Inspection Reports for
The Gables of Ammon

.009.06.c Use of previous criminal history and background check: three of seven employees did not have the Idaho State Police background check completed prior to working alone with residents.

.215.08.f Notification to licensing agency within one business day: the facility did not notify Licensing and Certification within one business day when residents fell and required hospital or emergency room assessment and treatment.

.300.01 Licensed Registered Nurse (RN): the facility RN did not conduct ninety-day nursing assessments or complete initial nursing assessments; some assessments were completed by the LPN without physical resident assessment by the RN.

.305.06 Self-administered medication: Resident #3 did not have a self-administration of medication assessment completed by the facility RN.

.320.08 Periodic review: Residents #1, #5, and #6's Negotiated Service Agreements were not reviewed every 12 months (previously cited 8/11/2023).

.310.04.e Psychotropic or behavior modifying medication: Residents #1, #3, and #6 were taking psychotropic medications longer than six months without six-month medication reviews completed.

.319 Comprehensive assessment requirements: Residents #3, #4, and #9's comprehensive assessments were not completed prior to admission; Resident #8's assessment was not completed by the RN prior to admission; Resident #2 lacked demographics, nursing, and maladaptive behavior assessments prior to admission.

.330 Requirements for facility records: the facility did not maintain as-worked schedules for three previous administrators dating back to 2/15/24 through 1/10/25; the current administrator could not locate these schedules.

.600.04.b Sufficient personnel: eight of nine sampled direct care staff did not have current first aid and/or CPR certifications; the administrator could not confirm that at least one direct care staff had current certification on each shift.

.154.01 Response of Staff to Accidents, Incidents, or Allegations of Abuse, Neglect, or Exploitation of Residents: facility staff were not adequately trained on emergency response for residents on hospice and reporting incidents; staff were not allowed to call 911 immediately and failed to notify hospice and facility nurse promptly when a resident was injured.

.215.08.b Investigation within Thirty Days: the administrator did not conduct investigations within 30 days for injuries of unknown origin sustained by residents, including failure to investigate falls and wounds.

.215.08.f Notification to Licensing Agency within One Business Day: the facility failed to notify Licensing and Certification within one business day of injuries sustained by residents, including falls and wounds of unknown origin.

.250.14 Call System: the call light system was not consistently functioning; staff did not always receive pages when residents pushed call pendants, resulting in delayed assistance and residents having accidents.

.305.02.b Current Medication Orders and Treatment Orders: residents did not consistently receive medications and treatments as ordered, including incorrect dosing of Fentanyl patches and failure to administer oxygen when indicated.

.305.03 Resident Health Status: nursing assessments were not consistently conducted when residents experienced changes in physical or mental health status, including pressure injuries, respiratory symptoms, swelling, and pain.

.320.01 Use of NSA: residents did not consistently receive cares as outlined in their Negotiated Service Agreements; staff failed to reposition, assist with transfers, and engage residents in activities as required, partly due to staffing shortages.

.320.08 Periodic Review: NSAs were not updated to reflect significant changes in care needs or health status, including failure to address wounds, fall prevention, and hospice care delineation.

.600.04 Personnel Management: the facility did not schedule sufficient personnel to provide care during all hours; overnight shifts often had only two staff, leaving units unattended and residents at risk, including unresponded bed/chair alarms.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: the facility had multiple issues including magnetic locking on main entrance doors restricting egress, an 18" x 18" transfer grille compromising fire/smoke barrier, two non-operational emergency lights, missing 90-minute annual emergency lighting test documentation, a malfunctioning laundry room door self-closing device held open by a door chock and rock, missing one of two semi-annual kitchen hood suppression system inspections and hood cleaning/inspection, fire extinguishers not inspected annually, and missing quarterly waterflow alarm testing documentation (previously cited 12/17/2021).

.155.01 Relocation agreements: the facility had two relocation agreements but they had not been updated annually; the last known review was in 2019.

.250.09 Plumbing: the hot water temperature at resident plumbing fixtures was 126°F, exceeding the allowed maximum of 120°F.

.250.10.a Heating, ventilation, and air-conditioning (HVAC): portable space heaters were observed in the sprinkler riser room and the Assistant Executive Director's office.

.305.02.b. Current Medication Orders and Treatment Orders: residents were not provided with their medications as ordered, including multiple missed doses of antibiotics, nerve pain medication, antifungal medication, and others (previously cited 10/4/2018 and 8/27/2021).

.600.04.a. Sufficient Personnel: insufficient staffing to meet residents’ needs resulted in dirty clothes, cluttered rooms, unanswered call lights, inadequate supervision, and missed medication doses (previously cited 8/27/2021).

.009.06.c Use of Previous Criminal History and Background Check: two employees who required a state police background check did not have one completed; the administrator confirmed the background checks had not been completed.

