Inspection Reports for
The Lodge at Bristol Heights

.305.02.b. Quarterly Nursing Assessments: the facility did not ensure residents received medications and treatments as ordered; multiple residents' Medication Assistance Records had many blank entries without documentation, leaving it ambiguous whether medications were given (previously cited 9/12/2025).

.625.03.k. Content for Training: the facility did not ensure infection control training was completed for three of eight employees; one staff member was observed not cleaning a resident's abdomen prior to insulin injection, and the administrator stated the staff were hired prior to her start and had not completed training.

.625.01. Number of Hours of Training: five of eight staff did not have 16 hours of orientation training; some staff reported less than 16 hours before working alone, and orientation often consisted of shadowing one 8-hour shift; the administrator stated these staff were hired prior to her employment and did not receive orientation training.

.630. Training Requirements for Facilities Admitting Residents with a Diagnosis of Dementia, Mental Illness, Developmental Disability, or Traumatic Brain Injury: five of eight staff did not have specialized training for residents with developmental disability, mental illness, traumatic brain injury, or dementia; the administrator stated these staff were hired prior to her employment and did not receive specialized training.

.009.06.c Use of Previous Criminal History and Background Check: three of four employees did not have an Idaho State Police background check completed (previously cited 7/25/2023).

.250.13 Secure Environment: the facility did not provide a secure environment for residents with cognitive impairments at risk for elopement, including Resident #5 who exited the facility and entered other residents' rooms unsupervised.

.305.02.b Current Medication Orders and Treatment Orders: residents did not receive medications as ordered, including multiple missed doses for Residents #1 through #9.

.305.03 Resident Health Status: nursing assessments were not conducted when residents experienced changes in health status, including Residents #2 and #3 who were not properly assessed after hospital visits and falls.

.310.04.e Psychotropic or Behavior Modifying Medication: psychotropic medication reviews were not completed for six residents requiring them, including Residents #6, #7, and #9.

.319 Comprehensive Assessment Requirements: pre-admission comprehensive and nursing assessments were not completed for Residents #3, #4, and #7.

.320 Negotiated Service Agreement (NSA) Requirements: NSA was not completed within 14 days of admission for Resident #10.

.320.08 Periodic Review: NSAs were not updated to reflect significant changes for Residents #2 and #9, including after health declines and annual reviews.

.330.04.a Resident Care Records: facility staff documentation was not completed by the staff making observations; medication technicians charted for caregivers who lacked computer access.

.330.04.c.iii Resident Care Records: medication technicians did not document insulin amounts for Resident #6 for the entire month of August 2025; communication documentation for PRN medications was incomplete.

.330.04.c.vii Resident Care Records: changes of condition were not documented for Residents #6 and #9 after falls and hospital visits, though assessments were performed but not recorded (previously cited 7/25/2023).

.330.06 Behavior Documentation: the facility did not evaluate or develop interventions for ongoing behaviors of Residents #5 and #10, including threats and combative actions; behavior plans were not developed.

.330.13 Personnel Records: staff records lacked required documentation such as orientation and infection control training; documentation was not maintained at the facility.

.450 Requirements for Food and Nutritional Care Services: the facility did not meet Idaho Food Code standards; kitchen inspection failed and mandatory re-inspection was required within 10 days.

.600.02 Detached Buildings or Units: buildings were left unattended for short periods due to insufficient staffing; medication technicians had to swap with caregivers to pass medications (previously cited 7/25/2023).

.600.04.a Sufficient Personnel: insufficient staffing was scheduled to meet resident needs, including memory care unit with only one care staff for several hours; staff and family reported inadequate assistance.

.645.02 Delegation: medication passing delegations were not done individually and lacked skill demonstration; RN did not conduct observations (previously cited 7/25/2023).

39-3308 Assessment (4)b Assessments: the facility nurse did not implement all residents' orders; some orders were only reviewed by the RCC prior to medication administration.

39-3316 Resident Rights (2) Privacy: residents' privacy was not protected due to cameras in Resident #8's room and bathroom without proper signage; family members observed care including toileting via cameras.

39-3321.2.c Qualifications and Requirements of Administrator: the administrator did not ensure facility incidents were investigated, including falls and injuries for Residents #6, #8, and #9.

39-3321.2.d Qualifications and Requirements of Administrator: the facility did not develop interventions to prevent recurrences after residents' incidents, including multiple falls for Residents #2, #6, and #9.

.215.02 Availability of Administrator: the facility did not have a licensed administrator from 12/31/24 to 1/29/25 for 28 days; the former administrator was not available on-site or by phone to ensure safe and adequate care, including ordering necessary supplies.

.215.09 Administrator's Designee: the former administrator did not authorize in writing a designee to act in her absence during multiple periods; staff did not know who was the designee.

.310.02 Discontinued and Expired Prescriptions: the facility had an accumulation of unused, discontinued, or expired medications for more than 30 days; medication destruction logs lacked dates, methods, or required signatures.

.410 Requirements for Emergency Actions and Fire Drills: the facility did not conduct fire drills on a bimonthly basis; fire drill log documented drills only on 10/22/24 and 4/18/25; administrators confirmed drills were not completed bimonthly.

.430.06 Basic Supplies: the facility did not provide basic necessary supplies and medical supplies for residents; staff reported shortages of paper towels, laundry detergent, cleaning supplies, toilet paper, alcohol swabs, and blood glucose supplies; staff sometimes purchased supplies themselves.

.410 Requirements for emergency actions and fire drills: facility failed to conduct emergency egress/fire drills as required, with only one normal sleeping hours drill since February 2024, last documented drill in October 2024, and drill documentation lacking designated evacuation meeting locations.

.405.01.a Electrical installations and equipment: prohibited use of multi-plug adapters and extension cords was identified in multiple buildings and rooms during facility tour.

.405.02.a Prohibited applications: oxygen concentrators were found plugged into relocatable power taps in multiple buildings, which is prohibited.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: facility failed to maintain standards including lack of self-closing laundry room doors, inoperable emergency lights in multiple locations, emergency lights not tested monthly since December 2024, missing smoke detector sensitivity testing within last 5 years or initial acceptance testing, missing semi-annual fire suppression waterflow alarm testing documentation, and lack of periodic employee instruction on emergency operations procedures.

.009.06.c Use of Previous Criminal History and Background Check: two of three employees did not have required State Police Background Checks completed, confirmed by the administrator.

.330.04.c.vii Resident Care Records: the facility nurse assessed residents after changes of condition but did not consistently document these assessments for multiple residents.

.600.02 Detached Buildings or Units: the facility did not schedule sufficient certified staff on night shift in each building to pass medications, resulting in staff switching buildings and leaving them unsupervised.

.645.02 Delegation: five staff who passed medications were not delegated by the current facility nurse, confirmed by the administrator.