Inspection Reports for
Sage Grove Assisted Living
290 North 4064 East, Rigby, ID, 83442
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Inspection Report — Feb 11, 2026
Complaint Investigation
Date: Feb 11, 2026
Visit Reason
A health care complaint investigation survey was conducted to assess compliance with regulations.
Findings
Four non-core deficiencies were found related to incomplete criminal history checks and medication labeling and policy compliance issues.
Deficiencies (4)
.009.01 Criminal History and Background Check: two employees did not have a Department Criminal History and Background Check completed.
.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.
.310.01 Medication Distribution: several medication bottles for residents were unlabeled, lacking resident names and physician instructions, confirmed by the facility nurse.
39-3321.2.a Qualifications and Requirements of Administrator: the administrator or designee did not ensure policies and procedures were developed and implemented to comply with the medication responsibilities policy; over-the-counter medications brought by families were not bubble packed as required.
Inspection Report — Jul 26, 2024
Routine
Date: Jul 26, 2024
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with Idaho RALF regulations.
Findings
The survey identified multiple deficiencies related to staff training, administrator responsibilities, secure environment, housekeeping, medication management, resident assessments, behavior documentation, and delegation. The facility failed to ensure proper training, secure environment, medication availability, and documentation of resident care and behaviors.
Deficiencies (16)
.154. Staff training requirements: the facility did not ensure all staff were sufficiently trained on facility policies, documentation, responding to residents’ behaviors, proper use of medical equipment, and when to notify the nurse; staff frustrations and inconsistent documentation were noted.
.215.01. Administrator responsibility: the administrator did not ensure all facility policies fulfilled IDAPA16.03.22, including abuse/neglect/exploitation reporting procedures and contact information for local adult protection and law enforcement.
.250.13. Secure environment: the facility did not provide a secure environment for residents with cognitive impairments and elopement risk; residents had access to door codes and unsecured exits, and staff supervision was inadequate.
.260.06. Housekeeping and maintenance services: the facility was not maintained in a clean, safe, and orderly manner, with broken gates, worn concrete, missing furnace covers, chipped tiles, frayed carpet, soiled vent covers, stains, scuff marks, and missing paint observed.
.260.07. Toxic chemicals: toxic chemicals were stored unsecured in areas accessible to cognitively impaired residents, including laundry rooms, kitchens, and resident bathrooms, despite prior technical assistance.
.305.02.b. Current medication orders and treatment orders: the facility nurse did not ensure all ordered medications were available; multiple residents missed doses due to unavailability, and some medications were held without documented nurse direction.
.305.03. Resident health status: the facility nurse did not consistently assess residents after changes in condition; staff administered PRN medications without nurse permission, and nurse was unaware of assessments and medication administration.
.310.01.c. Medication distribution system: medication refrigerator temperatures were not monitored or maintained within required ranges, with frequent out-of-range temperatures and lack of staff awareness.
.310.01.g. Medication distribution system: three residents did not have as-needed medications available at the facility, and the nurse was unaware of the shortages.
.310.04.e. Psychotropic or behavior modifying medication: six residents requiring six-month psychotropic medication reviews did not have them; the facility was behind on performing these reviews.
.319.03. Nursing assessment: five residents admitted after 7/1/20 did not receive physical assessments prior to admission; the nurse was unaware of this requirement.
.330.04. Resident care records: the nurse did not ensure text messages and communications were documented in residents' records; assessments and medical records were inconsistently documented or missing.
.330.06.a. Behavior documentation: the facility did not evaluate residents’ behaviors when they became physically aggressive or exhibited new maladaptive behaviors, despite staff documentation and resident statements.
.330.06.b. Behavior documentation: the facility did not develop behavior plans with interventions for residents exhibiting new maladaptive behaviors.
.330.14. As worked schedules: the facility's as-worked schedule did not document dates and times for the administrator and nurses, nor include positions of all other staff; times were not recorded accurately.
.645.02. Delegation: one staff member who passed medications was not delegated by the nurse and worked six night shifts alone without delegation.
Report Facts
date: Jul 7, 2024
date: Jul 15, 2024
date: Mar 25, 2024
date: Jun 27, 2024
date: Feb 26, 2024
date: May 20, 2021
count: 28
count: 5
count: 21
count: 10
count: 15
count: 17
count: 12
count: 5
count: 14
count: 16
count: 6
Inspection Report — Jul 20, 2022
Life Safety
Date: Jul 20, 2022
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety standards.
Findings
Three deficiencies were found related to relocation agreements, fire and life safety standards, and emergency fire drills. The facility's relocation agreements were outdated, fire suppression and safety testing were not documented, and fire drills had not been conducted as required.
Deficiencies (3)
.155.01 Relocation agreements: documented relocation agreement is dated 2018; the facility must have at least two relocation agreements with separate locations reviewed annually.
.403 Fire and life safety standards: old building fire suppression system gauges were outdated with no documented five-year calibration or piping inspection; automatic alcohol-based hand rub dispensers lacked documented testing after refills; no documented sensitivity testing for new and old buildings as required (previously cited 2017 and 2018 gauges).
.410 Requirements for emergency actions and fire drills: no documented fire drills since 2020; facility must conduct at least six drills per year including two on night shift when residents are sleeping.
Inspection Report — Nov 1, 2017
Life Safety
Date: Nov 1, 2017
Visit Reason
A Fire Life Safety Survey was conducted to assess the safety environment of the facility.
Findings
Non-core issue deficiencies were identified related to the sprinkler system's anti-freeze solution testing and documentation.
Deficiencies (1)
.415.05 Automatic Fire Extinguishing System Service and Testing: sprinkler system anti-freeze solution was not being tested according to concentration based on percentage, but by temperature. No documentation on the sprinkler report or the sprinkler riser as to the percentage of anti-freeze installed.
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