Inspection Reports for
Unique Senior Care – Assisted Living

.009.01 Criminal History and Background Check: one of five employees did not have a Department Criminal History and Background Check completed (previously cited 8/27/2021).

.152.03.a.ii Policies of Acceptable Admissions: the facility did not arrange for services or have an updated Negotiated Service Agreement for a private duty caregiver hired by a resident's family (previously cited 8/27/2021).

.310.01.c Medication Distribution System: medication refrigerator temperatures were not monitored and documented daily between June 2024 and October 2024.

.330.14 As Worked Schedules: the facility's as-worked schedule did not document dates and times the administrator, facility nurse, or other staff were present (previously cited 8/27/2021).

.450 Requirements for Food and Nutritional Care Services: the facility did not have a Certified Food Protection Manager at the time of survey; the administrator's certification expired in October 2023 and was not renewed.

.600.04.b Sufficient Personnel: one of five staff members who worked alone did not have evidence of current CPR or First Aid certification despite requests to provide it (previously cited 8/27/2021).

.645.02 Delegation: three of five staff who passed medications were not delegated by the current facility nurse; multiple requests to arrange delegations were unsuccessful.

.155.01 Relocation agreements: the facility had only one relocation agreement with a separate location dated 2012 instead of the required two agreements reviewed not less than annually.

.330.15 Fire and life safety records: the facility was missing records for review including annual fire alarm inspection and annual fire suppression system inspection reports.

.009.01 Criminal History and Background Check: two of five employees reviewed did not have a Department Criminal History and background check.

.152.03.a.ii Policies of Acceptable Admissions: the facility utilized a private-duty caregiver for Resident #3, for which they did not arrange services, as families paid caregivers directly.

.310.01 Medication Distribution System: the facility had a house supply of Tylenol which was distributed as a PRN medication; this was previously cited 9/20/2018.

.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not complete six month psychotropic medication reviews for Resident #1 who had taken Lorazepam and escitalopram for longer than six months.

.330.04.c.vii Resident Care Records: the facility nurse did not document assessments after Resident #3 fell on 7/24/21 and 4/9/21, despite completing assessments.

.330.14 As Worked Schedules: the facility's as-worked schedules did not document the times the facility nurse, activities staff, or Resident #3's private duty caregiver worked nor their names and titles.

.335 Requirements for Infection Control: the facility did not follow CDC recommendations for COVID-19 prevention; staff and visitors were not screened or required to wear masks, and the administrator was observed touching medications with bare hands.

.600.04.b Sufficient Personnel: two of three employee records reviewed lacked evidence of first aid certification; staff worked alone without certified backup.

.415.02 Fuel-Fired Heating: No documentation for a current annual inspection of fuel fired systems. Last known 8/2/2017.

.415.04 Fire Alarm Smoke Detection System Service and Testing: All facility smoke detectors were replaced on 1/25/2018. No documentation could be produced for a sensitivity test at one year after replacement (NFPA 101 9.6.1.4 & NFPA 72 7-3.2.1).

.415.05 Automatic Fire Extinguishing System Service and Testing: No documentation could be produced for a monthly visual inspection of sprinkler system gauges and control valves (NFPA 25, 2-2.4.1 & 9-3.3.1).

.415.06 Fire Watch: No documentation could be produced for a facility fire watch policy.

.161.01 Policy on Smoking: Facility smoking policy was missing required content. Missing from the policy: no smoking in areas with flammable liquids, gases or oxidizers; no smoking in bed; prohibits unsupervised smoking by residents not mentally or physically responsible and those affected by medication; prohibits smoking in combustible storage areas; designates specific areas where smoking is permitted.

.410.02 Fire Drills: Missing fire drills for 1st shift 4th quarter 2018 and all second shift fire drills for 1st through 3rd quarter 2019 and 3rd through 4th quarter 2018.

.405.07 Exit Door Locks: All three exits at the front of the facility are non-single operational. All have knob locks that must be unlocked before the door knob can be turned and opened.

.250.01 Building Character: Approximately 4" x 4" x 5" triangular penetration in the wall of resident room #6 behind the recliner.

.157.01.d.iv. Medication Policies: the facility did not have a medication policy to direct staff on what to do when narcotic medications went missing. A bubble pack was observed containing Tylenol tablets labeled as Tramadol.

