Inspection Reports for
Heritage Senior Living

.154.09.d Smoking area signage: the facility's smoking area did not contain required signage designating the smoking area; staff and maintenance supervisor confirmed the absence of the sign.

.250.06 Plumbing: the facility did not keep water temperatures between 105 and 120 degrees F, with observed temperatures ranging from 76.6 to 127.2 degrees F in various rooms.

.330.03.a.v Resident care records: the facility nurse did not document assessments when residents experienced changes in physical or mental health status, despite stating assessments were done.

.405.01 Medical gases: the facility failed to store oxygen tanks securely in racks or carts; tanks were observed unsecured and standing upright in multiple locations.

.405.04.a Prohibited applications: one Multi-Plug Adapter was observed in use with an oxygen concentrator plugged into it, which is prohibited.

.410 Requirements for emergency actions and fire drills: the facility did not conduct quarterly fire drills; the most recent drill was on 6/17/26 with prior drills on 1/17/26 and 8/26/25.

.305.02.b. Current Medication Orders and Treatment Orders: the facility nurse did not ensure residents received medications and treatments as ordered, including continued administration of discontinued medication and missed doses of several medications (previously cited 5/21/2024).

.310.01.c. Medication Distribution System: the temperatures for the facility's East building medication refrigerator containing insulin were not monitored and documented daily, with 15 missing temperature records (previously cited 5/21/2024).

.310.01.g. Medication Distribution System: the facility did not ensure all ordered as-needed (PRN) medications were available to residents at all times, including morphine, lorazepam, nystatin powder, and ibuprofen (previously cited 5/21/2024).

.330.06.b. Behavior Documentation: the facility did not develop a behavior plan with at least one intervention for a resident exhibiting refusal behaviors, and interventions were not documented; the resident care coordinator had not developed a behavior plan but was working on the process (previously cited 5/21/2024).

.009.03.b. Availability to Work: one staff member worked alone with residents without a completed criminal history background check, which was still pending at the time of survey.

.009.06.c. Use of Previous Criminal History and Background Check: one employee did not have the Idaho State Police background check completed prior to working alone with residents since December 2023.

.154.01. Response of Staff to Accidents, Incidents, or Allegations of Abuse, Neglect, or Exploitation of Residents: staff were not adequately trained on notifying the nurse after resident health changes or incidents; Resident #4's fall was not promptly reported and staff lacked training on care for such injuries.

.215.01. Administrator Responsibility: the administrator did not ensure implementation of facility policies and procedures, including incident reporting and admission assessments for residents who experienced incidents.

.215.08.e. Corrective Action: the facility failed to implement effective corrective actions to prevent recurrence of falls for multiple residents, including Resident #4 who fell 31 times.

.215.08.g. Identify and Monitor Patterns: the administrator did not monitor incident patterns or develop interventions; Resident #4's falls were not tracked or effectively addressed.

.250.09. Plumbing: hot water temperatures were not consistently maintained between 105 and 120 degrees Fahrenheit, with readings up to 129 degrees in memory care and main building rooms.

.260.07. Toxic Chemicals: toxic chemicals were stored in unlocked areas accessible to cognitively impaired residents on multiple occasions.

.300. REQUIREMENTS FOR NURSING SERVICES: policies and procedures were not developed or implemented to ensure nursing services and coordination of care; facility nurses did not consistently follow up on outside agency nurse assessments or recommendations.

.305.02.b. Current Medication Orders and Treatment Orders: residents did not consistently receive medications and treatments as ordered, including diet orders and medication availability; insulin doses were held without provider orders.

.305.03. Resident Health Status: the facility nurse did not perform assessments after changes in resident health or mental status, including falls and wounds; medication technicians administered PRN medications without nurse oversight.

.310.01. Medication Distribution System: bubble packs of medications were stored as house supply without proper labeling for individual residents, contrary to policy.

.310.01.a. Medication Distribution System: over-the-counter medications were unsecured in resident rooms and memory care unit doors were observed unlocked.

.310.01.c. Medication Distribution System: medication refrigerator temperatures were not monitored or documented daily, with multiple days missing documentation.

.310.01.g. Medication Distribution System: not all ordered PRN medications were available to residents; many were kept only in house supply and not stocked on medication carts.

.319.03. Nursing Assessment: the RN did not consistently assess residents prior to or on admission day, missing diagnoses and conditions such as clostridium difficile colitis.

