Inspection Reports for
Post Falls Ops, LLC, dba Guardian Angel Homes

.305.03 Change in Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including residents with falls, fractures, and behavioral issues.

.320.01 Use of NSA: the facility did not coordinate Resident #6's needs when the Negotiated Service Agreements did not clearly reflect their needs nor describe the services to be provided.

.330.06.a Additional Resident Records: the facility did not evaluate residents' behaviors, including suicidal and homicidal ideation and inappropriate sexual comments and threats.

.330.06.b Additional Resident Records: the facility did not develop or review interventions specific for maladaptive behaviors to evaluate effectiveness and continued need.

39-3321.4 Qualifications and Requirements of Administrator: the administrator did not immediately implement corrective action to ensure incidents and accidents did not recur after multiple falls by Resident #6.

.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: UL testing of fast response sprinkler heads was overdue and no documentation was provided; smoke detector sensitivity testing was not identified since 2017 for multiple buildings.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: a 6" by 8" penetration of the ceiling membrane in the laundry room was identified, violating smoke partition continuity requirements.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: a 1" gap between panels of UL listed hood assembly filters was found, allowing grease laden vapors to bypass filtration.

.405.01.a Electrical installations and equipment: multi-plug adapters and a multi-plug extension cord were used in various rooms, which is prohibited.

.405.02.a Prohibited applications: oxygen concentrators in two rooms were powered by relocatable power taps, which is prohibited.

.009.01 Criminal history and background check: one of ten employees worked alone for at least seven shifts before the facility obtained their completed Department Criminal History and Background Check.

.300.01 Licensed professional nurse (RN): the facility RN did not complete initial nursing assessments for several residents and was behind on timely quarterly nursing assessments (previously cited 2/28/2020).

.305.02.a Current medication orders and treatment orders: medication labels were not up-to-date with providers' orders, including discrepancies in dosing instructions for multiple residents.

.305.02.b Current medication orders and treatment orders: residents did not receive medications as ordered, including missed doses and delays in starting new medications; medications were sometimes unavailable.

.310.01.c Medication distribution system: medication refrigerator temperatures were not maintained between 38 and 45 degrees F, with documented lows as low as 32 degrees.

.310.01.g Medication distribution system: the facility did not ensure all residents' as-needed (PRN) medications were available, with multiple medications missing for several residents.

.310.02 Discontinued and expired prescriptions: accumulation of unused, discontinued, or expired medications for more than 30 days was observed, including expired fentanyl patches.

.310.04.e Psychotropic or behavior modifying medication: residents were taking psychotropic medications for longer than six months without six-month medication reviews (previously cited 2/28/2020).

.320.08 Periodic review: negotiated service agreements were not consistently updated to reflect significant changes in residents' health status, including skin conditions and hospice status.

.330.04 Resident care records: documentation requirements were not met, including incomplete signatures and failure to document unusual events concerning residents.

.335. Requirements for infection control: the facility did not maintain sanitary controls in the kitchen; sanitizing solution was not properly mixed, knives were not properly washed, and the walk-in refrigerator and freezer contained numerous food debris on the floor.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: facility could not produce documentation for a 3-year full-trip test of the dry suppression system, sensitivity testing data for addressable smoke alarm systems was missing, last annual fire alarm inspection was in 2019, semi-annual kitchen hood cleaning was last completed in 2020, and emergency lighting was non-operational in two building areas.

.250.10.b Heating, ventilation, and air-conditioning (HVAC): operational gas fireplaces and heat producing built-in electric fireplaces did not have safety barriers.

.405.04 Fuel-fired heating: facility could not produce documentation to show operational gas fireplaces had been inspected in the past 12 months.

.009.06.c Use of Previous Criminal History and Background Check: two of seven sampled employees did not have documentation of Idaho State Police background checks prior to working alone at the facility.

.300.01 Licensed Professional Nurse (RN): ten of ten sampled residents' 90-day nursing assessments did not include a physical assessment, and nursing assessments were not conducted when three residents experienced changes in condition.

.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not provide behavioral updates to the physician for three residents to facilitate informed decisions about their psychotropic medication.

.600.06.b Sufficient Personnel: two of eight caregivers did not have documented evidence of CPR or First Aid training prior to working alone (previously cited 4/26/2017).

.405.01 Medical gases: cadet heater blocked by recliner in Timber building Room 13 and nurse's office switch plate cover missing.

.405.01.b Electrical installations and equipment: relocatable power taps were used improperly in multiple staff areas including marketing office, breakroom, basement, and Tudor House nurse's office.

.405.03 Medical gases: two unsecured oxygen cylinders found in Inn building Room 10; oxygen cylinders must be secured per NFPA 99.

.405.05 Structure, maintenance, equipment to assure safety: fire alarm pull station blocked in Marketing office of Timber building; pull stations must not be blocked per NFPA 72.

.415.05 Automatic fire extinguishing system service and testing: no record of 10 year dry pendant testing or replacement in all buildings per NFPA 25.

.405.05 Structure, Maintenance, Equipment to Assure Safety: emergency light in the dining room was not operational.

.405.07 Exit Door Locks: delayed egress doors were not properly labeled with signage, and several exit doors had delayed egress components that were non-operational and did not release after 15 seconds.

.415.01 Maintenance of Equipment and Systems: only six inches of clearance at the Ansul System pull station and Class K Fire Extinguisher in the kitchen, not the required three feet.

.415.04 Fire Alarm Smoke Detection System Service and Testing: no documentation for a five year sensitivity testing in the Tudor, Timber and Craftsman buildings.

.600.06.b Sufficient Personnel: two of ten sampled staff members, who worked alone, did not have evidence of completing either CPR or First Aid training.

.250.01 Building Character: multiple penetrations in walls and ceilings around pipes and wires in mechanical rooms.

.415.02 Fuel-Fired Heating: missing annual inspection for the fuel-fired heating systems; last inspection was 8/26/2015.

.415.03 Portable Fire Extinguisher Service and Testing: multiple fire extinguishers are mounted higher than 60 inches (between 63 and 65 inches).