Inspection Reports for
Lincoln Court Assisted & Senior Living
850 Lincoln Dr, Idaho Falls, ID 83401, ID, 83401
Back to Facility Profile9 Reports
Inspection Report — Oct 10, 2024
Routine
Date: Oct 10, 2024
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
Two deficiencies were identified related to behavior documentation and staff certifications. The facility failed to evaluate multiple residents' maladaptive behaviors and lacked sufficient personnel with current first aid certification.
Deficiencies (2)
.330.06.a Behavior documentation: the facility did not evaluate multiple residents' maladaptive behaviors including scratching wounds, refusals of care, aggression, excessive call button use, and hallucinations; the administrator and nurse confirmed evaluations were not completed.
.600.04.b Sufficient personnel: eight of ten sampled direct care staff did not have current first aid certification, and multiple shifts in October 2024 lacked at least one certified direct care staff; the administrator and business office manager confirmed this.
Report Facts
staff_count: 8
staff_sample_size: 10
month: 10
year: 2024
Inspection Report — Oct 9, 2024
Life Safety
Date: Oct 9, 2024
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A fire life safety and sanitation licensure survey was conducted to assess compliance with electrical installations and equipment safety standards.
Findings
Three non-core deficiencies were identified involving prohibited use of multi-plug adapters, extension cords, and relocatable power taps supplying power to medical devices and appliances.
Deficiencies (3)
.405.01.a. Electrical Installations and Equipment: multiple devices in rooms #211 and #189 were powered by prohibited multi-plug adapters; extension cords were used in series in the main dining room to supply power to holiday décor.
.405.02.a. Prohibited Applications: a portable oxygen concentrator and a CPAP machine in room #245 were powered by a relocatable power tap, which is prohibited.
.405.02.c. Prohibited Applications: a miniature refrigerator in the upper-level nurses office was powered by a relocatable power tap, which is prohibited.
Inspection Report — Nov 19, 2021
Routine
Date: Nov 19, 2021
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
Six deficiencies were cited in the areas of notification to Adult Protection and law enforcement, medication distribution system, and resident care records documentation.
Deficiencies (3)
.215.07 Notification to Adult Protection and Law Enforcement: the facility did not notify Adult Protection and law enforcement when an unsampled resident inappropriately touched a memory care resident, and the administrator failed to report this incident as required (previously cited 9/16/2015).
.310.01.c Medication Distribution System: the medication refrigerator temperatures were not maintained within required ranges on multiple occasions, and temperatures in residents' room refrigerators were not monitored or documented daily.
.330.04 Resident Care Records: the facility used a notebook documenting multiple residents on each page, preventing proper filing; calls and communications regarding resident issues were not consistently documented in residents' records by caregivers and medication technicians.
Inspection Report — Mar 17, 2021
Life Safety
Date: Mar 17, 2021
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A Fire Life Safety Survey was conducted to assess compliance with fire and life safety standards at Lincoln Court Retirement Community.
Findings
Non-core issue deficiencies were identified related to staff training documentation, inspection and signage of safety equipment, relocation agreements, HVAC safety barriers, and medical gas storage practices.
Deficiencies (4)
.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: facility lacked documentation for staff training on oxygen use, inspection of alcohol-based hand rub dispensers, visual inspections of suppression system gauges, and required delayed egress door signage; directional exit sign was partially obstructed.
.155.01 Relocation agreements: the facility had only one relocation agreement instead of the required two, and the agreement had not been updated annually since 2018.
.250.10.b Heating, ventilation, and air-conditioning (HVAC): facility gas fireplaces were not equipped with a safety barrier.
.405.03 Medical gases: full and empty oxygen cylinders were not segregated, and empty cylinders were not marked to avoid confusion and delay.
Inspection Report — Jan 28, 2019
Life Safety
Date: Jan 28, 2019
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A Fire Life Safety Survey was conducted to assess compliance with fire safety and sanitation licensure requirements.
Findings
Eleven deficiencies were found related to fuel-fired heating, fire extinguisher service, automatic fire extinguishing system testing, electrical installations, emergency lighting, fire drills, smoke detection system testing, medical gases, resident sleeping rooms, and building character.