.151 Activity requirements: during observations in the memory care unit from 8/23/21 to 8/26/21, no activities were offered to residents except one resident escorted to a church service on 8/25/21; the administrator stated the lack of activities needed to be addressed.

.154.01 Response of staff to accidents, incidents, or allegations of abuse, neglect, or exploitation of residents: the facility's policy did not include all necessary components such as steps when the alleged perpetrator was a visitor or another resident, protection of residents, and timely reporting to law enforcement within 4 hours as required by Idaho statute 39-5303 (previously cited 10/4/18).

.215.08.b Investigation within thirty days: falls sustained by Residents #5, #6, and #7 were not investigated by the administrator; an empty morphine syringe prescribed to Resident #6 was found and this incident was investigated (previously cited 10/4/18, 7/27/17, and 12/15/16).

.215.08.c Resident protection: the facility did not protect Resident #8 when there was an allegation of physical and verbal abuse by a staff member on 4/6/21; the alleged perpetrator was allowed to continue working the remainder of the shift and the next shift; the undated abuse policy stated suspension until cleared of wrongdoing.

.215.08.e Corrective action: the administrator did not ensure appropriate corrective action when Resident #6 fell 20 times in six months; for example, after a fall on 8/18/21, the only intervention was to remind the resident to use their call light.

.260.06 Housekeeping and maintenance services: multiple maintenance issues including missing fence slat, unsecured fence posts, missing flooring causing trip hazard, torn furniture, weeds, sun-rotted window screens, boxes of siding outside, half-burnt firewood, debris and stains in common areas, ripped cushions, debris bags, hanging heat strip extension cord, and strong urine odor near room 257.

.305.02.b Current medication orders and treatment orders: residents did not receive medications as ordered, including Resident #2 missing diuretic medication for seven days and four doses of Adempas, Resident #6 missing thirteen doses including tramadol, and Resident #7 missing fifteen doses including quetiapine (previously cited 10/4/18).

.310.01.a Medication distribution system: the medication room storing overflow and medications waiting to be destroyed was unlocked on 8/23/21 and 8/24/21; the memory care medication cart was unlocked on two occasions on 8/23/21.

.330.14 As worked schedules: the facility's as-worked schedule did not document exact times staff were at the facility; a time card report included times but did not include all first names or positions.

.451.01.d Menu: the facility did not document menu substitutions for several months as confirmed by the certified food protection manager.

.600.04.a Sufficient personnel: the facility did not schedule sufficient staff during all hours to meet residents' needs; observations noted residents in same clothes for four days, a confused resident chewing fake fruit unattended, and staff too busy to review care plans; multiple residents, staff, family, and agency staff reported long call light response times and up to two hour waits for as-needed pain medications.

.405.01 Medical Gases: electrical connections were not enclosed in termination boxes or covers, including an open 3-inch diameter electrical box in the nurse's closet, an open outlet behind east smoke barrier doors, and an open four-inch junction box above the main hood in the kitchen with exposed wiring.

.405.05 Structure, Maintenance, Equipment to Assure Safety: no record of last fire damper testing on heating/ventilation system; doors to hazardous areas did not self-close as required, specifically the door to the main kitchen did not self-close when activated from the hold-open device interconnected to the fire alarm system.

.405.03 Medical Gases: oxygen cylinders were unsecured in multiple rooms including room 118, 123A, 107, and the transfill room.

.410.02 Fire Drills: no record of evening (2-10) shift fire drill for the fourth quarter of 2019.

.415.02 Fuel-Fired Heating: no record for annual fireplace inspection of gas-fire fireplace.

.415.04 Fire Alarm Smoke Detection System Service and Testing: fire alarm report did not demonstrate all devices were tested; quantity of pull stations was not identified; number of horn strobes tested was listed as 18 but visual inspection identified more than 18 installed; report showed both smoke and heat detectors but did not indicate number tested and box for heat was left empty, indicating not all devices were tested.

.415.05 Automatic Fire Extinguishing System Service and Testing: no record of quarterly waterflow alarm testing for 3 of 4 quarters of 2019; no record of last ten-year replacement of walk-in dry barrel pendants, which date from 2004.

.009.06.c Use of previous criminal history and background check: two of six current employees did not have documentation of Idaho State Police background checks, confirmed by the facility administrator and business officer manager.

.153.01 Response of staff to abuse, neglect or exploitation of residents: the undated policy lacked clear directions on reporting, protection during investigations, investigation responsibilities, and report completion; it also contained unrelated policy references and stated residents would be "detained" against their will, violating Idaho laws.

.225.02 Intervention: the facility used the same generic list of interventions for every resident behavior rather than developing individualized interventions, resulting in caregivers responding inappropriately to residents by holding their wrists.

.305.02.b Current medication orders and treatment orders: the facility did not implement diet orders for a resident's gluten free diet, causing concerns from the resident and family about insufficient food.

