.645.01.a Training Requirements: one medication technician lacked an Idaho Board of Nursing approved medication assistance course in their record; certification could not be located.

39-3308 Assessment (4)b Assessments: the facility nurse did not implement medication orders for Resident #1, including lorazepam and morphine; nurse was unaware only licensed nurses could implement new orders.

39-3321.2.a Qualifications and Requirements of Administrator: the facility did not follow its Abuse and Neglect Policy; mandatory reporting and investigations were not completed as required.

39-3321.2.e Qualifications and Requirements of Administrator: investigations and written reports were not completed within 30 days for incidents, complaints, and allegations of abuse and neglect involving multiple residents; administrator stated investigations were incomplete.

39-3321.4 Qualifications and Requirements of Administrator: the administrator did not implement immediate corrective action to prevent recurrence of problems after accidents and incidents; corrective action was not implemented.

.155.01 Relocation agreements: the two relocation agreements had not been reviewed since 2013 and 2022; they must be updated at least annually.

.403 Fire and life safety standards: fire extinguishers were not inspected or serviced, the laundry ceiling had penetrations, and sprinkler, alarm and emergency-light testing was not documented (previously cited 12/17/2021).

.405.01.a Electrical installations and equipment: multiple multi-plug adapters were used to power lamps, chargers, mini fridges, and fans, which are prohibited.

.405.02.c Prohibited applications: Relocatable Power Taps (RPT) were used to supply power to miniature refrigerators, a toaster, and a coffeemaker, which is prohibited.

.405.04 Fuel-fired heating: facility provided documentation identified last fuel-fired heating inspection and testing was conducted on 1/27/2023.

.410 Requirements for emergency actions and fire drills: only two documented fire drills were on file for the year, fewer than the required six, with at least two during sleeping hours (previously cited 12/17/2021).

.009.01 Criminal History and Background Check: one of eight employees did not have a Department Criminal History and Background Check completed.

.250.10 Heating, Ventilation, and Air-Conditioning (HVAC): the facility did not ensure all residents' rooms and common areas remained between appropriate temperatures; some residents lacked air conditioning and experienced discomfort.

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe, and orderly manner with trash, dirty furniture, cobwebs, urine odor, gouges in paint, mold in showers, and dirty kitchen appliances.

.305.02.b Current Medication Orders and Treatment Orders: the facility nurse did not ensure all residents' medications were available and given as ordered, with multiple missed doses and no discontinuation orders for some medications.

.310.01.c Medication Distribution System: the facility did not maintain medication refrigerator temperatures between 38 and 45 degrees F and failed to document temperatures daily as required.

.310.01.g Medication Distribution System: the facility did not ensure all ordered as-needed medications were available for residents.

.330 REQUIREMENTS FOR FACILITY RECORDS: the facility did not maintain complete, accurate resident records, including documentation discrepancies and inconsistent recording of caregiver communications.

.330.04.c.vii Resident Care Records: residents' changes of condition assessments were not consistently documented despite assessments being performed.

.600.04.b Sufficient Personnel: two of eight sampled direct care staff did not have current first aid or CPR certification as required.

.403 Fire and life safety standards for existing buildings: door locks on exit doors required two operations to exit, emergency lighting was not tested or operational, fire/smoke alarm inspections and sensitivity tests were not documented, wet suppression system inspections were not documented, staff training on oxygen handling was not documented, and mechanical room had ceiling and wall penetrations.

.410 Requirements for emergency actions and fire drills: the facility failed to perform bimonthly drills, did not conduct the required two night-time drills, and drill documentation was incomplete regarding descriptions, resident responses, problems, and recommendations.

.250.10.b Heating, ventilation, and air-conditioning (HVAC): natural gas fireplaces in buildings A and B lacked safety barriers.

.155.01 Relocation agreements: the facility had only one relocation agreement instead of two, and the agreement had not been updated annually since 2013.

.250.09 Plumbing: hot water temperature at resident plumbing fixtures was 127°F, exceeding the maximum allowed 120°F.

.405.01.a Electrical installations and equipment: multiple appliances were plugged into a relocatable power tap in the staff break room, which is prohibited.

.405.02.c Prohibited applications: a full-sized refrigerator in building B was plugged into an extension cord, which is prohibited.