Deficiencies (11)
.415.02 Fuel-Fired Heating: no gas fireplace inspection report; last known inspection was July 28, 2017.
.415.03.e Portable Fire Extinguisher Service and Testing: fire extinguishers were not checked monthly during 2018; all were missing checks in September and most were missing several months.
.415.05 Automatic Fire Extinguishing System Service and Testing: painted sprinkler head in stairwell next to rooms #116 and #285, missing documentation for quarterly sprinkler inspection 2nd quarter 2018, and no placard for Class K extinguisher in kitchen.
.405.01 Medical Gases: blocked electrical panels in the kitchen office.
.405.01.b Electrical Installations and Equipment: zip extension cord in room #290, daisy chained Relocatable Power Taps for aquariums, refrigerators plugged into RPTs in reception and break room, and microwave and refrigerator plugged into RPT in second floor break room.
.405.05 Structure, Maintenance, Equipment to Assure Safety: emergency lighting non-operational on 1st floor between rooms #185 and #187 and on second floor across from room #296, no monthly testing of emergency lights since April 2018, and no documentation for 90 minute annual test.
.410.02 Fire Drills: missing fire drill documentation for 2nd and 3rd shifts second quarter 2018 and 3rd shift fourth quarter 2018.
.415.04 Fire Alarm Smoke Detection System Service and Testing: no documentation for 5 year sensitivity test of smoke detectors.
.405.03 Medical Gases: unsecured oxygen tank in resident room #176.
.250.13.l Resident Sleeping Rooms: resident rooms #174, 181, 275, and 290 missing closet doors with no variance on file for removal.
.250.01 Building Character: approximately 2' x 4" penetration in wall behind washing machine in second floor laundry room and multiple penetrations at pipes and conduits in mechanical/electrical rooms.
Inspection Report — Sep 19, 2017
Life Safety
Date: Sep 19, 2017
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with fire and life safety standards.
Findings
Multiple penetrations were found in walls and ceilings in various areas, fire doors lacked required self-closing and hold-open devices, electrical panels were blocked or unlabeled, and unsafe electrical installations were observed. Oxygen tanks were unsecured, emergency lighting and smoke detector testing were deficient, a portable space heater was improperly located, and fire extinguishing system maintenance was incomplete.
Deficiencies (8)
.250.01 Building Character: the following areas had penetrations at the wall or ceiling including laundry, business office, memory care mechanical room, maintenance bay, and kitchen dish area.
.400. Requirements For Fire And Life Safety Standards: the two doors between the kitchen and dining room need to be self-closing and on magnetic hold open devices interconnected to the fire alarm system to protect the dining/corridor from the hazardous area in the kitchen.
.405.01 Medical Gases: electrical panels were blocked in the memory care mechanical room and maintenance bay, and electrical panels behind the front desk and in memory care were not labeled properly.
.405.01.b Electrical Installations and Equipment: multiple areas were utilizing multi-plug adapters, extension cords, or daisy chaining relocatable power taps including rooms 170, 104, hair salon, 211A, 148, and 153.
.405.03 Medical Gases: resident was transfilling oxygen in room 156, oxygen transfilling room lacked adequate ventilation, and unsecured oxygen tanks were found in rooms 104, 200, and 128.
.405.05 Structure, Maintenance, Equipment to Assure Safety: missing annual 90 minute testing of emergency lighting since December 2015, emergency lights in kitchen and hallway were not operational, and no documentation for testing smoke detectors with battery backup power.
.405.05.f Structure, Maintenance, Equipment to Assure Safety: a portable space heater was located in the bathroom of resident room 156.
.415.05 Automatic Fire Extinguishing System Service and Testing: no placard for Class K extinguisher in kitchen, last 5-year internal pipe/gauge inspection was in 2012, no sprinkler in walk-in freezer, missing escutcheon rings in multiple locations, and painted sprinkler head in marketing closet.
Report Facts
date: 2015-12
date: May 24, 2012
count: 2
count: 3
count: 5
count: 6
Inspection Report — May 12, 2016
Life Safety
Date: May 12, 2016
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety standards.
Findings
Six non-core deficiencies were cited involving fuel-fired heating inspections, electrical installations, exit signage and door operations, fire extinguishing system maintenance, and elevator and smoke door functionality.