.320.08. Periodic Review: residents' Negotiated Service Agreements were not updated to reflect significant health changes or care needs, including transfer and diet requirements.

.330.04.c.vii. Resident Care Records: assessments of residents' changes in condition were not consistently documented, including wounds and symptoms.

.330.04.c.xii. Resident Care Records: residents' refusals of care and medications were not consistently documented or communicated to providers.

.330.05.b. Admission Records: history and physical results were not obtained or reviewed for all residents at admission, including Resident #6.

.330.06.b. Behavior Documentation: behavior plans with interventions were not developed for residents exhibiting medication refusals or combative behaviors.

.330.14. As Worked Schedules: schedules did not document times the administrator or facility nurses were present at the facility.

.450. REQUIREMENTS FOR FOOD AND NUTRITIONAL CARE SERVICES: no staff had current Certified Food Protection Manager certification; the Dietary Manager's certification expired in January 2024.

.630. TRAINING REQUIREMENTS FOR FACILITIES ADMITTING RESIDENTS WITH A DIAGNOSIS OF DEMENTIA, MENTAL ILLNESS, DEVELOPMENTAL DISABILITY, OR TRAUMATIC BRAIN INJURY: multiple staff lacked specialized training for mental illness, Alzheimer/dementia, and developmental disability despite residents with these diagnoses.

.405.02.d. Prohibited Applications: a receptacle power tap (RPT) was used to power multiple electronic devices in Room 4 instead of permanent installed receptacles.

.405.04. Fuel-Fired Heating: the facility failed to have an annual inspection on all fuel-fired heating systems and devices.

.410. Requirements for emergency actions and fire drills: the facility did not conduct the required six annual bi-monthly fire/emergency evacuation/relocation drills, including two drills during nighttime hours when residents would be sleeping.

.215.07 Notification to Adult Protection and Law Enforcement: the administrator failed to report all allegations of abuse to Adult Protection immediately; notification was delayed until after the investigation was completed.

.215.08 Procedures for Investigations: the administrator failed to implement policies for a thorough investigation of abuse allegations, including proper notifications, documentation, and investigation.

.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: hood systems had only one documented cleaning/inspection instead of semi-annual inspections, and fire suppression tanks were over 12 years old requiring hydro testing.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: drop testing of rolling fire doors was not documented, and no documented education or certification of staff for testing was provided.

.405.01 Electrical installations and equipment: cadet heaters in multiple rooms were equipped with combustible materials less than three feet away, violating safety labeling requirements.

.410 Requirements for emergency actions and fire drills: emergency egress and relocation drills were conducted fewer than six times per year with only one drill documented during night hours, and assembly points were not documented.

.260.06 Housekeeping and maintenance services: bifold doors in the laundry area providing access to the fire suppression riser were not functional and leaned against running dryer components.

.130 Inspection of facilities: mechanical room housing fuel-fired furnace was locked with missing key, restricting access.

.405.01.a Electrical installations and equipment: a 3-1 non-grounded extension cord was in use in room West 13.

.405.02.c Prohibited applications: relocatable power taps were used with appliances in rooms South 9 and South 2, contrary to listing requirements.

.405.03 Medical gases: no policy for elimination of ignition sources and misuse of flammable substances; multiple resident rooms with oxygen lacked required signage; oxygen storage outside dedicated areas exceeded allowed cubic feet.

.330.15 Fire and life safety records: no documentation was available for fire alarm inspection completed during 2021.

.300.02 Licensed Nurse: the facility nurse did not assess residents who experienced changes of condition, including wounds, blisters, vomiting episodes, and falls (previously cited 4/01/2017 and 11/16/2018).

.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not provide behavior updates to the physician or authorized provider for 4 of 4 residents requiring psychotropic medication reviews.

.335.02 Standard Precautions: the facility did not implement standard precautions as outlined by CDC guidelines when caring for diabetic residents; staff were observed not consistently wearing gloves or performing hand hygiene during blood sugar checks and insulin administration.

.155.01 Relocation Agreements: only one relocation agreement with one alternate location dated April 2016 was present; the facility must have two relocation agreements with two separate locations reviewed annually.

