Inspection Reports for
The Cottages Assisted Living and Memory Care-Boise

.405.03 Telephone: the facility failed to store oxygen tanks securely in racks or carts; two tanks were unsecured and standing upright by the door in room #4, despite multiple requests for a stand.

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

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: two emergency lights were non-operational and staff training on the emergency plan was not documented as conducted periodically or bi-monthly.

.410. Requirements for emergency actions and fire drills: the facility conducted only one night drill in the past 12 months and was missing required bi-monthly drills for certain months in House #1 and House #2.

.151. Activity requirements: no activities were offered to residents in Building #1 despite a calendar showing two activities per day; residents reported being bored.

.215. Requirements for a facility administrator: the facility lacked a licensed administrator for 24 days between 3/31/22 and 4/24/22 (previously cited 2/9/22).

.215.08.b. Investigation within thirty days: investigations were not conducted within 30 days for incidents involving Resident #5 and Resident #4; the administrator stated investigations were incomplete.

.216.01. Initial resident assessment and care plan: the facility did not document an interim care plan for Resident #8, a flight risk, despite verbal communication of concerns.

.250.13. Secure environment: the facility was not secured, allowing Residents #6 and #8, both at risk for elopement, to leave and be found in another state (previously cited 5/13/21).

.305.03. Resident health status: nursing assessments were not conducted for changes in residents' health status, including falls and elopements involving Residents #5, #6, and #8 (previously cited 5/13/21).

.310.01.c. Medication distribution system: the medication refrigerator was not maintained between 38 and 45 degrees F, with documented temperatures below range multiple times in early 2023.

.310.04.a. Psychotropic or behavior modifying medication: non-drug interventions were not attempted prior to medication requests for Residents #4, #5, and #6; behavior management plans were incomplete or missing.

.310.04.e. Psychotropic or behavior modifying medication: six-month psychotropic medication reviews were not completed for three residents taking such medications longer than six months.

.319. Comprehensive assessment requirements: assessments for Residents #4 and #5 lacked demographics, nursing, and maladaptive behavior evaluations prior to admission.

.320.01. Use of NSA: residents' negotiated service agreements did not clearly reflect needs or services, such as hospice coordination and wound care for Resident #4.

.320.03. Signature, date, and approval of agreement: NSAs were not signed and dated by residents or their legal representatives for Residents #1 through #5.

.330.04.c.vii. Resident care records: change of condition assessments were not documented for incidents involving Residents #1 and #2 despite nursing assessments.

.330.06.a. Behavior documentation: evaluations were not completed for Residents #1, #2, #3, #5, #6, and #8 regarding various behaviors including suicidal ideation and elopement.

.330.06.b. Behavior documentation: behavior plans with specific interventions were not completed for Residents #1, #2, #3, #5, #6, and #8 as required.

.330.14. As worked schedules: the facility's schedules did not document the times the nurse or maintenance supervisor were present at the facility.

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: no documented quarterly waterflow alarm testing since 2018, insufficient viewing of control valve positions, smoke detector failure not replaced, past due 5-year internal obstruction inspection, no emergency light testing since October 2021, and past due full flow trip testing (previously cited).

.410. Requirements for emergency actions and fire drills: no documented fire drills since February 2021 (repeat deficiency).

.215. Requirements for a facility administrator: the facility did not have a licensed administrator for three different periods in the last six months, resulting in difficulties reporting incidents and unreported injuries (previously unknown).

.600.04.a. Sufficient personnel: the facility did not schedule enough staff during all hours, particularly overnight, causing caregivers to leave buildings unattended and resident care needs, such as showers, to be missed.

.250.13 Secure environment: the facility did not provide a secure environment because an unsampled resident knew and used the codes for the front door and gate to exit and re-enter the facility.

.305.03 Resident health status: the facility nurse did not assess residents after changes in condition, including choking, falls, blisters, and diarrhea.

.600.04.b Sufficient personnel: a night shift caregiver worked alone without current CPR certification (previously cited 9/6/2019).

.410. Requirements for emergency actions and fire drills: facility could not produce documentation for fire drills during second quarter 2020 for second and third shifts; under the new rule requiring bi-monthly fire drills, facility had not performed any fire drills since August 20, 2020.

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: facility did not maintain compliance with the 2018 edition of NFPA 101, Life Safety Code, Chapter 33, as evidenced by lack of documentation for staff training on oxygen use and handling and non-operational emergency lighting in building #2 at multiple locations (this is a repeat deficiency).

.625.03.e. Content for training: facility could not produce documentation showing staff are trained at the time they are hired and annually thereafter on how to respond in an emergency.

.405.01. Electrical installations and equipment: building #2 had miscellaneous storage items in front of the electrical panels in the garage, making the electrical panels inaccessible.

.405.02.b. Prohibited applications: building #2 had a daisy chain at the west corner of the garage; a non-grounded "zip" style extension cord had been plugged into a heavy duty extension cord to provide power to the exterior Christmas lights.

.250.12.j. Resident sleeping rooms: resident room #5 in building #1 would not latch.

.405.01.b. Electrical Installations and Equipment: Resident rooms #4/5 and #11, Building #1 had a "zip" style extension cords; Resident room #2, Building #2, had a Multi-Plug Adapter.

.405.05. Structure, Maintenance, Equipment to Assure Safety: The following emergency lights in Building #1 were non-operational: Exit light by room #1; Exit light at front door; Hallway by room #15.

.405.05.f. Structure, Maintenance, Equipment to Assure Safety: Resident room #2, Building #2, had a portable space heater in the bathroom.

.410.02. Fire Drills: Building #2 did not have documentation for a fire drill, 1st shift, 2nd quarter 2019.

.401. Fire And Life Safety Standards For Buildings Housing Three Through Sixteen Residents: The self-closing door to the furnace room in building #1 was held open with a door chock.

.215.01 Administrator Responsibility: the facility administrator did not implement the facility's policies and procedures related to investigating allegations of abuse, neglect, or exploitation when a caregiver involved in an alleged abuse incident continued to work at the facility during the investigation.

.600.06.b Sufficient Personnel: for approximately four months, a night shift caregiver worked alone in Building #2 without CPR and first aid certification.

.510 Requirements To Protect Residents From Abuse: the facility failed to protect residents from abuse after a reported allegation; a caregiver involved in the alleged abuse was transferred to another building and continued working during the investigation, potentially affecting all residents in the facility.