Inspection Reports for
Quail Ridge

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

.009.06.c Use of Previous Criminal History and Background Check: two of five staff members did not have documentation of an Idaho State Police background check within thirty days of obtaining previous results.

.305.02.a Current Medication Orders and Treatment Orders: medication orders were inconsistent between the medication bubble pack and the medication administration record for two unsampled residents.

.305.03 Resident Health Status: the facility nurse did not conduct change of condition assessments for residents after hospitalization or episodes of diarrhea (previously cited 11/30/2022).

.310.01.c Medication Distribution System: the medication refrigerator temperatures were not maintained between 38 and 45 degrees Fahrenheit, documented between 30 and 37 degrees for 16 days in August 2025, with no corrective actions taken.

.310.01.d Medication Distribution System: medication technicians did not contact the facility nurse prior to assisting cognitively impaired residents with PRN medications, contrary to facility policy.

.310.01.g Medication Distribution System: not all ordered PRN medications were available to residents at all times, including simethicone, cetirizine, guaifenesin, albuterol, Metamucil, and Ayr nasal drops.

.310.02 Discontinued and Expired Prescriptions: the medication destruction log did not document all non-narcotic and narcotic medication disposals, nor consistently include resident names or methods of destruction.

.330.06.a Behavior Documentation: the facility did not evaluate residents when they exhibited maladaptive behaviors, including Residents #9 and #11 (previously cited 2/9/2024 and 11/30/2022).

.330.06.b Behavior Documentation: the facility did not develop behavior plans with specific interventions for Residents #9 and #11 as required (previously cited 2/9/2024 and 11/30/2022).

.330.06.c Behavior Documentation: the facility did not document each instance observed nor the effectiveness of interventions after Residents #9 and #11 engaged in maladaptive behaviors.

39-3321.2.d Qualifications and Requirements of Administrator: the facility did not develop interventions to prevent recurrences after residents' incidents, including multiple falls experienced by Residents #5, #8, and #10.

.404 Fire and life safety standards: the facility failed to maintain fire suppression visual inspection of pressure gauges on the wet system and failed to maintain UL 300 hood ventilation systems due to gaps between kitchen hood filters (previously cited 7/5/2022).

.405.02.a Prohibited applications: oxygen concentrators in Rooms 802 and 709 were powered using relocatable power taps, which is prohibited.

.405.02.c Prohibited applications: a coffeemaker in Room 602 was powered using a relocatable power tap, which is prohibited.

.405.03 Medical gases: four 'A' oxygen cylinders were not secured properly; one was on the floor and three were placed within a seat cushion, contrary to NFPA 99 requirements.

.215.08.d. Written Response to Complaint within Thirty Days: the facility did not provide written responses to complainants within 30 days despite six complaints documented from May to December 2023.

.310.04.a. Psychotropic or Behavior Modifying Medication: the facility did not attempt non-drug interventions before prescribing antipsychotic medication to Resident #6, and no behavior evaluation or plan was in place prior to medication.

.330.06.a. Behavior Documentation: the facility failed to evaluate residents' maladaptive behaviors including frequent call light use, hitting, yelling, entering other residents' rooms, and taking belongings; this was previously cited on 11/30/2022.

.330.06.b. Behavior Documentation: the facility did not develop behavior plans with specific interventions for Residents #5, #6, and #7, and multiple staff confirmed no behavior plans were available; previously cited on 11/30/2022 for not implementing interventions.

.150. Policies and procedures: the facility's abuse/neglect/exploitation policy did not include all required elements such as the phone number for adult protection, steps to protect residents from further abuse, education for residents and visitors, restrictions on alleged perpetrators, and procedures if the administrator is the suspected abuser. The facility was previously provided technical assistance on 12/4/2019 and given an Abuse Policy Checklist to update their policy.

.215.08.b. Investigation within Thirty Days: the administrator did not conduct an investigation within 30 days when Resident #3 attempted to remove Resident #1's shirt on 10/31/22 and when Resident #10 sustained four falls from 5/30/22 to 10/27/22. The administrator confirmed no investigations were conducted for these incidents.

.215.08.e. Corrective Action: the administrator did not develop interventions to prevent recurrences of incidents and accidents involving Resident #3 and Resident #10 despite their documented incidents.

.305.03. Resident Health Status: the facility RN did not conduct physical assessments when residents experienced changes in condition, including Resident #1's increased confusion and weakness, Resident #7's unassessed breast mass and infections, and Resident #8's nose bleed which was not known to the nurse.

.305.06.b. Self-Administered Medication: the facility nurse did not assess Resident #8's ability to self-administer medications every 90 days, including self-injection of insulin, and the RN confirmed these assessments were not completed.