.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: no documented monthly control valve and wet system riser inspections, no documented inservice training for residents on emergency roles, no documented bi-monthly staff training reviews on emergency plans, no documented testing of automatic hand sanitizer dispensers at refill, antifreeze loop documentation incomplete, emergency plan lacks point of assembly for drills, no documented first quarter 2021 waterflow alarm testing, fire suppression system inspection and testing past due, no documentation of rolling fire door drop tests, no visible placard for fire extinguisher operation, storage clearance not maintained in activities closet, and prohibited transfer grilles installed in multiple closets (previously cited 12/17/2021).

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documented monthly control valve and wet system riser inspections, no documented inservice training for residents on emergency roles, no documented bi-monthly staff training reviews on emergency plans, no documented testing of automatic hand sanitizer dispensers at refill, antifreeze loop documentation incomplete, emergency plan lacks point of assembly for drills, fire suppression system inspection and testing past due, and only one of two hood systems documented as cleaned semi-annually (previously cited 12/17/2021).

.405.01 Electrical Installations and Equipment: a cadet heater in room 15 North of the West building was blocked by a wooden dresser, violating the required three feet clearance per manufacturer's safety warnings.

.405.03 Medical Gases: no documented annual inservice training for staff on oxygen risks, and one unsecured oxygen cylinder found in the maintenance office.

.405.04 Fuel-Fired Heating: no documented annual fuel-fired heating inspection completed since September 2019.

.410 Requirements for Emergency Actions and Fire Drills: emergency egress and relocation drills lacked documentation on personnel and resident responses, problems encountered, or recommendations; drills from February 2020 onward only documented room checks due to COVID.

.415.05 Automatic fire extinguishing system service and testing: no documentation for weekly visual inspections of dry sprinkler system gauges and control valves or monthly visual inspections of wet sprinkler system gauges and control valves.

.405.01.b Electrical installations and equipment: use of a "Zip" style extension cord in west building room south 6, an extension cord on the exterior near the walk-in freezer, and a relocatable power tap plugged into a power strip in nurse's office creating a daisy chain.

.250.01 Building character: every mechanical/electrical room in both east and west buildings had annular penetrations at pipes and conduits carrying wires and cables through walls and ceilings not properly sealed.

.250.02.a. Plans and Specifications: no stamped architectural plans for remodeling of office spaces, bathroom renovation, sprinkler coverage modification, fire alarm system impact, and resident room modification (finding modified to reflect communications with owner and Fire/Life Safety AHJ).

.250.02.b. Plans and Specifications: failure to submit plans and specifications for new addition and remodeling work including electrical modifications; no permits available on site; no further work allowed until permits and approvals are received (finding modified to reflect communications with owner and Fire/Life Safety AHJ).

.415.05. Automatic Fire Extinguishing System Service and Testing: sprinklers showing signs of leaking and corrosion must be replaced; no monthly inspections documented on sprinkler control valve; antifreeze solution not tested by concentration as required.

.405.08. Portable Fire Extinguishers: K-style fire extinguisher in kitchen not signed per NFPA 10; sign must indicate use instructions and hood suppression system manual pull station activation.

.405.05. Structure, Maintenance, Equipment to Assure Safety: manual pull station blocked by fire extinguisher; penetrations in smoke and fire resistive assemblies unsealed; storage room requires self-closing hinge per NFPA 101.

.405.01. Medical Gases: electrical panels missing labeling and breaker identification; outlet not connected and missing cover; cadet heater blocked by table violating clearance requirements.

.405.01.b. Electrical Installations and Equipment: prohibited use of extension cords and multiple plug adapters in several rooms including gutter heater and pantry window.

.305.03 Resident Health Status: the facility nurse did not conduct assessments following changes of conditions for five residents, including delayed or missing assessments for wounds, falls, low blood sugar, and rashes.

.711.08.c Care Notes: the facility did not document when Resident #10 fell on three occasions, including a fall resulting in ER transportation and stitches; the administrator did not complete an investigation or facility response to these incidents.

.405.01 Medical Gases: Breaker #29 of the electrical panel in the west building, west corridor was not labeled.

.405.03 Medical Gases: Signage missing for oxygen in use with intermittent signs observed; unsecured oxygen cylinders found in rooms 10 North and 8 North in the West building.

.405.07 Exit Door Locks: Non-single operational locks in both buildings' exit doors to means of egress including administrator office, laundry room, both building salons, and both pantries in west building (systemic).

.410.02 Fire Drills: Missing documentation for graveyard shift fire drill in second quarter 2017.