.215.11. Administrator's Designee: the facility administrator did not have documentation of who was authorized to act in her absence. Staff interviewed on 9/18/2018 could not state who was designated to act as administrator when she was absent.

.215.12. Ability to Reach Administrator or Designee: the facility administrator was not reachable or available at all times. Eight of nine current and former staff stated the administrator was not available when off-site and did not respond to calls or texts for hours.

.300.01. Licensed Professional Nurse (RN): the licensed nurse did not observe medication technicians prior to delegating medication assistance nor monitor to ensure proper assistance. The nurse signed delegation documents without observation and did not visit the facility after delegation to ensure proper medication assistance.

.305.03. Resident Health Status: the facility nurse did not assess residents after changes in condition, including Resident #3 after falls and injuries, Resident #4 when no longer able to walk, another resident's wound condition, and a fourth resident's rash around the mouth.

.305.04. Recommendations: the facility nurse did not make recommendations to the administrator when changes were needed to residents' Negotiated Service Agreements, such as hospice services for Resident #3 and increased toileting assistance for Resident #4.

.310.01. Medication Distribution System: medications were not appropriately labeled per pharmacy standards; a Tramadol label was placed on a bubble pack containing Tylenol tablets.

.310.01.a. Medication Distribution System: medication care was unsecured on 9/18/18 and 9/20/18. On 9/20/18, medications were observed lying on top of the medication cart.

.310.01.e. Medication Distribution System: plastic cups with residents' names were observed in the medication cart. Staff stated multiple employees pre-poured medications into cups prior to passing them out. A family member reported finding a cup of medications in their loved one's room.

.320.01. Use of Negotiated Service Agreement: NSAs were not updated to reflect residents' specific needs. Resident #3's NSA was not updated after health decline and hospice services began; Resident #4's NSA was not updated to include inability to walk and use of bedside commode.

.330.01. Individual Resident Care Record: residents' records were not maintained in a complete, accurate, or authenticated manner. Caregivers documented information in electronic logs that was later changed or removed.

.350.03. Resident Protection: the facility did not protect residents when allowing a suspended caregiver into the facility during an abuse investigation.

.600.01. On-Duty Staff During Residents' Sleeping Hours for Facilities of Fifteen Beds or Less: staff were not awake at all hours. Family, present, and previous staff confirmed an employee slept while on duty.

.009.06.c Use of previous criminal history and background check: one employee who required an Idaho State Police check did not have it in their personnel file (previously cited 7/17/16).

.305.03 Resident health status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including multiple falls, incontinence, diarrhea, and physical aggression; one resident was assessed by EMS after a fall.

.711.08 Care notes: the facility did not ensure care notes were signed and dated by the person providing care, and this information was not included in residents' records; daily logs contained multiple unsigned entries and missing notes for December 2017 and January 2018.

.250.13.l Resident sleeping rooms: resident rooms #1 and #3 had an old variance for removal of closet doors dated June 12, 2012; both rooms were vacant at the time of the survey. New residents desiring door removal will require a new, temporary variance specific to the individual resident.

.415.04.a Fire alarm smoke detection system service and testing: no documentation was provided for a five year sensitivity test of the smoke detectors.

.415.05 Automatic fire extinguishing system service and testing: deficiencies from the annual sprinkler inspection on 12-8-16 were not corrected, including a past due 5-year sprinkler inspection and a cracked ball valve on the flush for the check valve that leaks when open.

.405.07 Exit Door Locks: double action locks found at all exit doors; all exit doors shall be single action locking mechanisms.

.410.02 Fire Drills: there were no fire drills performed on second shift.

.415.02 Fuel-Fired Heating: missing annual inspection of the fuel fired heating system; last date of inspection 5/6/2015.

.009.05.a. New Criminal History and Background Check: two of four staff records did not contain documentation of a completed criminal history background checks.

.009.06.c. Use of Previous Criminal History and Background Check: two of four staff did not have documented evidence of completed state only background checks.

.730.01 Personnel: an employee's record was not maintained in the facility.

.415.03.e. Portable Fire Extinguisher Service and Testing: no monthly or annual inspection of fire extinguishers.

.415.05. Automatic Fire Extinguishing System Service and Testing: no current annual sprinkler inspection.

.410.02. Fire Drills: facility not conducting fire drills one per shift per quarter.