Inspection Reports for
The Gables of Pocatello Memory Care

.410. Requirements for emergency actions and fire drills: the facility failed to conduct fire drills as required, with only 4 drills documented between 7/29/25 and 5/21/26 and only one on the night shift, not meeting the bi-monthly and night shift requirements.

.450. Requirements for food and nutritional care services: the facility's Certified Food Protection Manager's certificate expired on 10/10/23 and the administrator was unaware of the expiration.

.320.01. Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or services, missing wound care and catheter care instructions for Residents #2 and #3.

.310.04.e. Psychotropic or behavior modifying medication: Resident #3's psychotropic medication reviews were delayed by eight months and behavioral updates were not documented for fluoxetine medication.

.305.02.b. Quarterly nursing assessments: the facility failed to ensure medications were given as ordered, including continued administration of discontinued hydrochlorothiazide, incomplete antibiotic dosing, incorrect scheduling of magic mouthwash, and missed doses of miralax.

.405.01.a. Electrical Installations and Equipment: during facility tour it was identified in room #1, a CPAP and an Oxygen concentrator plugged into a multi-plug adapter, in room #15 a television, charging device and an electronic photo frame were plugged into a multi-plug adapter. The use of multi-plug adapters is prohibited.

.410. Requirements for emergency actions and fire drills: during record review it was identified the seven conducted emergency egress/fire drills held between 1/16/2024 to 1/29/2025 were all conducted between 1:30 and 3:30 PM, not meeting the requirement of at least two being conducted during the night when residents are sleeping.

.250.10.b. Heating, Ventilation, and Air-Conditioning (HVAC): during facility tour it was identified the gas-fired fireplace located in the main living room area was equipped with the heat-tempered glass cover but did not have a provided safety barrier as required. All fireplaces must provide a safety barrier and have heat-tempered glass fireplace enclosures equivalent to ASTM Standard.

.310.01.c. Medication Distribution System: the facility's medication refrigerator temperatures, which contained insulin, were not monitored and documented accurately daily; temperature logs showed 37 degrees F 29 times and the same staff member appeared to document without checking the temperature (previously cited 9/16/2022).

.009.06.c. Use of Previous Criminal History and Background Check: one of four employees did not have an Idaho State Police background check completed prior to working unsupervised.

.215.08.b. Investigation within Thirty Days: the administrator did not conduct investigations within 30 days for missing medications, incorrect insulin doses, and injuries sustained by residents.

.250.13. Secure Environment: the facility's four-foot tall fence was not secure enough for residents with cognitive impairments who could physically scale it.

.305.02.b. Current Medication Orders and Treatment Orders: residents did not receive multiple doses of prescribed medications, including insulin and antibiotics, and incorrect insulin types were administered.

.305.03. Resident Health Status: residents were not assessed after significant health events including skin biopsy, suicidal ideation, coughing, low blood glucose, and incorrect insulin administration.

.310.01.a. Medication Distribution System: medications were stored unsecured in an unlocked hallway closet accessible to cognitively impaired residents.

.310.01.c. Medication Distribution System: the medication refrigerator was below required temperature on 18 occasions between July and September 2022.

.330.04.c.vii. Resident Care Records: resident assessments after changes in condition were not documented despite being performed.

.330.06.b. Behavior Documentation: no behavior plan was implemented for a resident exhibiting aggressive behaviors toward staff and a roommate.

.330.13.h. Personnel Records: documentation of criminal history and background checks was missing for three of five sampled staff members who worked alone or out of sight of cleared employees.

.450. REQUIREMENTS FOR FOOD AND NUTRITIONAL CARE SERVICES: the facility failed to meet Idaho Food Code standards; kitchen inspection failed and mandatory re-inspection was required within 10 days.

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: the facility did not maintain compliance with NFPA 101, including lack of documentation for Alcohol Based Hand Rub dispenser inspections, combustible storage in mechanical and sprinkler riser rooms without self-closing doors, obstructed electrical panel access, no documented in-service training on emergency plan roles for residents, no documentation of staff training or bi-monthly review of the emergency plan, and only five spare sprinklers instead of the required six.

.155.01. Relocation agreements: the facility had two relocation agreements but they had not been updated annually; the last known review was in 2020.

.410. Requirements for emergency actions and fire drills: the facility produced bi-monthly drills but documentation failed to include all required elements such as date, time, description, response, problems, and recommendations.

.215.07 Notification to Adult Protection and Law Enforcement: the administrator did not notify Adult Protection of incidents of exploitation when six residents had money or possessions stolen from their rooms.

.330.04.c.vi Resident Care Records: the facility did not maintain complete and accurate records when staff failed to document notifying the facility nurse of changes in residents' conditions, including blood glucose levels, wounds, and agitation requiring medication.

.330.09 Water Supply: the facility failed to maintain a current admission and discharge register, with multiple residents lacking discharge dates and one current resident listed twice with different admission dates.

.330.14 As Worked Schedules: the facility work records failed to reflect personnel on duty and their positions, including missing first and last names of the nurse and maintenance personnel (previously cited 10/19/17).

.600.04.a Sufficient Personnel: the facility failed to schedule sufficient personnel during all hours, with only one staff member scheduled overnight despite residents requiring two-person assistance.

.520-11 Inadequate Care - Acceptable Admission and Retention: the facility admitted and retained four residents in a secured environment who did not have cognitive impairment or history of elopement, failed to ensure compatibility among residents, and caused resident distress and inadequate care.

.415.05 Automatic Fire Extinguishing System Service and Testing: expansion tank for fire suppression system is not approved for use with anti-freeze, only rated for potable water; no record of replacement to date; fire department inspection from April 2019.

.415.04 Fire Alarm Smoke Detection System Service and Testing: no record of five-year sensitivity testing completed within the past five years; fire alarm systems must be tested for sensitivity per NFPA 72; addressable systems may print sensitivity testing report from the Fire Alarm Control Panel (FACP).

.250.09 Ventilation: the facility had multiple plug in air fresheners, which were overpowering and initiated coughing and nasal drainage in visitors and employees.

.320.01 Use of negotiated service agreement: the facility's NSAs did not clearly identify the resident needs; Resident #1, #2, #3 and #4's NSAs did not describe night needs, washing/grooming, supervision and transportation needs. Further, Resident #1's NSA did not describe changes of condition, such as wounds.

.335.03 Standard precautions: the facility did not ensure infection control practices were put into place. For example caregivers were observed wearing one pair of gloves for multiple tasks in the kitchen. Further, a caregiver was observed using her teeth to open two packages of green beans after removing them from the microwave.

.730.02.a Work records: the facility work records failed to document the times the administrator and maintenance staff worked at the facility.

.405.01.b Electrical installations and equipment: the following areas had extension cords, multi-plug adapters, daisy chains, and relocatable power taps being used for small appliances in multiple rooms including Room #15, Maintenance/Riser room, Room #13, Room #12, Room #9, Room #7, Room #4, and Room #3.

.405.05 Structure, maintenance, equipment to assure safety: no documentation for 30 second monthly or 90 minute annual emergency lighting testing was found, and the emergency light in the TV room was not operational.

.405.07 Exit door locks: doors were not equipped with a single operational locking arrangement at the exit door beside room #7, office, laundry, and main front door off alcove.

.405.05 Structure, maintenance, equipment to assure safety: delayed egress locking arrangement at exit door by room #1 and off dining room would not release under excessive pressure but released under keypad control; exit signs were blocked by lighting fixtures and did not indicate the path or direction to a means of escape.