Inspection Reports for
MorningStar Senior Living of Idaho Falls

.009.06.c Use of Previous Criminal History and Background Check: four of five employees did not have the Idaho State Police background check completed prior to working alone with residents.

.305.02.b Current Medication Orders and Treatment Orders: the facility failed to ensure residents' medications were given as ordered, including missed doses of melatonin and unavailable fentanyl patch and Haloperidol for Resident #10 (previously cited 3/2/2023).

.310.01.c Medication Distribution System: medication refrigerator temperatures were out of range multiple days from August to October 2025 with no corrective action taken, and the facility nurse was unaware.

.310.01.g Medication Distribution System: three of eleven sampled residents did not have their PRN medications available in the facility, including Resident #5, #7, and #10.

.310.02.e Discontinued and Expired Prescriptions: medication destruction logs did not include all required components, such as the date medications were destroyed; staff will revise forms to improve documentation.

.330.04.c.vii Resident Care Records: resident care records lacked documentation of assessments after changes in physical or mental health status for Residents #5, #8, and #10, although assessments were performed.

.630.02 Mental Illness: all fifteen staff records reviewed lacked mental illness training despite the facility retaining 33 residents with mental illness (previously cited 3/2/2023).

.155.02 Written Procedures: facility failed to provide documentation of an established Fire Watch procedure for when the fire suppression system is out of operation for more than four hours in a twenty-four-hour period.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: thirty smoke detectors failed sensitivity testing and there was no evidence they were recalibrated, cleaned, or replaced.

.405.01.a Electrical installations and equipment: use of a multi-plug adapter was identified in room #15, which is prohibited.

.405.02.a Prohibited applications: use of a relocatable power tap to supply power to an oxygen concentrator in room #112, which is prohibited.

.215. Requirements for a facility administrator: the facility operated without a licensed administrator for 28 days from 1/29/20 through 2/26/20, leaving no administrator overseeing day-to-day operations (previously cited 10/24/2019).

.305.02.b. Current medication orders and treatment orders: the facility did not ensure residents received medications as ordered, with multiple missed doses for several residents (previously cited 6/19/2019).

.310.02.f. Discontinued and expired prescriptions: medication disposal records lacked signatures of both the disposing staff and a witness; the facility policy allowed only one staff member to destroy non-narcotic medications, requiring two only for narcotics.

.330.04. Resident care records: care records were not maintained with current and complete entries; caregiver notes were missing for all sampled residents, and verbal reports were not documented.

.630.02. Mental illness: ten of ten staff records reviewed showed no mental illness training despite residents with mental illness; the administrator confirmed lack of training on 3/2/2023 (previously cited 1/12/2017).

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: facility lacked documentation for quarterly waterflow alarm testing, 5-year sensitivity test of smoke detectors, weekly and monthly inspections of suppression system gauges, testing of alcohol-based hand rub dispensers, bi-monthly emergency plan training, and annual inspection of fire rated doors.

.155.01 Relocation agreements: the facility had two verbal relocation agreements but no written agreements that could be reviewed and updated annually as required.

.155.03 Emergency generators: the facility could not produce documentation for weekly inspections during specified weeks, monthly load tests for November 2021 and March 2022, and monthly conductivity tests of the battery(s).

.450. Requirements for food and nutritional care services: the facility did not meet the standards for the Idaho Food Code; the kitchen inspection failed and a mandatory re-inspection was required within 10 days.

.335. Requirements for infection control: the facility did not follow CDC recommendations to prevent COVID-19 transmission, as staff, visitors, and outside agencies were not screened for symptoms or required to wear masks, and a caregiver was observed wearing PPE improperly.

.405.01 Medical Gases: Cadet heaters must maintain 3 feet of clearance on all sides; the 110 stairway had a chair placed in front of the heater and the salon had a makeup table in front of the heater (corrected 1/24/20).

.405.05 Structure, Maintenance, Equipment to Assure Safety: Facility must maintain 2-hour separation from assisted living to independent living; the 2-hour fire door assembly on the first floor would not close and latch. Storage under stairs shall be of a non-combustible type; a boxed Christmas tree was stored under the main stairs (this item corrected 1/24/20).

.415.04 Fire Alarm Smoke Detection System Service and Testing: No record of last sensitivity testing completed in the past five years.

.415.05 Automatic Fire Extinguishing System Service and Testing: Facility was originally constructed in 2008. No record of the ten-year dry system UL testing or replacement of dry system sprinkler pendants due in 2018.

.215.14 Notification to Licensing and Certification Unit: the facility failed to notify Licensing and Certification within 3 business days of a change in administrator; the previous administrator's last day was 9/28/19 but notification was not made until 10/23/19.

.215 Requirements For A Facility Administrator: the facility has not had a licensed administrator since 9/28/19.

.215.07 Notification of Adult Protection and Law Enforcement: the administrator failed to report all allegations of abuse, neglect, and exploitation to Adult Protection, including complaints in March 2018 and March 2019 involving stolen money.

.305.02.a Current Medication Orders and Treatment Orders: the facility nurse did not ensure residents' medications were consistent with physicians' orders; Resident #8 did not receive six ordered medications for six days, and Resident #1 missed two doses of Lasix due to a nurse error.

.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not complete an investigation and written report within 30 days for incidents involving complaints of stolen money in March 2018 and March 2019.

.405.03 Medical Gases: Room 101 had 30 oxygen cylinders stored in the closet that was not properly signed or constructed to meet the one-hour requirement; Room 112 had one unsecured oxygen cylinder; Room 203 had two oxygen concentrators, one plugged into a relocatable power tap (RPT). All deficiencies corrected on site.

.305.03 Resident health status: the facility nurse neither assessed nor documented the size, location and healing status of Resident #2 and #8's wounds.

.320.01 Use of negotiated service agreement: NSA's were not updated to reflect residents specific care needs, including assistance to cut up meat, wound care and preventive measures, incontinence needs, and preference to sleep in recliner.

.630.02 Mental illness: ten of ten staff, whose records were reviewed, did not have documentation of mental illness training.

.711.08 Care notes: the facility did not ensure care notes were signed and dated by the person providing the care and services, nor included in individual residents' records.