.350.02 Administrator or designee investigation within thirty days: the facility administrator did not conduct an investigation after a caregiver documented restraining a resident to calm her down.

.451.03 Therapeutic diets: the facility did not have a therapeutic menu approved, signed, and dated by a registered dietitian prior to serving gluten free and vegetarian diets.

.711.13 Nursing assessments: facility nurses did not document nursing assessments in a timely manner after changes of condition such as falls; documentation was delayed several days and lacked actual dates and times of assessments.

.305.03 Resident health status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including painful swollen foot, pus filled vesicles, and changes resulting in hospital stay (previously cited 12/15/2016, 7/27/2017).

.711.08.c Care notes: care notes were not kept in each resident's record, including text messages between RN and LPN, and there was no documentation regarding bed bugs observed in a resident's room or management notifications.

.215.05 Responsibility for Acceptable Admissions: the facility administrator admitted residents who were incompatible with other residents, such as residents admitted to the memory care unit who did not require a secured environment (previously cited 12/15/2016).

.225 Requirements For Behavior Management: the facility did not develop interventions for each behavioral symptom exhibited by residents, including verbal and physical aggression (previously cited 12/15/2016).

.305.03 Resident Health Status: the facility nurse did not document assessments when residents had changes in mental and physical condition, including observations of soreness and hallucinations, and multiple falls with injuries (previously cited 12/15/2016).

.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not document investigations of incidents such as falls, resident-to-resident altercations, and resident elopements (previously cited 12/15/2016).

.550.23.a Fee Changes: there was no documentation that the facility administrator gave a resident's representative written notice of a fee increase for one-to-one supervision.

.520-11 Inadequate Care - Acceptable Admission and Retention: a core deficiency was cited during the healthcare follow-up and complaint investigation related to acceptable admission and retention.

.405.07 Exit door locks: exit doors are equipped with magnetic locking arrangement and without delayed egress; exit locks must be single operational in accordance with NFPA 101 Chapter 7.

.405.03 Medical gases: unsecured oxygen cylinders in rooms 135 and 128, and the oxygen transfill room fan was not operational (previously cited 03/24/2016).

.415.05 Automatic fire extinguishing system service and testing: two corroded sprinkler heads in the kitchen and sprinkler report indicates dry system pendants are past due for 10-year testing or replacement.

.405.01 Medical gases: room 125 was using a three-to-one non-grounded extension cord (corrected on site) (previously cited on 03/24/2016).

.215.05 Responsibility for Acceptable Admissions: the facility admitted Resident #1 who had a pressure ulcer greater than a Stage II and Residents #3, #9, #11 and #12 who were incompatible with other residents.

.225 Requirements For Behavior Management: the facility did not develop interventions for each behavioral symptom exhibited by Residents #9, #11 and #12, including aggressive behaviors and wandering into other residents' rooms.

.225.02.c Intervention: the facility did not evaluate the effectiveness of interventions for Resident #9's wandering into other residents' rooms.

.300.01 Licensed Professional Nurse (RN): the facility nurse did not delegate assistance with medications to all caregivers who provided medication assistance to the residents.

.305.03 Resident Health Status: the facility nurse did not document an assessment when Residents #2, #4, #7 and #10 had changes in their mental or physical condition such as emergency room visits and wounds.

.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not provide behavioral updates to the physician when submitting 6-month psychotropic medication reviews.

.320 Requirements For The Negotiated Service Agreement: Resident #11 neither had an interim service plan nor a negotiated service agreement within 14 days of admission.

.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not document investigations of incidents such as falls, resident-to-resident altercations and residents wandering into other residents' rooms.

.505.01.b Separate Trust Account Established: the facility did not have signatures of both the resident and the facility representative on financial transactions.

.520-10 Inadequate Care - Resident Rights: the facility failed to prevent Residents #9, #6, #11 and #12 from violating the rights of other residents to privacy and a safe environment, including wandering into rooms, physical aggression, and taking belongings.

.520-11 Inadequate Care - Acceptable Admission and Retention: the facility admitted and retained residents with physical, emotional and social needs incompatible with others, including a resident with a pressure ulcer greater than Stage II, and failed to assess residents prior to admission to ensure appropriate level of care.

.405.05 Structure, Maintenance, Equipment to Assure Safety: cross corridor doors near the Kitchen and Salon did not close and latch properly, two doors leading to the Kitchen lacked self or automatic closures for hazardous area separation, and the corridor door to room 133 did not latch when closed.

.405.05.a Structure, Maintenance, Equipment to Assure Safety: medical carts were stored in corridors near rooms 115 and 207 obstructing the exit access.

.405.01.b Electrical Installations and Equipment: inappropriate multi-plug adapter was in use in room 114.

.405.03 Medical Gases: two unsecured oxygen bottles were found in room 118.