8 Reports
Inspection Report — Jan 23, 2025
Life Safety
Date: Jan 23, 2025
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety standards.
Findings
The facility failed to maintain Life Safety Code standards including lack of smoke detector sensitivity testing, inadequate ventilation in oxygen transfilling rooms, and insufficient emergency fire drills and evacuation procedures.
Deficiencies (3)
.404 Fire and life safety standards for existing buildings: facility could not provide documentation of a smoke detector sensitivity test conducted within the last five years, with the initial test cited in 2020.
.405.03 Medical gases: Building 1 and Building 2 have exterior oxygen transfilling rooms without mechanical or natural ventilation as required.
.410 Requirements for emergency actions and fire drills: facility failed to conduct bi-monthly emergency egress/fire drills with at least two at night, averaging only four drills per year, and policy lacks designated evacuation meeting location.
Inspection Report — Mar 21, 2024
Routine
Date: Mar 21, 2024
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations and identify any deficient practices.
Findings
The facility was found deficient in multiple areas including background checks, medication management, behavior plans, nursing assessments, and staffing. Several previously cited deficiencies remain uncorrected.
Deficiencies (13)
.009.06.c Use of Previous Criminal History and Background Check: two facility nurses did not have Idaho State Police background checks completed as required.
.260.07 Toxic Chemicals: disinfectant spray was stored in an unlocked laundry room accessible to cognitively impaired residents, posing a safety risk.
.305.02.b Current Medication Orders and Treatment Orders: residents did not receive medications as ordered, including incorrect dosing and missed doses (previously cited 9/9/22).
.310.01.g Medication Distribution System: residents lacked availability of as-needed medications such as acetaminophen and tramadol; cart audits were infrequent.
.310.04.a Psychotropic or Behavior Modifying Medication: psychotropic medications were used as first resort without behavior plans; some residents lacked behavior plans despite multiple medications.
.310.04.e Psychotropic or Behavior Modifying Medication: six-month medication reviews were incomplete or missing behavioral updates for residents on psychotropic medications.
.319.03 Nursing Assessment: residents did not have comprehensive nursing assessments completed prior to admission (previously cited 9/9/22).
.319.04 Maladaptive Behaviors: the facility did not evaluate all residents' behaviors with all required components; some residents were not fully evaluated prior to admission.
.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or services, lacked behavior plans, and omitted important information about care and visitors.
.320.03 Signature, Date, and Approval of Agreement: several residents' NSAs were not signed by legal representatives or conservators as required.
.330.04 Resident Care Records: care staff did not consistently document notifications to nurses of unusual events or PRN medication requests and effectiveness.
.330.06.c Behavior Documentation: the facility did not track ongoing behaviors or intervention effectiveness; incidents were undocumented and behavioral tracking was lacking.
.600.04.a Sufficient Personnel: insufficient staffing was observed on multiple occasions, with staff switching buildings to pass medications leaving buildings unattended (previously cited 9/9/22).
Report Facts
: 30
: 20
: 2
: 52
: 2
Inspection Report — Sep 9, 2022
Routine
Date: Sep 9, 2022
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including lack of a licensed administrator, failure to implement corrective actions for resident falls, medication administration errors, incomplete nursing assessments, inadequate personnel documentation, and insufficient staffing during overnight shifts.
Deficiencies (9)
.215. Requirements for a facility administrator: the facility had no licensed administrator to oversee daily operations on four separate occasions (27, 13, 3, and 22 days) (previously cited 12/11/2020).
.215.08.e. Corrective action: the facility did not ensure appropriate corrective actions were put into place to prevent recurrence of residents' falls, with no interventions after falls of Residents #7 and #1.
.305.02.b. Current medication orders and treatment orders: residents did not receive medications and diets as ordered, including Resident #1 receiving regular soup instead of thickened liquids and multiple missed medication doses for Residents #1, #3, #5, and #6.
.305.02.c. Current medication orders and treatment orders: not all residents' records contained current, signed orders for all medications and treatments; an unsampled resident received crushed medications without an order, and Resident #5 lacked orders for several medications removed from their record.
.310.01.c. Medication distribution system: the medication refrigerator in building #2 was not monitored for appropriate temperatures or documented daily; administrators stated monitoring had not been done.
.319.03. Nursing assessment: seven sampled residents did not have comprehensive nursing assessments completed prior to admission.
.330.04.c.vii. Resident care records: the facility did not maintain documentation of all change of condition assessments; documentation was lost for wounds and falls of Residents #3, #5, and #7.
.330.13.i. Personnel records: five of seven direct caregiving staff lacked documentation of delegation from the facility nurse.
.600.04. Personnel management: the administrator did not schedule sufficient personnel during all hours, including lack of medication technician overnight on multiple dates; one staff member lacked CPR/first aid certification (previously cited 12/11/2020).
Report Facts
days: 27
days: 13
days: 3
days: 22
dates: 4
missed doses: 5
missed doses: 15
missed doses: 20
missed doses: 30
residents: 7
staff: 5
staff: 2
Inspection Report — Apr 6, 2022
Complaint Investigation
Date: Apr 6, 2022
Visit Reason
A health care complaint investigation survey was conducted to assess compliance with regulations and investigate alleged deficiencies.
Findings
The facility was found to have multiple deficiencies including poor housekeeping and maintenance, inadequate infection control practices, and insufficient staffing to meet residents' needs.
Deficiencies (3)
.260.06 Housekeeping and maintenance services: the facility was not maintained in a clean, safe and orderly manner with stained carpets in multiple areas and a resident's fitted sheet stained with urine and covered up with bed linens.