.415.05 Automatic Fire Extinguishing System Service and Testing: Both buildings' antifreeze solution tested only for temperature, not concentration as required; temperature on propylene glycol mixture in West building showed -50 degrees; East building glycerin mixture showed -46 degrees; missing second quarter sprinkler flow tests for both buildings.

.415.05 Automatic Fire Extinguishing System Service and Testing: Corroded sprinkler heads found, one at laundry and three at kitchen in West building.

.009.01 Criminal History and Background Check: One of two staff, who required a criminal history and background check, did not have one.

.009.06.c Use of Previous Criminal History and Background Check: One of seven employees, who required an Idaho State Police (ISP) check, did not have an ISP check in their personnel file.

.219.02 Interim Care Plan: There was no documentation of an interim care plan for Resident #9.

.220.02 Written Agreement: Three of 10 residents did not have current admission agreements. One resident's admission agreement was not signed by all responsible parties. And two residents' admission agreements weren't dated.

.300.01 Licensed Professional Nurse (RN): The facility's licensed nurse did not delegate assistance of the medications to 3 of 4 medication technicians. In addition, the facility nurse did not document she had completed a 90-day assessment for Resident #2.

.305.02.a Current Medication Orders and Treatment Orders: The facility did not ensure physician's orders were correct and implemented. For example, three medications were missing for Resident #5. Resident #10 did not receive her Clotrimazole as ordered. Resident #2 had a medication in the cart for which there was no physician order. And Residents #1 and 7 did not receive insulin as ordered.

.305.02.c Current Medication Orders and Treatment Orders: The facility did not have current and signed medication orders in Resident's #1, 2, 3, 5, 7, and 8's record.

.305.03 Resident Health Status: There was no documentation the facility nurse assessed Resident #1 for a change of condition when the resident incorrectly received insulin which resulted in vomiting. Or when Resident #7 had multiple changes of condition, such as wound status, severe bloating, and his response to receiving another resident's insulin.

.305.06 Self-Administered Medication: The facility nurse did not assess Residents #2, 3, 4, and 6's ability to self-administer medications.

.305.08 Resident and Facility Staff Education: The facility nurse did not assess, document, or recommend health care related training for caregivers. For example, managing Resident #1's withdrawal from Risperidone when the medication was terminated suddenly and not tapered. And when a caregiver administered insulin for Resident #1 when she had a blood sugar in normal range.

.310.01.a Medication Distribution System: Insulin was left unsecured in the refrigerator in the medication room.

.320.01 Use of Negotiated Service Agreement: NSA's did not clearly describe care needs and services for 10 of 10 sampled residents. For example, Resident #1's NSA stated she had a job and could communicate her needs, however, she was observed to be non-verbal and contracted. Resident #6 had instructions for denture care in her NSA, however she does not wear dentures. And Resident #1's NSA was 8 months late.

.320.03 Signature, Date and Approval of Agreement: Resident #1's NSA was not signed and dated by her legal guardian.

.625.01 Number of Hours of Training: There was no documented evidence that 16 hours of orientation training was completed one employee.

.630.01 Dementia: One employee, whose record was reviewed, did not have documentation of dementia training.

.630.02 Mental Illness: One employee, whose record was reviewed, did not have documentation of mental illness training.

.630.03 Developmental Disability: One employee, whose record was reviewed, did not have documentation of developmental disability training.

.705.02 Written Admissions Agreement: Resident #5 did not have an admission agreement signed by the administrator. And Resident #9 had no admission agreement.

.710.04 Prior History and Physical: Resident #9's record did not contain a physician's history and physical that had been conducted within 6 months prior to admission.

.711.08 Care Notes: The facility did not ensure care notes were signed and dated by the person providing the care and services. For example, when the facility nurse responded to caregiver notes in resident records, the time and date were not included.

.725.01 Admission and Discharge Register: The facility did not maintain an up-to-date admission and discharge register.

.520-06 Inadequate Care - Assistance and Monitoring of Medications: The facility failed to provide assistance and monitoring of medications for 2 of 7 sampled Residents (#1 and #7) who were receiving insulin. Resident #1 was given insulin with a blood glucose level of 90 mg/dL and immediately started vomiting without documented medical evaluation or education for staff. Resident #7 was accidentally given another resident's insulin. Medication assistance staff were not trained or provided consistent parameters to ensure proper insulin administration, placing all diabetic residents at risk for complications including hypoglycemia, insulin shock, diabetic coma, or death.