Inspection Reports for
Wellspring Meadows Assisted Living

.151. Activity requirements: residents reported boredom due to no activities being offered; the facility lacked an activity director and staff were responsible for providing activities.

.250.13 Secure environment: the memory care building did not provide a secure environment as the gate and front door were sometimes left open or ajar, risking resident safety; staff were aware and the administrator planned to tighten the gate mechanism and re-educate staff.

.310.01.c. Medication distribution system: medication refrigerator temperatures were not monitored or documented daily and were not maintained between 38 and 45 degrees F; temperature logs showed temperatures at 36 degrees F and insulin was stored in the refrigerator.

.415.05 Automatic fire extinguishing system service and testing: the Syringa house lacked a specialized wrench for fire sprinklers and had only 4 spare sprinklers instead of 6; boxes obstructed a recessed sprinkler in the Administrator's office closet; no documentation existed for monthly visual inspections of sprinkler gauges and control valves at both houses.

.415.04 Fire alarm smoke detection system service and testing: no documentation for an annual fire alarm inspection was found, with the last known inspection dated 9/5/2017.

.405.03 Medical gases: an unsecured oxygen cylinder was found under the sink at the staff washing station in the Syringa house.

.405.05 Structure, maintenance, equipment to assure safety: an emergency light across from resident room #15 in the Buttercup house was non-operational and there was no documentation for a 90-minute annual test of the emergency lighting.

.405.07 Exit door locks: both buildings had non-single operational locking arrangements; the Buttercup house had magnetic locks with keypad override and a deadbolt on the rear door but no delayed egress component; the Syringa house had magnetic locks with keypad override and a deadbolt at the rear exit but was not a secure facility.

.410.02 Fire drills: the Buttercup house was missing fire drills on third shift for second, third, and fourth quarters of 2019 and on first and second shifts for the fourth quarter of 2019; the Syringa house was missing fire drills on third shift for all four quarters of 2019 and on first and second shifts for the fourth quarter of 2019.

.250.14 Secure environment: testing revealed the magnetic lock on the rear yard door at the Buttercup house was not engaged and could be opened without keypad override; the gate on the west end of the secured yard was left unlocked and wide open.

.250.01 Building character: multiple penetrations were observed in the mechanical and electrical rooms where wires and pipes ran through walls and ceilings at both houses.

.225.01 Evaluation for Behavior Management: the facility did not evaluate the behaviors of residents who inappropriately grabbed another resident and hoarded items to pick bugs out of their skin; technical assistance was previously given on this issue on 11/6/15.

.250.14 Secure Environment: residents with cognitive impairments were observed sitting unsupervised on unsecured front patios; exterior yards and interiors were not secure as residents had access codes and could enter buildings by pushing doorbell buttons, allowing others to leave.

.300.01 Licensed Professional Nurse (RN): the RN did not conduct change of condition assessments for residents after falls, injuries, or medication errors, including documented redness and multiple falls; no assessments were documented after specific incidents.

.305.02.a Current Medication Orders and Treatment Orders: residents did not receive ordered treatments including eye drops, thickened liquids, adaptive equipment, scheduled and PRN medications, and prescribed diets; some medications were unavailable.

.310.04.e Psychotropic or Behavior Modifying Medication: six-month psychotropic medication reviews were not conducted and behavioral updates were not provided to the physician for over one year for a resident's medications; previously cited on 11/6/15.

.350.07 Notification of Licensing and Survey Agency Within Twenty-Four Hours: the facility failed to notify Licensing and Certification of reportable incidents when multiple residents were discovered with bruising of unknown origin on 5/5/19; previously cited 12/15/17.

.405.03 Medical Gases: oxygen cylinders were observed unsecured in multiple rooms and hallways in two houses; previously cited 9/05/2017.

.600.06.a Sufficient Personnel: the administrator did not schedule sufficient personnel to provide required two-person assistance with transfers; residents were left alone multiple times monthly during night shifts when caregivers switched buildings; previously cited 11/06/15.

.350.02 Administrator or Designee Investigation Within Thirty Days: the facility did not complete or document an investigation had been conducted when a resident had an accident in the facility's van which resulted in a fractured elbow (previously cited 11/06/2015 and 06/23/2017).

.350.07 Notification of Licensing and Survey Agency Within Twenty-Four Hours: the facility did not notify Licensing and Certification of 12 reportable incidents in a six month period.

.405.01 Medical gases: room 15 in Buttercup building used a relocatable power tap to supply power to medical equipment and refrigerator.

.405.03 Medical gases: two unsecured oxygen cylinders were found in room 15 of Buttercup building.

.405.07 Exit door locks: both building front doors had non-single operational locking arrangements with magnetic locks lacking delayed egress or access control; exit doors required more than one operation to exit. Facility declared sixteen beds as secured but it was unclear which building was secured.

.410.02 Fire drills: both buildings were missing pm fire drills for the second and fourth quarters.

.415.02 Fuel-fired heating: no record of fuel-fired heating inspection for fireplaces on both buildings.

.415.04 Fire alarm smoke detection system service and testing: no record of sensitivity testing completed within the last five years.

.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not complete an investigation and written report within thirty calendar days of each incident, accident, complaint or allegation of abuse (previously cited 11/06/2015).

.350.03 Resident Protection: the administrator failed to protect residents during the investigation of a resident-to-resident incident.

.350.04 Written Response to Complaint Within Thirty Days: the administrator did not provide a written response to all complainants within 30 days.

.350.05 Facility Notification to Appropriate Agencies: the facility did not notify Adult Protection as per Section 39-5303 of the Idaho Code after a resident-to-resident incident that could have been seen as abuse (previously cited 11/06/2015).

.350.08 Identify and Monitor Patterns: the facility did not identify a method for monitoring patterns of incidents and accidents to develop interventions to prevent recurrence; House 1 had at least 13 different incidents and accidents in the last six months that were not monitored for patterns.

.009.06.c Use of Previous Criminal History and Background Check: one staff member did not have the required state only background check completed (previously cited 8/25/2011).

.153.01 Response of Staff to Abuse, Neglect or Exploitation of Residents: the abuse policy did not include exploitation or proper procedures for reporting Adult Protection and law enforcement.

.250.10 Plumbing: the facility's water temperature exceeded 120 degrees.

.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not complete psychotropic medication reviews on all residents receiving psychotropic medications.

.335.03 Standard Precautions: six of seven staff did not have evidence of infection control training; there were no paper towels in residents' rooms who required personal care assistance; staff overused gloves.

.350.02 Administrator or Designee Investigation Within Thirty Days: the facility did not complete or document an investigation when medications were missing.

.350.05 Facility Notification to Appropriate Agencies: the facility did not appropriately report to Adult Protection or law enforcement.

.600.05 Supervision: the facility administrator did not provide adequate supervision to ensure residents received their mechanical soft diets as outlined in the Idaho Dietary Manual.

.600.06.a Sufficient Personnel: the facility administrator did not schedule sufficient staff to ensure staff were available in each building to meet residents' needs at all times on the night shift.