.335 Requirements for infection control: one staff member and two outside agency nursing staff were observed not wearing masks, and three staff wore masks improperly without covering nose and mouth; all staff should wear masks appropriately at all times.
.600.04.a Sufficient personnel: the facility did not schedule sufficient staff during all hours; seven staff reported being unable to provide assistance with all ADLs including showers, meals, activities, transfers, housekeeping, laundry, carpet cleaning, and medication assistance; a resident scheduled for a shower was not assisted and had soiled linens unchanged.
Report Facts
: Apr 6, 2022
: May 6, 2022
: 15
: 14
: 7
Inspection Report — Dec 29, 2021
Life Safety
Date: Dec 29, 2021
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety codes and regulations.
Findings
The facility failed to maintain required documentation for smoke alarm inspections, wet suppression system inspections, emergency lighting tests, staff training on oxygen use and emergency action plans, fuel-fired heating inspections, emergency drills, and sprinkler system inspections.
Deficiencies (4)
.403. Fire and life safety standards for existing buildings: the facility lacked documentation for annual smoke alarm inspection, monthly wet suppression system gauge inspections, monthly and annual emergency lighting tests, and periodic staff training on oxygen safety and emergency action plans (repeat findings).
.405.04. Fuel-fired heating: the facility could not produce documentation showing annual inspection, service, and cleaning of fuel-fired heating devices; last known inspection was 4/27/2020.
.410. Requirements for emergency actions and fire drills: emergency egress and relocation drills were not documented for the past 12 months; staff reported some drills but no records were found.
.330.15.a.i. Fire and life safety records: the facility could not produce documentation for the annual sprinkler system inspection; the sprinkler riser tag showed inspection in March 2021 but no report was available.
Report Facts
: Jun 3, 2020
: Jun 7, 2021
: Apr 27, 2020
: 2021-03
Inspection Report — Jul 6, 2021
Follow-Up
Date: Jul 6, 2021
Visit Reason
A health care core deficiency follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
One non-core deficiency was found related to incomplete 90-day assessments for sampled residents. No core deficiencies table was provided despite the survey type indicating core deficiency follow-up.
Deficiencies (1)
.300.01 Licensed Registered Nurse (RN): 3 of 3 sampled residents that required 90-day assessments did not have their current assessment completed.
Inspection Report — Dec 11, 2020
Original Licensing
Date: Dec 11, 2020
Visit Reason
A health care initial licensure survey with a complaint investigation was conducted to assess compliance with Idaho RALF regulations.
Complaint Details
The complaint investigation addressed concerns about abuse incidents including hitting, yelling, and grabbing residents, which were found to be unreported and uninvestigated.
Findings
The facility was found deficient in multiple areas including fingerprint submission delays, inadequate policies for admissions and abuse response, lack of licensed administrator, failure to notify and investigate abuse, insufficient behavior documentation and infection control, inadequate staffing, and admission of residents without cognitive impairments into a secured environment creating a mixed population.
Deficiencies (13)
.009.04 Submission of Fingerprints: one of five employees documented the facility waited 52 days to request a criminal history background check after their hire date.
.152.03.a.ii Policies of Acceptable Admissions: the facility did not arrange for services when Resident #7 hired a private duty caregiver without a contract; Resident #7 paid the caregiver directly.
.154.01 Response to Accidents, Incidents, or Allegations of Abuse, Neglect, or Exploitation of Residents: the abuse, neglect and exploitation policy was inadequately written, lacking proper definitions, staff education instructions, contact procedures, forms, and interventions to prevent recurrences.
.215.02 Availability of Administrator: the facility had no licensed administrator overseeing daily operations from 7/18/2020 to 8/14/2020.
.215.07 Notification to Adult Protection and Law Enforcement: observed instances of abuse including hitting, yelling, and grabbing residents were never reported to authorities.
.215.08.a Administrator Notification: the previous administrator was not notified of observed abuse incidents.
.215.08.b Investigation within Thirty Days: the facility did not conduct investigations of abuse incidents; no abuse investigations had been completed since opening.
.215.08.c Resident Protection: residents were not protected after caregivers observed abuse at the facility.
.330.06.a Behavior Documentation: the facility did not evaluate Resident #6's suicide ideation and refusal of care or Resident #11's hitting and cursing behaviors.
.330.06.b Behavior Documentation: the facility did not develop interventions after residents displayed maladaptive behaviors.
.335 Requirements For Infection Control: multiple caregivers rarely wore aprons when serving food after providing care to residents.
.600.04.a Sufficient Personnel: an incident report documented Resident #7 fell during the night shift when only one staff was working; emergency services had to assist the resident off the floor.
.520-11 Inadequate Care - Acceptable Admission and Retention: the facility admitted and retained Residents #7, #9, #10, and #11 without cognitive impairments into a secured environment intended for cognitively impaired residents, restricting their freedom to come and go and creating a mixed population.
Report Facts
: 52
: 10/28/2020
: 4
Inspection Report — Sep 4, 2020
Life Safety
Date: Sep 4, 2020
Visit Reason
A Fire Life Safety Survey was conducted to assess compliance with fire safety and sanitation licensure requirements.
Findings
Non-core issue deficiencies were identified related to lack of documentation for annual training on emergency roles and fire alarm sensitivity testing, as well as staff training on oxygen risks.
Deficiencies (2)
.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: no documentation of annual training conducted with both staff and residents on emergency roles and responsibilities, and no documented sensitivity testing for the fire alarm system installed in May 2019.
.405.03 Telephone: no documentation for annual training for staff qualifications on the risks associated with oxygen; all staff shall be trained at least annually in accordance with NFPA 99.
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