Deficiencies (5)
.415.02 Fuel-Fired Heating: no record of fireplace inspection since February 2015 and no record of furnace inspection since 2013 (repeat).
.405.01.b Electrical Installations and Equipment: room number 146 using two 3-1 multiple plug adapters (repeat).
.405.05 Structure, Maintenance, Equipment to Assure Safety: installed exit signs in multiple locations incorrectly point to dead ends or walls; memory care exit doors have magnetic locking and delayed egress releasing without signage; delayed egress door next to room 132 not releasing under 15lbf.
.415.05 Automatic Fire Extinguishing System Service and Testing: painted sprinkler head in hall outside lobby by under-stair closet and painted head in second floor landing of stairwell abutting room 278.
.405.05 Structure, Maintenance, Equipment to Assure Safety: elevator smoke doors on upper and lower floors would not self-close; oxygen transfill door not closing and latching; smoke doors by room 296 not latching (repeat).
Inspection Report — Feb 11, 2016
Follow-Up
Date: Feb 11, 2016
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A health care non-core deficiency follow-up survey with complaint investigation was conducted to assess compliance with licensing requirements.
Findings
Two non-core deficiencies were identified related to plumbing and work records. The facility water temperature exceeded the allowed maximum, and staff schedules were not maintained as required.
Deficiencies (2)
.250.10 Plumbing: the facility water temperature exceeded 120 degrees Fahrenheit when it was temped at 130.6 degrees (previously cited 9/16/2015).
.730.02.a Work Records: the facility did not maintain an "as worked" staff schedule for the previous 3 years.
Report Facts
temperature: 130.6
duration: 3
Inspection Report — Sep 16, 2015
Follow-Up
Date: Sep 16, 2015
Visit Reason
A Health Care Core Deficiency Follow-Up and complaint investigation survey was conducted to assess compliance with state regulations and to investigate complaints.
Complaint Details
The survey included a complaint investigation component; however, specific details about the complaint and its substantiation were not provided in the report.
Findings
The survey identified multiple deficiencies in staff background checks, abuse reporting, notification procedures, resident care documentation, and facility policies. Several issues were previously cited and remain uncorrected.
Deficiencies (14)
.009.06.c Use of Previous Criminal History and Background Check: the facility did not have evidence that Idaho State police background checks had been conducted for 2 employees (previously cited 5/1/2015).
.153.01 Response of Staff to Abuse, Neglect or Exploitation of Residents: the facility's abuse policy did not include reporting to Adult Protection, per state statutes.
.215.07 Notification of Adult Protection and Law Enforcement: the administrator did not ensure that Adult Protection and Law Enforcement were notified of all allegations of abuse according to Idaho Code.
.220.02 Written Agreement: the facility's admission agreement was not transparent and clearly understandable regarding how level of care charges were determined.
.225.01 Evaluation for Behavior Management: the facility did not evaluate residents' specific behaviors (previously cited 5/1/2015).
.250.10 Plumbing: the water in the MC Unit was tempered at 126.6 degrees.
.305.03 Resident Health Status: the facility nurse did not document the status of residents' wounds or when residents had changes in condition (previously cited 6/13/2013 and 5/1/2015).
.310.04.d Psychotropic or Behavior Modifying Medication: the facility did not monitor residents for side-effects of psychotropic medications that impacted residents' health and safety (previously cited 5/1/2015).
.350.01 Notification of Accidents, Incidents, and Complaints: the administrator was not notified of all incidents, accidents, and complaints.
.350.04 Written Response to Complaint Within Thirty Days: the administrator did not provide a written response to complainants (previously cited 5/1/2015).
.451.02 Snacks: the facility did not offer snacks to all residents three times a day.
.711.01 Ongoing Resident Care Records: the facility did not track residents' behaviors to include the date and time a specific behavior was observed, what specific interventions were used, and the effectiveness of the intervention.
.730.02.a Work Records: work records did not include the days and hours the facility nurses and administrator worked (previously cited 5/1/2015).
.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not conduct investigations of all incidents, accidents, and complaints (previously cited 5/1/2015).
Report Facts
temperature: 126.6
employees_count: 2
snack_offerings: 3
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