.319.04. Maladaptive Behaviors: the facility did not evaluate behaviors for Residents #3 and #6 despite reports of Resident #3's aggressive and inappropriate behaviors and Resident #6's verbal aggression and use of vulgar language. Records lacked evaluations and the RN, LPN, and administrator confirmed no evaluations were done.

.320.01. Use of NSA: Residents #1, #3, #6, #7, and #9's Negotiated Service Agreements did not clearly reflect their specific needs or describe services to be provided including eating, toileting, bathing, dressing, mobility, and night needs. Canned language was used without detailed, resident-based instructions.

.330.06.b. Behavior Documentation: the facility did not develop behavior plans with interventions for Resident #3's unsolicited inappropriate behaviors or Resident #6's verbal and physical aggression. The RN stated no behavior plans were in place for these behaviors.

.330.14. As Worked Schedules: the facility's as-worked schedule did not document exact times staff members were at the facility. The administrator, LPN, and RN did not have documented as-worked schedules.

.404 Fire and life safety standards for existing buildings: the facility did not maintain compliance with the 2018 edition of NFPA 101, Life Safety Code, Chapter 33, as it could not produce documentation for quarterly waterflow alarm testing for fourth quarter 2021 and monthly visual inspections of wet suppression system gauges and secured control valves.

.155.03 Emergency generators: the facility elected to have an emergency generator on site but could not produce documentation for weekly inspections for all of 2021 and the 2nd and 3rd week of July 2022 as required by NFPA Standard 110.

.250.10.d Heating, ventilation, and air-conditioning (HVAC): fire and smoke dampers must be inspected, serviced, and cleaned once every four years by a professional; the facility was not able to produce documentation to show dampers had been inspected in the past four years.

.405.04 Fuel-fired heating: fuel-fired heating devices and systems must be inspected, serviced, and cleaned at least annually by a professional; the last known inspection was May 28, 2021.

.155.01 Relocation agreements: the facility had two relocation agreements but they had not been updated annually.

.404 Fire and life safety standards for existing buildings: facility activity office had a hole in the wall, non-factory painted sprinkler heads were present, Alcohol Based Hand Rub dispensers lacked inspection documentation, and staff training on oxygen use was not documented.

.405.04 Fuel-fired heating: the facility had two gas fireplaces and gas-powered furnaces but could not produce documentation of inspection within the past 12 months; last known inspection was in 2018.

.405.01 Electrical installations and equipment: prohibited extension cords and multi-plug adapters were in use, including a non-grounded extension cord running through a cabinet and drawer, and multi-plug adapters in the maintenance shop and basement laundry room.

.405.02 Prohibited applications: Relocatable Power Taps were used improperly, including daisy chaining at the basement TV room and multiple appliances plugged into a single RPT in the housekeeping office.

.155.03 Emergency generators: the facility could not produce documentation for monthly conductivity testing of the battery as required by NFPA Standard 110.

.300.01 Licensed Professional Nurse (RN): the facility nurse did not conduct nursing assessments when residents experienced a change in condition, including issues such as red leg, wounds, dizziness, hallucinations, and falls.

.305.02.b Current Medication Orders and Treatment Orders: residents did not have current medication or diet orders, and ordered medications were not available for two days; this was previously cited 12/01/2017.

.305.06 Self-Administered Medication: the facility nurse did not assess residents' ability to self-administer medications.

.310.04.e Psychotropic or Behavior Modifying Medication: six month psychotropic medication reviews for residents did not include behavioral updates; previously cited 6/17/2015.

.600.06.a Sufficient Personnel: staff, family, and residents reported insufficient staffing; the facility had 46 residents with varying acuity and limited staff coverage during the day and afternoon shifts; previously cited 12/01/2017.

.711.08.e Care Notes: caregivers did not document notifying the nurse prior to giving PRN medication or wound care, nor changes in condition; previously cited 6/17/2015.

.730.01.e Personnel: three of seven staff records lacked documentation of Mental Illness Training; the facility had not included this training in orientation.

.730.01.h Personnel: one medication technician lacked documentation of delegation by the nurse prior to administering medications; the nurse did not delegate staff before training on the medication cart.

.305.02.b. Current Medication Orders and Treatment Orders: the facility did not ensure Resident #2 received her oxygen as ordered and another resident's oxygen tank was empty; Resident #2 lacked Cyclobenzaprine for about 30 days; Resident #1 refused hydrocodone for about 1 month without physician notification.

.600.06.a. Sufficient Personnel: the facility did not schedule sufficient staff to ensure all residents received baths as agreed upon in their NSAs.